Control of Substances Hazardous to Health (COSHH) - COSHH
Hazardous materials: MedlinePlus Medical Encyclopedia
hazardous materials list in hospital
hazardous materials list in hospital - win
Some common gender myths and their rebuttals
It seems like the same discussions come up around Reddit a lot, so I figured I'd gather up some common topics, and their rebuttals. Many of these arguments can be expanded with more points and sources but I'm trying to keep this as compact and to the point as possible.
Myth 1: "Sexism against men is never institutional or systematic"
Many forms of sexism and discrimination against men are explicitly institutionalized or systemic in society. Examples include police violence, court biases, incarceration, child custody discrimination, military service, educational biases, health research and spending, insurance, housing discrimination, reproductive rights, bodily autonomy rights, and many others. The widespread ignorance and denialism around these issues can itself be interpreted as a form of systemic discrimination against men as well. Note that some of these are institutional because they boil down to statutory legal rights which exist in the realm of government policy and administration. And the government is obviously an institution.
Myth 2: "Most politicians and CEOs are men, and this has led to a society that privileges men and disenfranchises women"
The fact that many positions of formal power are occupied by men does not translate into measurable privileges for the average man. The assumption this is based on is the idea that men have an in-group bias and prefer other men over women. Which is an idea that has been debunked over and over again in the academic literature. The gender bias among men is almost zero, and sometimes manifests as an out-group bias sightly in favor of women, not other men. In-group bisses do exist among women though. In fact some research has found evidence for very strong gender biases among women. Including when it comes to educators, bosses, and hiring managers. Women in formal positions of power do actually seem to prefer other women over men, in much the same way that men are accused of behaving. So maybe this is just projection: people who themselves have gender biases assume that everyone else does as well. http://www.ncbi.nlm.nih.gov/pubmed/15491274 https://www.sciencedirect.com/science/article/abs/pii/S0022103101915112 https://link.springer.com/chapte10.1007/978-3-030-04384-1_9
Myth 3: "Women were uniquely oppressed in history compared to men"
Myth 4: "Domestic violence and sexual assault are primarily women's issues"
Domestic violence and sexual assault affects everyone, and at nearly identical rates between men and women. In the US, roughly 37.3% of women have been victims of domestic violence, stalking, sexual harassment, and sexual abuse. Including 1.4 million women who experience sexual assault annually. For men that same figure is 30.9%. Including 1.7 million men who experience sexually assault annually (defined as "made to penetrate"). The vast majority of these men are also victimized by women, not by "other men" (which is another myth). This pattern is similar across the world, including in poor and underdeveloped nations (see here for a collection of studies), and is consistent with a wide range of research demonstrating "gender parity" between men and women for this topic. https://www.cdc.gov/violenceprevention/pdf/NISVS-StateReportBook.pdf http://webshare.law.ucla.edu/Faculty/bibs/stemple/Stemple-SexualVictimizationPerpetratedFinal.pdf https://1in6.org It's also not true that there's a significant difference in severity between male and female victims. Around 66% of intimate partner homicides do have women as victims (which is hardly a staggering majority), but when you include intimate partner related suicide deaths (including assisted suicides), a greater number of men are killed because of domestic violence than women. These statistic also ignore the fact that lesbian relationships are more violent than heterosexual and gay male relationships. Which inflates these numbers and doesn't necessarily back up the idea that women are being uniquely victimized by men. We should obviously work to fight against abuse in any form, but our current, gendered approach to this doesn't seem to be helping very much. It is also commonly used as an excuse for misandry. Many people who discuss abuse against women do not actually care about female victims. All they care about is advancing a culture of hatred and sexism against men. https://web.csulb.edu/~mfiebert/assault.htm https://www.emerald.com/insight/content/doi/10.5042/jacpr.2010.0141/full/html https://www.frontiersin.org/articles/10.3389/fpsyg.2018.01506/full See also: https://www.reddit.com/MensRights/comments/f4rvop/some_sources_on_the_severity_of_domestic_violence/ https://www.reddit.com/MensRights/comments/koinom/some_sources_on_the_sexual_abuse_of_men_and_boys/ https://www.reddit.com/MensRights/comments/f5tes5/gender_parity_for_sexual_assault_academic_studies/ "But women are afraid to walk down dark alleyways at night!" As they should. And as do men. Most violent crime targets men. And fear is subjective. This is hardly evidence of some kind of unique oppression against women (at least one that doesn't also affect men), and it ignores the fact that men are usually afraid of finding themselves in those same situations as well. Men are stronger and more capable of defending themselves so I wouldn't blame someone for having gendered views or assumptions here. But let's try not to minimize male victimization or blame it on things like "male oppression".
Myth 6: "Men commit suicide more often than women, but women still attempt suicide more often than men"
This idea has its origins with faulty hospital reporting which lumps suicide attempts in with self-harm (which is something that's more common among women). Women are also more likely to report their suicide attempts than men. And even if this statistic were accurate, it ignores the obvious fact that a suicide survivor can attempt again, thus artificially inflating this statistic. The fact is, most suicid deaths are men, and most evidence points to there being more unique attempts by men. Any evidence that men are "better" at it than women has been interpreted as evidence for greater motivation of success, due to the very same factors that lead them to attempt suicide to begin with. Not as evidence that women are somehow attempting suicide at rates similar to men in the background. https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-017-1398-8 See also: https://www.reddit.com/MensRights/comments/cvpyve/comment/ey5xeda
Myth 7: "Men make more money because of their gender, and this is evidence of male privilege"
Existing gender norms encourage men to earn money in order to meet the financial demands that are placed on them by women. This causes them to work harder and sacrifice more for their careers than women. Which they do in part because their income is tied to how successful they are with women, and whether or not they qualify as "marriage material". The wage gap is therefore an example of a gender norm that harms men just as much as it does women. 92% of workplace deaths are men. Men work on average an extra 4 to 10 hours a week (depending on your source) than women. They start working at a younger age (often skirting child labor laws). They retire later (which is also during their peak earning years). And they die sooner than women. Men have worse health outcomes than women and that's largely because of the pressures that society puts on them to be successful and earn money to spend on women. This is the other side of the wage gap that is equally as important, and that is equally as harmfully to men as it is to women. And it's really just the tip of the iceberg. In many ways the wage gap is just a reflection of the financial exploitation of men in society. Which is facilitated by things like hypergamy and unfair marriage and divorce practices. See also: https://www.reddit.com/MensRights/comments/kzvfcg/about_the_wage_gap/ https://www.reddit.com/MensRights/comments/dxaimc/the_wage_gap_is_created_by_women_and_reflects/
Myth 8: "Men don't go to the doctor because of toxic masculinity"
The main reason that men sometimes don't seek help is a lack of time to see a doctor. Men work longer hours than women at jobs that are less flexible, and more stressful, than jobs that women usually work at. Men overall engage in an extra hour of paid and unpaid labor per day compared to women, and an extra 45 minutes commuting to jobs that are further away. Meaning men on average have quite a bit less free time to go see a doctor than women do. This is also something that changes during retirement: retired men are just as likely to go to the doctor as retired women. https://bmjopen.bmj.com/content/3/8/e003320 A general lack of help and support, especially financial support, for men who need medical help also contributes to this. There is a myth that men are better taken care of than women which has resulted in gendered policies that help women, but exclude men. Even though it's men who often need that help more.
Myth 9: "Men don't speak up about sexism as much as women, so it's obviously not as big of an issue"
This is because people are less likely to care or listen to them. In part because many men who do speak up are silenced and accused of being misogynistic. A situation known as testimonial injustice or epistemic oppression. Men are told to keep quiet and many end up internalizing the idea that only women can be discriminated against, since this is what society tells us to believe. Instead, men often adopt different terminology when they discuss gender issues. Like referring to differences in treatment between men and women as "double standards" instead of sexism or discrimination.
Myth 10: "Most men's issues are caused by men themselves"
Myth 11: "Toxic masculinity is harming men and their mental health"
The concept of toxic masculinity has never been empirically tested, and some research questions the validity of it in the context of psychology and mental health. Even if you do think it is valid though, it is still commonly used in a way that is sexist and hateful torwards men. In recent years it has become associated with female supremacy, feminist hostility towards men, and misandry in general. And as a result, the vast majority of men find the term to be sexist and offensive. Men who identify with traditional masculine values have greater self-esteem, better mental health, better relationships with women, and are usually better educated than men who are opposed to masculinity or who accept feminist views about the patriarchy and toxic masculinity. The key to better mental health for men might therefore be an embracement of masculinity, not a shunning of it. Instead of trying to redefine masculinity, we should work to understand it better, and offer men better services based on an honest acknowledgement that men's and women's mental health might require different approaches. Men are not "defective women", and treating men's mental health in that context does not seem to be working very well. https://www.nytimes.com/2019/01/17/opinion/apa-guidelines-men-boys.html https://zenodo.org/record/3871217#.X-p1ji2l2J_ https://link.springer.com/chapte10.1007/978-3-030-04384-1_5
Myth 12: "Most men's activists just hate women or are opposed to feminism. They don't really care about men."
This rhetoric is normally used to silence the voices of men (and women) who support men's rights and prevent them from expressing themselves. Which makes it another example of testimonial injustice or epistemic oppression. The fact is that many people do care about men's issues, and that's why they become MRAs. Feminism does get discussed in the men's movement, but there are a couple reasons for that:
Many feminists, "radical" or otherwise, have advocated against men and have even pushed for public policy in ways that are harmful to men or discriminates against men. Feminists themselves tend to not fight against this, meaning it's often up to MRAs to address it.
Many MRAs are themselves current or ex-feminists who were ostracized for daring to take the feminist rhetoric about "also caring about men" a little too seriously.
Warren Farrell is a great example of this. He used to be on the board of directors for NOW, the world's largest feminist organization. And then he said that we need to work on child custody equality and reproductive rights for men. Topics that he assumed should fall under the umbrella of feminism since they are issues pertaining to gender equality. Instead of agreeing with him though, he ended up being excommunicated from the feminist movement. And now he's often regarded as the "father of the modern men's movement" for carrying on his advocacy outside of feminism. The problem that many MRAs have with feminism is that it usually stops half way when advocating for gender equality. So sometimes what MRAs are doing is just taking it the rest of the way towards actual gender equality. Our frustration with feminists comes from the fact that they refuse to see this as valid (or do it themselves to begin with). See also: https://www.reddit.com/MensRights/comments/ihmb2p/by_denying_that_the_feminist_establishment_is/ https://www.reddit.com/MensRights/comments/9v6tqj/a_list_about_feminism_misandry_for_anyone_who/
Myth 13: "Men don't receive custody of their children because they're bad fathers and don't bother requesting custody"
A majority of child abuse is actually committed by women, and especially by mothers. This is even more true when you include emotional abuse and neglect instead of just physical abuse. By some metrics, the biological father is the safest person for a child to be with. This is because when men do abuse children, it often happens while under the custody of the mother. Who is sometimes complicit in the abuse or even encourages it. Close to half of child abductors and traffickers are also women, not men. And many of their victims are boys. Boys face sexual abuse and are also used for forced labor and organ harvesting. They are less likely to survive or escape, are less likely to be reported on or identified, and they suffer from higher rates of abuse than girls who are trafficked. And yet very little attention is given to this. Missing boys, and especially missing minority boys, are often ignored by society and the media. To the point that people often assume that most of the victims are girls. Something which is known as the missing white woman syndrome (although in Canada there is a lot of attention given to missing indigenous women, even though 71% of missing indigenous people are men and boys). Note that I'm not saying these things to attack women, imply that they shouldn't receive custody, or to downplay the plight of girls. Which is a lot more than you can say about people who try to paint men as the villains in this picture. We should however be fair about what the facts are, and give male victimization, including victimization by women, the attention that it deserves. https://www.ncbi.nlm.nih.gov/pubmed/16165212 https://www.cdc.gov/violenceprevention/pdf/childmaltreatment-facts-at-a-glance.pdf http://www.breakingthescience.org/SimplifiedDataFromDHHS.php https://www.sciencedirect.com/science/article/abs/pii/S0145213416302599 https://www.savethechildren.org/us/charity-stories/child-trafficking-myths-vs-facts Fair is fair and equal is equal. Gender equality will never be fixed if we refuse to look at both sides of the coin. We need to be honest about what the problems are, and stop ignoring them when they involve men, fathers, and boys.
Clover (IPOC) CEO response to Hindenburg Research piece from yesterday
from the SEC: https://www.sec.gov/Archives/edgadata/1801170/000119312521029637/d66346dex991.htm click for all the tables/images. EX-99.1 2 d66346dex991.htm EX-99.1 Exhibit 99.1 In Response to Short Seller Firm’s Questions 📷 Andrew Still-Baxter 18 min read From: Vivek Garipalli, CEO and Andrew Toy, President of Clover Health Clover’s mission is to improve every life. We do that by scaling the Clover Assistant platform across physicians to drive a meaningful positive clinical impact towards as wide a percentage of our membership as possible. We align our incentives for the Clover Assistant by embedding our software platform inside of the business of our Medicare Advantage plan. As we improve outcomes, and lower costs, Clover can pass those savings on to consumers, improving the attractiveness of our plans and spurring rapid growth. We ultimately seek to transform healthcare for each and every one of us. Clover welcomes questions about our business, as it gives us the opportunity to share our vision and to address any skepticism, whether founded or unfounded. As you will see from our detailed, point-by-point response to the short seller firm’s questions, the alleged “report” is rife with ad-hominem attacks, sweeping inaccuracies and gross mischaracterizations. Importantly, the short seller firm did not contact Clover, and we had no knowledge of the short seller report prior to it being made publicly available. In our view, it belies a desperate attempt for publicity while sacrificing any regard for the truth. In addition, we would note that the report’s title specifically calls out the involvement of “The King of SPACs,” Chamath Palihapitiya, and accuses him of a dearth of diligence. This, as we will show, is completely untrue, and we suspect this was done in order to sensationalize what is otherwise a rather underwhelming piece of research. Given the market’s latest views on short sellers, we believe that Hindenburg, which takes pains to call out their altruism in saying that they are not short on CLOV stock, is foolheartedly seeking to redeem itself by posturing as a white knight of the financial markets. We’ve put together this response as rapidly as possible. We hope you will find it extremely informative. ##
Did Chamath and/or Clover know about the ongoing DOJ investigation? If so, why was it concealed from investors?
Chamath and Clover were fully aware of the DOJ inquiry. To be clear, Clover does not believe it is, or has been, in violation of any rules or regulations related to the inquiry. We went through both an IPO and de-SPAC due diligence process, and this subject received extensive focus and attention. Consistent with the views of Clover’s outside counsel, Social Capital’s outside counsel, and independently retained outside counsel of third parties, including IPO underwriters’ counsel, we concluded that the fact of DOJ’s request for information was not material and was not required to be specifically disclosed in our SEC filings. How could a DOJ inquiry not be considered material information? As heavily regulated organizations participating in Medicare Advantage, Clover and its peers receive frequent requests for information from regulatory bodies. These are typically confidential. We promptly respond to these requests as and when they come in. As the short selling firm points out, the DOJ also often reaches out to ex-employees, including by civil investigative demands, as part of their information-gathering process. For absolute clarity: • Clover Health believes it has made all appropriate disclosures, which were reviewed and vetted by outside counsel to all parties. • Clover has not received any civil investigative demands or subpoenas from the Department of Justice. • Clover has received a request for information from the Justice Department, to which, as we do with all requests from regulatory bodies, we responded. This was on a voluntary basis. • Clover has conducted a detailed review of matters potentially addressed by the DOJ request for information and has concluded that it is in compliance with all laws and regulations material to its business. • Up until the publishing of the short selling report yesterday morning, Clover was unaware of any other ongoing investigations of the Company, its officers, or any companies with which they are affiliated. • Following the report yesterday, Clover received notice of an investigation from the SEC. We believe this inquiry is based on the short selling report issued yesterday morning.
Is Clover aware of any other regulatory investigations into the company or Vivek Garipalli and his related companies? If so, what are the details?
Clover is unaware of any other ongoing regulatory investigations, except, as noted above, following the short selling firm’s report yesterday morning, Clover received an inquiry from the SEC. We believe this request is based on the short selling report issued yesterday morning.
Has Clover received any subpoenas or civil investigative demands from regulators? If so, how many and from which regulators?
No. Clover has not received any civil investigative demands or subpoenas from the Department of Justice. Clover has received a request for information from the Justice Department, to which, as we do with all requests from regulatory bodies, we responded on a voluntary basis.
Why does Clover’s subsidiary, “Seek Insurance” operate a website called “SeekMedicare.com” claiming to offer “independent” and “unbiased” advice on selecting Medicare plans without disclosing that it is owned by a Medicare plan provider, representing a blatant conflict of interest?
Seek Medicare is a startup that was incubated and set up as a separate company from Clover — it has its own management team, outside investor (a nationally-recognized public company), board and employees. Clover and the outside investor share in governance of Seek at the board level, including decisions such as the nomination of the CEO. Clover has the right to appoint a Board Member (currently Andrew Toy, Clover’s President & CTO), the outside investor has a right to appoint a Board Member (currently an employee of the outside investor), and the third Board Member, the CEO, must be mutually agreed upon. In addition, this investor has a unilateral contractual option to convert its investment into 50% equity ownership of Seek. It’s not unusual for payors to create or have stakes in FMOs. What makes Seek different is its fundamental belief that Medicare consumers are simply not well-informed and that hurts their ability to get affordable, great healthcare. Seek is purpose-built to deliver against that problem. In order to make sure it could effectively pursue its goals, Seek was set up as a separate company, and it has raised nearly all of its capital from the outside investor. At Clover, we obviously want everyone to pick a Clover plan, but we want to earn that business by providing great and affordable healthcare coverage. The most important thing is that Medicare eligibles end up in the right plan for them. One final note here: Seek is a brand new startup, and its website is still in version 1.0. Please take a look back next week when its planned version 2.0 comes out.
Clover’s subsidiary, Seek Insurance, claims on its website “We don’t work for insurance companies. We work for you” despite literally being owned by Clover, an insurance company. What is your response?
While Seek is an affiliate, as we said, it operates separately from Clover, with its own financing and its own goals, which are to provide neutral, objective advice to Medicare eligibles and to empower, educate and assist them. Seek offers Clover plans but, more importantly, Seek also offers many more coverage options. In fact, in every market in which Seek operates, Seek endeavors to offer at least 80% of available plans in that market. Even though Seek began very recently, it was able to stand up its agency in the most recent AEP and also launched a pilot in ~100 retail locations in six states, with a focus on markets in Georgia, New Jersey and Texas. If you want to see the objectivity of Seek, we think the results of Seek’s initial sales period speak for themselves: Percent of Seek sales, by insurance plan, in the most recent AEP: 1. Cigna: 20% 2. Humana: 20% 3. CVS/Aetna: 17% 4. Clover: 13.5% 5. UnitedHealth Group: 11.3% 6. WellCare: 8.5% 7. Horizon: 5.7% 8. Other (unrelated to Clover): 4.0% In terms of scale, applications from Seek totaled less than 1% of the total applications Clover received in the most recent AEP.
How much has Clover paid B&H Assurance, the undisclosed outside brokerage firm run by Hiram Bermudez (its Head of Sales) since inception?
Clover has paid approximately $160k directly to B&H since 2017. Hiram has disclosed the following in connection with his B&H relationship: • He does not receive any compensation, direct or indirect, from B&H Assurance for any work related to Clover. • He maintains a 50% ownership interest in B&H Assurance, which he has owned since before he joined Clover. • Hiram’s only work on behalf of B&H Assurance is monitoring compliance and negotiating contracts, from time to time, with parties that do not include Clover. • He maintains an ownership interest in B&H Assurance so that, in case he separates from Clover, he has the option to go back to the brokerage agency he co-founded and not have to start over. As a general matter, Clover engages with brokers in each of its markets in order to distribute its plans. This is standard operating procedure in the Medicare Advantage space. Broker payments are statutorily defined by state insurance regulators, broker scripts are actively monitored by both internal compliance and CMS — including via “secret shopper” and other methods — and we take our obligations to CMS, our members and potential members very seriously. We believe our marketing materials and the brokers that represent us accurately reflect and portray our plans to our members and potential members and do so with transparency and integrity.
What portion of Clover’s business has been referred by B&H Assurance since inception? How many members?
Approximately 8,200 of our current members were referred by B&H Assurance to Clover. While B&H has been a strong producer, we strongly disagree with the statement that B&H alone has “fueled” Clover’s growth. We believe that all Medicare Advantage plans have key producer relationships, and to say those relationships somehow illegitimately fuel growth is a misnomer. We believe Clover plans are appealing because they are often amongst the lowest cost plans in our established markets, and they offer the same cost-sharing for in-network and out-of-network primary care and specialist visits. As we expand across the country, we intend to establish relationships with additional brokers and key producers.
Former employees told us that the relationship between Clover and B&H Assurance was transferred into the name of Hiram Bermudez’s wife “for compliance purposes”. NAIC filings confirm it was transferred into his wife’s (maiden) name weeks after the go-public announcement. What is the explanation for this?
The statement underlying this question is false and misleading. The reason that B&H Assurance’s appointment list does not include Clover is that B&H has what is referred to as a “downline” relationship with Ritter Insurance Marketing, which contracts directly with Clover (note that it appears B&H does contract directly with a number of other plans based on the cited NAIC record page). Rather than a nefarious circumstance, this is also a standard construct in the Medicare Advantage world. Further, the statements interpreting Yesenia Rivera (Bermudez)’s NAIC profile are incorrect in their conclusions: (1) there was no transfer of any relationship between Clover and B&H Assurance from Hiram to his wife; (2) the NAIC filing simply shows that on August 14, 2020, Mrs. Bermudez was directly appointed by Clover Health to be able to sell Clover plans as an agent. For context, Hiram underwent a major organ transplant surgery at the end of last summer due to chronic kidney disease. He, thankfully, is doing very well healthwise after the surgery. Hiram informed us that he and his wife made a decision for her to go through broker certification so that, if his condition deteriorated further, she would be able to take over his 50% ownership in B&H. No one should ever feel compelled to share this type of personal and private health information publicly, but we deeply respect Hiram’s desire to disclose this to make clear he had no malicious intent. Hiram is highly mission-oriented and an amazing teammate at Clover, and pathetic attempts to slander him are shameful.
Will Clover produce the agreement showing the transfer of the relationship into Hiram Bermudez’s wife’s name? Who signed off on the agreement and which senior members of management knew about the deal?
See previous response.
Is Clover aware that disclosure of significant transactions with key senior employees is something investors like to know about, so they can be made aware of potential material conflicts of interest?
Consistent with applicable laws and regulations, Clover has conflict of interest policies requiring employees to disclose any existing or potential conflicts of interest. Clover follows SEC rules and regulations regarding the public disclosure of these relationships.
Was Chamath aware that the DOJ was looking into issues of potential upcoding when he mentioned, unprompted, on CNBC “they don’t motivate doctors to upcode or do all kinds of things in order to get paid”?
We agree (as does Chamath) that upcoding is a significant problem in the Medicare Advantage industry, and Chamath was fully aware that we have built the Clover Assistant to address the problems in the approaches used by other insurers. To be clear, Chamath’s statement that “we do not motivate doctors to upcode or do all kinds of things to get paid” is accurate: • We pay Clover Assistant Primary Care physicians a fixed, flat payment per office visit. • Unlike other plans, we never compensate more for agreeing with the Clover Assistant. We never pay less for disagreeing with the Clover Assistant. This payment is fixed and guaranteed, and physicians use their own judgment on what they believe is clinically correct in relation to their direct understanding of the patient. • Put another way, a clinician could choose to disagree with every suggestion, which means there are no additional diagnoses and no additional risk adjustment codes, and they still get paid the exact same amount as if they did agree. There is NO financial motivation that we provide to physicians to answer in any particular way. • This is why we specifically do not believe in capitation contracts the same way that others do. These contracts often share risk adjustment back to physicians — i.e., an indirect way to reward them for coding more. Clover does not support those types of strategies. To be clear, the focus of the Clover Assistant is driving clinical value. Because of its important role in early and improved detection of disease burden, accurate risk adjustment is one of the byproducts of clinical engagement with the Clover Assistant. Notably, however, much of the content in the Clover Assistant has absolutely nothing to do with risk adjustment. More than 50% of the clinical data we capture through Clover Assistant visits has no risk score impact whatsoever. Here are just a few examples of the Clover Assistant driving clinical value: 📷 Colorectal Cancer Screening Medication Therapy Management: 📷 For Chronic Kidney Disease 📷 For Statins Addressing risk: 📷 Fall Risk 📷 Mortality Risk Covid — 19 Response 📷 Mail Order and Home Drug Delivery
Clover reported that “onboarded” physicians used Clover Assistant for 92% of member visits in 2019, but never defined “onboarded”. We found that less than half of Clover’s in-network doctors are considered “Clover Preferred”. What is the definition of an “onboarded” physician? What percentage of Clover’s in-network doctors actually use the Clover Assistant?
This is a good question. Similar to enterprise software, there are two phases of bringing on physicians to Clover Assistant: Contracting: Where we explain the benefits of Clover Assistant to the physicians and they have agreed to use the software. Onboarding: Where the physicians have received their initial training and have created their accounts, and we have answered their questions. Basically, they’re ready to use the software. We also refer to the physicians as the “Live” physicians. We use the Onboarded/Live number (as opposed to Contracted) when discussing engagement because that correlates to the physicians that are trained and ready to use the Clover Assistant. We typically have a pipeline of Contracted physicians waiting to be onboarded at any given time, and our goal is to go from Contracted to Live within 60 days. Speaking to the second question, currently 22% of all in-network Primary Care Physicians are Live. This correlates to 4% of the total in-network physicians (including PCPs, specialists, etc.), but the Clover Assistant is currently built as a tool for PCPs, so we believe 22% is a more useful number. That said, we don’t view either of those figures to be particularly relevant to the scalability and impact potential of the Clover Assistant. Instead, we focus on membership coverage. More specifically, as of YE 2020, 56% of our membership were attributed to one of those 22% Live PCPs. An additional 11% are attributed to a PCP who is contracted but in the onboarding pipeline (bringing us to 67% total coverage for Clover Assistant as of YE 2020). This is because as we bring on physicians, we focus on contracting and onboarding those with more Clover members first, so a disproportionate number of our members are attributed to Clover Assistant-Live PCPs. As we continue to deploy the Clover Assistant, we intend to bring on the remainder of these physicians and we expect to see these numbers converge more. Right now we’re very proud of that 67% coverage number of all Clover members as of year-end 2020.
If Clover’s software is so “delightful” to use, why does Clover have to pay doctors extra ($200 per visit) just to use it?
We think this is a big part of the innovation model of Clover and why it’s so important that we build this tool internally as a payor. The Clover Assistant is a SaaS-type enterprise clinical decision tool, but rather than charge physicians to use it (like regular software startups), we instead reimburse PCPs to encourage them to use it and to recognize the incredibly important role PCPs play in assessing and taking care of our members and controlling costs. PCPs receive less than 5% of total medical expenses in the US, and we believe that to solve the ballooning health care expenses in our country, we need to shift more of our focus, resources, and compensation to primary care doctors. To be clear, the “extra $200 per visit” is not incremental or “just to use” the Clover Assistant, but represents the overall payment that covers both the PCP office visit and the use of the Clover Assistant. This translates to roughly twice the traditional Medicare fees paid to PCPs for an office visit, more in line with fees paid to specialists. Most critically, this is a flat fee. We don’t pay them more to agree with us, or less when they disagree. A lot of programs effectively do this, and that creates moral hazards like upcoding or trying to skimp on care. We pay the flat fee because we want to reward PCPs for great data-driven primary care without creating those moral hazards and bad incentives. Speaking to the delight point — we measure this in an objective, standard way in the form of Net Promoter Score surveys. We run these surveys within Clover Assistant for all Clover Assistant users on a quarterly basis to see how we’re doing in terms of user satisfaction and delight. We’ve traditionally received a score between 55–63 which we think is excellent — particularly for healthcare. Here’s a screenshot of our NPS survey: 📷 Clover Assistant NPS Survey 📷 Our most recent NPS results from the end of last year. As you can see, most of our Clover Assistant survey respondents give us very high ratings. There are a few “middle” scores, and there are, of course, some detractors who give us low scores. When we receive detractor feedback, we strive to send our Product and User Research teams to interview these users to find out how we can do better. We’re not perfect, but our fast iteration rate (releasing a new Clover Assistant version on average every 3–4 weeks) helps us continuously improve our platform.
Multiple doctors explained that it was difficult to remove prior diagnoses from the Clover Assistant. Is Clover aware of this? And can Clover guarantee that in future versions of the software doctors will be able to remove prior diagnoses, so as to ensure accuracy and cost efficiency?
For clarity, every diagnosis that appears in the Clover Assistant is for physician consideration, and they can choose to tell us they don’t think that diagnosis is currently relevant. Here’s a screenshot of how it’s shown. 📷 Every suggestion made is based upon clinical data that we have at Clover and personalized for each specific patient. Then the physician can tell us whether they can confirm the diagnosis. If they cannot confirm, they can easily select that option (shown above), and we ask them to share the reason why so we can update our internal data. Note that when a physician tells us a diagnosis is not currently relevant, we do not show that diagnosis again that calendar year unless there is a new reason to believe that the diagnosis applies (e.g., new clinical data). We may also resurface a diagnosis the following calendar year for reconfirmation. There’s a reason for this: many chronic diagnoses may come and go in terms of their diagnosis state. For example, diabetes may resolve (removing the diagnosis) if a patient loses weight, but if the patient puts the weight back on, diabetes will come back. Or, active cancer may go into remission, then unfortunately return. As such, it’s clinically appropriate to track these previous diagnoses. Bonus Question: Is Clover Assistant actually helpful to physicians in providing better care above and beyond their EHR?” This wasn’t actually in the list of questions addressed to us but was implicit in the short-selling firm’s commentary, so we wanted to hit this on the head, too. We are incredibly proud of the ways, in only a few short years, we have been able to build the Clover Assistant platform in order to support PCPs in providing better care for our members. The Clover Assistant is not attempting to be an EHR; rather, we are focused on building a product that is supplemental to the EHR and driven by physician feedback. We’ve supported the rapid transition to remote visits during the outbreak of COVID-19 this past spring, we’ve supported members getting their medications delivered to them when they couldn’t leave their home, and we’ve gotten clinical information otherwise not available to PCPs into the hands of those most equipped to utilize that information. We also surface evidence-based protocols specific to a member’s disease profile. To be clear, we do this in order to help our members receive the right medications, access the right testing, and achieve better outcomes. By doing so, we pay more money now in order to decrease costs and patient suffering down the line. If you take a look at our most recent investor presentation, you can easily see a view of that functionality on page 10. On page 19 of the same deck, you can also see a view of the Clover Assistant’s impact outside of accurate diagnosis capture. We are just starting this journey, and know that, like with any software, there are plenty of opportunities for fine tuning and further improvement. But we are motivated by those challenges and solicit that feedback from the healthcare community and our in-network physicians regularly. — The Clover Product, Clinical, and Engineering Leads
A former employee explained that Clover handed out gift cards to doctors and nurses to generate patient leads, a practice prohibited by CMS. These gift cards were justified as being for everything but recruitment, including “morale,” a “thank you,” “motivation,” and “friendship.” How do you respond?
Clover does not provide gift cards to doctors and nurses to generate patient leads. Clover prides itself on a strong culture of compliance. If we were to discover any violation of CMS regulations or any applicable law or regulation, our compliance department would take decisive and strong corrective action.
Does CEO Vivek Garipalli deny that his CarePoint hospitals at one point charged the highest emergency room prices in the entire nation?
It is important to note that CarePoint is a separate and independent business entity, with different management teams, investor structures, and boards of directors. We do not comment on its operations. We also do not respond to ad hominem attacks against our officers.
Why did CEO Vivek Garipalli make a secret $1 million donation to the Mayor of Jersey City?
The aforementioned contribution to a PAC has been reported in the media. Like any private citizen, Vivek makes contributions. As our first market, New Jersey is near and dear to us, and Vivek believes the Mayor of Jersey City has done a commendable job of attracting businesses and developing affordable housing policies. Vivek also donates to other causes in New Jersey and elsewhere — such as a $1MM contribution to the Goodwill Rescue Mission homeless shelter in Newark, NJ.
Why has Clover had such extensive executive turnover, with 3 CFOs, 3 COOs, and 2 General Counsels in the last 4 years?
Clover has evolved significantly over the past four years, and we needed different people with different skill sets at each stage of our journey. We are grateful for the contributions of every one of our employees, past and present, and are proud of our current management team. As is evident from our team’s background, they bring extensive experience across their areas of expertise. We believe we should always be looking to bring on more and more talented and mission-oriented individuals as we evolve and grow. In particular, we are grateful to our co-founder Kris Gale for his work as the original Clover CTO to build the fundamentals of the Clover data platform. When Andrew Toy, our current President and CTO, came on board, one of the first things he did was focus on the creation of a way to turn data into improved care by physicians. The result of that was the Clover Assistant.
[Let's Build] d100 Distinct Locations in a Fancy Estate
d100 Distinct Locations & Characters in a Fancy Estate
Channel your most Downton Abbey or period-piece drama, places where a fancy party, drama, folk or gothic horror, or violent excitement can occur on, or near a large estate.
Seaside Boathouse: Estate Grounds, Outbuilding. Down at bottom of cliff, complete w/ sea-wall, & 5-man ketch. Large enough for three bedrooms, servant's bunks, extra kitchen, & small stable! Its own little mini-estate! Loyal sailor mans place, w/ hook hand & peg leg, lost in war.
Apse Oceanus: Underground. Secret grotto at base of wave-wracked sea-cliffs; cave entrance just above high water line. Inside cave, beach-gravel floor; an apse, seemingly carved by nature - semicircular recess covered w/ hemispherical vault. In center is ancient granite cauldron perpetually filled w/ fresh, clear water, as if by magic.
Moaning Cavern: Underground. Partially natural staircase in cavern & sea-cliffs. When wind blows strongly from right direction, it moans & whistles w/ ghostly sounds. Staircase seems natural (but has actually been artfully worked to appear so), it heads further in, up into cliffs beneath Manor.
First Lord's Tomb: Underground. Remains of First Lord of Manor & few relatives, interred in carved grotto in stone, deep beneath Manor. Occasionally trick of wind & strong draft make moaning noises... nothing to be frightened of, surely.
Ossuary: Underground. Vaulted ceilings somehow make underground crypt feel imposing & cramped. Ossuary walls hold recesses for stone boxes nearly impossible to move alone, each box storing interred bones; mortally departed going back to start of noble name of the Family. Some ossuary chests currently empty in preparation for family members whose remains are still in earth, either in Cemetery on grounds or Elsewhere. (u/crimebiscuit)
Garden Wilderness: Estate Grounds, Garden, Wilderness. Transitional area between formal gardens & large park surrounding the house known as “the Wilderness”. Originally as meticulously planned as other areas of Estate, but here plantings more irregular & included native plants and trees; gravel walkways; lawns that resembled meadows; & areas where the vistas were framed to deliberately look natural. Now, without groundskeepers, the real Wilderness is overtaking the Garden. A “Ha-Ha”, low wall & ditch designed to blend into landscape separates area from Common Pasture & errant farm animals.
Gardener's Cottage: Estate Grounds. Leaky roof, made of thatch; needs repair. Single room, w/ hearth. Dried herbs & flowers hang throughout. Gardener is old, but has v. young & precocious niece or nephew.. too young to do much work.
Old Vegetable Garden: Estate Grounds. Said to be haunted at night in Fall. Nothing but weeds grow here, since Gardener is getting too old to do any gardening. Enclosed by a dying hedgerow & rotting wooden gate.
Orchard & Vineyard: Estate Grounds. Fruit-trees in need of pruning & an arborist. Medlar, Quince, Apple, Cherry, & Pear. Several long rows of trees, growing on terraced hillside, interspersed w/ sad, underperforming grape-vines; surrounded by hedgerows in need of maintenance. Small shed & woodbox hides an old copper still & moonshining equipment, along w/ shears & saws for trimming fruit trees, tubs for mashing grapes & other fruit. Still a few jugs of Orchard-keeper’s secret reserve “White Lightning” Fruit-Schnapps buried beneath Wood-pile. Also, that tree over there is where Orchard-keeper was found hanging by neck, five winters ago.
Apiary: Estate Grounds. Much of Estate’s Honey was cultivated here, until plague wiped out hives two years ago. Those that survived have flown off or been slaughtered by hornets this year. Next year’s fields will likely underperform without bee-driven pollination. Bee-keeper abandoned their post, too depressed to continue. Now all that is left is bunch of earthenware hives infested w/ killer hornets.
Main Stables: Estate Grounds, Outbuilding. One of several, for all the work animals that pull the carriages, etc. Hidden behind a wall from view of Main House & Gatehouse by wall. The Stable-master is dour, sullen drunk.
Gatehouse: Estate Grounds. Outbuilding. Literally built across front gate of Estate, part of wall surrounding Main House, Courtyard; 3-story house w/ lower level garage for carriage, small foyer, sitting room, 3 bedrooms, privy w/ new interior plumbing, small kitchen, basement & attic bunk for servants. Used to house Old Lord’s mistresses while Lady was home. Plaster fresco above main bedroom fireplace features prominent image of Lady’s stern & displeased face, supervising the activities in room.
Courtyard: Estate Grounds. Cobblestone & gravel driveway past the Gatehouse, Old Wellhouse to the Front-door of House. Drive around side of house to Coach-house, East Stair & Servant’s Entry. During parties, lit up w/ outdoor braziers, torches, & lanterns.
Petite “Cour de Marbre”: Estate Grounds, Entry. Former Lord, some generations ago, fell in love w/ foreign Ruler’s palace so much, decided to replicate it here in miniature. Striking, intricate patterned, polished black & white marble courtyard patio, up short flight of steps; Courtyard driveway goes right up to foot of it. Front Door opens onto it. Terribly slick in wet weather.
Main Kitchen: Servant’s Wing. Row of iron stoves & warming counters, wide hearth & spit w/ an excellent draw, butcher-block, slate, & flagstone everywhere. Several large copper tubs, pots, & pans. Room itself smells of smoke & food permanently etched into its soul.
Upper Battlements: Upstairs. Highest walls of Estate are adorned w/ stone merlons. Several gargoyles lay in stony wait perched atop walls. Some say they serve Master of the Estate; need only be summoned in order to come alive. (u/Milkslinger)
Morning Room: Upstairs. Small, high windowed office w/ excellent light. Wallpaper has cobwebs & mildew spots down by corner & floor, behind worn bookshelf loaded w/ moldering books. Close inspection might reveal secret behind bookshelf.
Batmen’s Quarters: Servant’s Wing. Long, narrow hallway w/ only one window at end, runs length of the entire Main Estate building. Chief Servant of the Master takes calls for whatever They may need, using this hallway to swiftly move from one end to another, unseen. Each room in House, adjacent to this hallway, has a secret door (DC Medium, Investigation) one may use to enter. Should PCs find this, may also find blueprints of Manor w/ all hidden passages; also rations & diary of Master of the House’s comings & goings. (u/TheBeginningOfMe)
Portrait Gallery: Upstairs. Series of interconnected rooms featuring most-recent portrait work of the artist the family currently patronizes. His idiosyncratic manner captures Family in a striking stylized fashion. But the real oddity is addition of one handsome scion who reoccurs in paintings that no one seems to have any recollection of. (u/crimebiscuit)
Long Gallery: Main Floor. V.long, tall ceilings room turned into something more than hallway, w/ other rooms, v.tall dbl-doors, opening into it; stretches entire length of Mansion, has excellent light, wooden parquetry floors, three fireplaces, two full sets ancient plate-armor, several large taxidermied curiosities, giant decorative vases, etc. Nobles take exercise here when weather is inclement.
White Stateroom: Main Floor. For meeting important people. Large room all in white, ornamental plasterwork on ceiling in shape of fluffy feathers & clouds. White & Cream wallpaper w/ motif of feathers. Cream curtains, nearly completely covered in embroidered silky white feathers. White furniture w/ white & cream upholstery. Pale hardwood parquetry floor, w/ gigantic cream & white ornamental carpet. Silvery, platinum-leaf decoratively applied to plaster mold-work. Maids work extra hard to scrub soot from fireplace’s white granite hearth.
Marble Hall: Main Floor. black & white chequered marble floor; stunning oak carvings, by famed craftsmen. On wall hangs a portrait of Ruler, inscribed w/ motto ‘Non sine sole iris’ (No rainbow without the sun). 23 sets of ivory & stags’ horn scrimshawed into chandeliers w/ scenes of ancient life. Carved Stone Fireplace w/ marble busts.
Green Salon: Upstairs. For entertaining guests at intimate parties; tall ceilings, cream & vibrant-green trimmed “boiseries”, ornamental wood panelings. Room imitates the Salon of a Foreign King; everything is given names that are fancy words in other language. In pride of place, matched set of “fauteuils á la reine”, ornamental armchairs wide enough that even largest panniers on court-dress can sit comfortably w/out wrinkling. V. large, gilded mirror above gigantic fireplace & mantle, v. expensive porcelain vases on display. Oval plasterwork bas-relief fresco of Old Lord’s (embellished) military victories.
Mirrored Ballroom: Main Floor. Colonnade supported large ballroom, surrounded in full-height mirrors. Mirrors enchanted to record & display glories of masquerades & balls past, dancing in time to whatever music is being played. Several large crystal chandeliers. Balcony over entrance overlooks Ballroom from Master’s Chambers, 2nd Balcony over musician canopy connects to Green Salon; Balcony in rear opens to Gardens.
Grand Dining Room: Main Floor. Marble walls, w/ magnificent painted murals higher up and on large vaulted ceiling. Large chandeliers, decorative magical sconces provide light. Grand dining table, seating for 30. Marble tile floor. Fancy dinners here.
Room of Abundance: Main Floor. Continuing decor of Grand Dining Room, but w/ more Gold, Silver. Painted walls & murals of abundance, statues of wealth & opulence. During parties, silver platters full of food placed here by caterers. Connects to Ballroom & Grand Dining Room.
Secret Passages: Hidden tunnels, hideaways, spider-holes; behind every statue & painting. The walls have ears. Eye holes in carvings, etc. Useful for clandestine maneuvering through House. Every major room has secret access routes, in addition to back-hallways used by servants; it’s just a matter of finding them.
Grand Office: Upstairs. Stateroom pretending to be an office-chamber, white, gold, & warm wood color-scheme. One lord was into business, decided to convert stateroom into fancy meeting-place. Square room made to look vaguely hexagonal, w/ facets carved into walls, low bookshelves mirroring & follow hexagon motif floor. Gold hexagon pattern tiled into floor. Huge desk placed on hexagonal raised step; supplicant must approach dias, placed in low, uncomfortable chair. Arched ceiling, ornamental plasterwork suggests beehives, hexagons, bees touched w/ gold-leaf. Wide hexagon fireplace, ornamental gilded plaster mantel of dripping honeycomb & bees. Single large circular window; ample light, hexagon shaped leaded panes & amber colored stained-glass bees. Hexagonal double door w/ stained glass beehive to enter. Bees magically enchanted, reflect attuned user of desk’s mood, move when no-one looks at them. “Secret” door on wall to Petite Office, concealed within woodwork.
Petite Office: Upstairs. Smaller office, (compared to the Grand Office, anyway) w/ private bath & privy. Wood paneling, lots of books, old gas & (new electric lighting from Galvanics). Worn, comfy executive chair. Wood paneled “secret” door connects to Grand Office. Knick-nacks & Taxidermy everywhere there isn’t books & paperwork.
Thinking Room: Main Floor. Small Alcove off Main Library; small table & chair. Eerily quiet, architecture baffles sounds from Library, making anything quieter than shouting easy to ignore. Encyclopedias, dictionaries & other reference materials usually found here, & upon finding books missing from Main Library, inexplicably one’s first inclination is to sit down & look up whatever one wants to know, instead of taking it back. People found after being missing for minutes or hours, sometimes looking up things unrelated to the subject they originally intended to; usually their reaction to being asked about this is a simple, "I got kind of curious." (u/thecomputerking)
Main Library: Main Floor. Wall to ceiling books, w/ brass rails & rolling ladder to reach multiple levels of books, v. little else. Grooves in well-worn wooden floor show extensive use of ladder happened at one point in history of Estate. Books may or may not be just for show. Roaring fireplace & lanterns provide warmth & light; "Thinking Room" & "Study" are adjacent.
Study: Main Floor. Large, padded leather, comfy chairs w/ high backs, resembles throne, along w/ small side-tables, lamps, & writing desk; all oriented to face set of v. tall, wide, windows for the best natural light. Adjacent to Main Library.
Nursery: Upstairs. Filled w/ all manner of children's Toys & complete w/ crop of Ankle-biters & accompanied strict Nurse. Alternatively, room that has been abandoned & seen much neglect.
Children's Quarters: Upstairs. Tiny beds or cribs where children sleep. Patterned w/ toile wallpaper, simple furniture. No doubt filled w/ ghosts of murdered children, there is no joy here. A small room adjacent to this is where Nurse sleeps.
Nurse's Chamber: Upstairs. Actually two small rooms, cramped bath, & privy w/ cranky, indoor plumbing. Nurse uses one tiny room to sew, & to lock naughty children in as punishment, there is one specific corner that is noticeably stained by tears & snot of unruly children. Second tiny room has bunk for Nurse to sleep & chest to keep things in.
Billiards Room: Main Floor. Huge table, ample room around sides for cues. Chandeliers provide ample light. Gilt trim & mirrors make room bright, opulent at same time. Cards tables, other entertainments available. Notable artwork in room: triptych story of Noble who hosted other Noble for fancy dinner, but failed providing standards of hospitality. Last panel of triptych: host is murdered by offended guest.
Attic: Museum of failed & forgotten dreams; furniture covered in tarps, dust, leaves, and bird nests. Surely haunted. Don’t let the Creepy Urchins scare you.
Garret: Attic. Habitable space, at top of House; small, dismal, & cramped, w/ sloping ceilings, often leaky roof. Where “unfortunate” members of the Lord’s family are kept. Optional: Set of manacles, collar, chain, other irons mounted to one beam, slop bucket. Alternatively, the cramped room contains small bunk & tiny writing desk, stool, & campy unfinished manuscript or private diary by servant w/ literary aspirations.
Servant’s Wing: Back of the house, covers several stories, many rooms & store-rooms; shared bunk-rooms for servants. One half has locked hallway to keep male staff & female staff separated. No shenanigans!
East Stair & Servant Entrance: Servant’s Wing. Steepest, Narrowest, most treacherous stair in house. Connects to Servant Entrance, Mud Room, lots of traffic as staff hurry up & down w/ tasks about House. Servant Entrance has Mudroom, none DARE use Front Entrance for Business.
Boot Room: Servant’s Wing. Where cleaning of boots, shoes & certain items of clothing take place. Don’t scuff the Lord’s Boots, worth more than lives of three servants in price.
Servants Hall: Servant’s Wing. Place of congregation for Staff House; sit & relax by fire during break, eat & play music on battered piano. Large table, chairs lines length of room. “Bell Board” w/ every upstairs room listed on it; each w/ their own bell, linked by clever pulley.
Butler’s Pantry: Servant’s Wing. Contains large desk, cupboard storing expensive silverware, & keys to House, wine pouring accouterments, & many other furnishings & fittings. Everything is always tasteful, & professional; even the stuffed fish & list of awards on the wall. Situated opposite Kitchen & alongside Housekeeper’s Sitting Room in the Servants' Wing.
Housekeeper’s Sitting Room: Servant’s Wing. Serves as Housekeeper’s Office; full of books & paperwork as well as small desk & swivel chair. Connected to small Housekeeper’s Bedroom; located next to the Butler’s Pantry in the Servant’s Wing.
Laundry: Basement. for washing loads of cloth generated by Estate. Large blue-ish stone cellar-room w/ tables, tubs, washboards, dry-lines for hanging. Of course entire place is moist & smells of soap/mildew, or filled w/ great billows of steam, depending on mood. (u/mr_earthman)
Gymnasium: Basement. Old timey barbells, medicine balls, & other implements of self-torture in the name of “health”. Room always reeks of cigar-sweat & sausage.
Sauna: Basement. Fiery Furnace, Hot Water Tank, & unholy mess of pipes & valves combine forces to create a steam-room sauna that can steam hams in just a blink should anything go awry. Some staff think there’s a poltergeist that writes things on mirrors, leaves blood everywhere - others doubt one exists, blame the blood on Estate Lords being.. “Oh so clumsy!”
Wine Cellar, Cheese Cave, & Tasting Room: Basement. Barrels & bottles gathering dust inside enormous, climate controlled, vaulted, brick-lined wine-cellar deep underground. Even deeper, perfectly climate controlled cheese-cave w/ cheddars older than most of Staff, just now achieving maximum ripeness! Includes medium sized tasting room, lit by lanterns (and recently, electric light from Galvanics). Secret entrance, perfect for clandestine rendezvous & intimate cult meetings. Secret exit to surface, good for villainous escapes.
Mad Laboratory: All sorts of creepy-crazy-unholy-weird in here. Scary experiments. Possibly long unused, at risk of catching fire any second now & burning whole place to ground. What are you doing w/ that match? Either located deep in basement, in secret dungeon in garden outbuilding, or in highest attic of furthest tower, in case of accidents.
Cozy Dungeon: Basement. Several cells, a vaulted torture chamber w/ flickering gas-lamp (also recently installed electric light from Galvanics), manacles, custom graffiti & wall scratches, etc. A Lord, three generations ago, had water piped in to have dankness adjustable, & to hose out cells whenever they got too filthy. Now mostly just used for illicit cult-sex-stuff & occasional dungeon-orgy. One wall is suspiciously bricked over, looks like it used to be another cell. Second wall has sconce that when pulled, reveals another secret entrance, for secret comings & goings.
Star Chamber: Basement. Every Estate needs an Occult Ritual Room for Cult meetings & such. 8- or 9-sided large underground room w/ polished marble terrazzo floor, polished marble walls, intricate design of clock face & zodiac motif on floor. Domed ceiling painted midnight blue, w/ magical pin-pricks of light to resemble stars in night sky. Pinpricks magically focus light on whoever is in room, so they glow & are lit, while giving illusion of everything being night around. Gold & Platinum magical braziers burn to represent sun, moons, levitate across ceiling in time w/ astronomy. V. special, v. mysterious. No less than 3 secret entrances, plus special dumb-waiter access, chair & table storage for multipurpose room.
"Family" Chapel: Small, single room w/ shrine, where house-staff & family practice religious devotions, away from prying eyes of yokels; who knows what dark deities Estate Lords worship?
Rooftop Observatory: Upstairs. Great domed contraption built into a tower; magnificent 360 degree view of sky. All sorts of equipment & charts strewn about benches crammed into this space, dominated by huge brass telescope. This behemoth, covered in all sorts of gears, cranks, & levers, can easily bring craters on Moon into focus, or... spy on midnight rendezvous in garden. In a place dedicated to the stars, what could possibly draw one's attention away from the heavens? (u/Longjumping_Piano55)
Local Chapel: Estate Grounds, Outbuilding, Church. Where yokels worship. Father Ted presides. Small brick structure w/ tile roof, seven pews, & small altar. Within sight of Manor-house, but far enough away to be "separate". Has small garden where Father Ted tries & fails to grow sweet-peas.
Vicar's Cottage: Estate Grounds, Outbuilding, Church. Even smaller than Gardener's Cottage, this one is at least still in repair. Father Ted lives here, Has but small bed & tiny desk to write sermons on.
Cemetery: Estate Grounds, Church, Cemetery. Small, lonely grave-site filled w/ locals from Village. Estate "lovingly" donated to Village Church by former Lord. Rusty mort-safes protect some of the remains.
Mausoleum: Estate Grounds, Outbuilding, Church, Cemetery. Imposing structure on grounds of Cemetery; may be connected to Underground Caverns & Ossuary. Occasionally haunted.
Widow Row: Estate Grounds, Outbuilding. When former staff families are retired, or die in service to Estate, their widows, children, & infirm elderly are offered small rooms in run-down worker's cottage-house that existed on site before even Grand Manor was built! Rooms barely bigger than a stall for horses in a stable have several family members crammed into them, but includes free use of tiny patch of garden. Hidden from Main House by wooded bit of hills & muddy track.
Mad Muckbang's Lab: Estate Grounds, Wilderness. Out near river on far estate edge; small cave w/ brambles growing over entrance. Inside, lab full of strange glass tubes & bubbling pots, liquids in thousand colors, & heavy cloying mist in the air. Alchemist & Inventor Finias Muckbang rents use of cave from the Nobles. Ignore occasional sound of explosions; possible entrance to Old Mines within.
Hermit's Shack: Estate Grounds, Gardens, Wilderness. Home of official Estate's Garden Hermit; resembles nothing more than few large stones & brush lean-to w/ tiny fire inside to keep warm. Out of the way part of Estate, but famously favorite destination for party-goers at former Lord's big shin-digs. Garden hermit gives guests fright; the Lord would enjoy themselves w/ their terror!
Rose Bush Labyrinth: Estate Grounds, Gardens. Wall of tall & sturdy rose bushes towers around exterior; suggests much the same inside. Plaque affixed by entrance to maze w/ message embossed: "To find your center, follow your heart." Hint to navigate labyrinth; always turning left leads you to center. Nearer you get to it, clearer the burbling, rippling sound of fountain that sits at heart of maze. (u/crimebiscuit)
Garden Fountain & Statues: Estate Grounds, Gardens. Statues or Ornamental Fountains throughout Gardens. Weeping Angels, Prancing Cherubim, Fanciful Animals, or Heroic/Historical Figures. Stone & Brass. Sometimes accompanied by water-feature.
Animated Topiary: Estate Grounds, Gardens. Large bushes trimmed to look like creatures, animated to patrol the garden-grounds.
False Gazebo: Estate Grounds, Gardens. Vine-covered gazebo oddly recessed without broad view their type usually affords. Stone cobbled floor, interior has moss extruding in strange geometrical, almost artificial shapes; might betray presence of subterranean level, cellar accessible through means not immediately evident. (u/crimebiscuit)
Stone Exedra: Estate Grounds, Gardens. Depressed semicircle in ground lined in fieldstone & tiles,; lichen covered limestone & granite benches. Old marble or granite columns, some toppled, decorate the semi circle. Little known, this area predated Estate by many centuries. Acoustics inside circle are excellent.
Tiled Stoa: Estate Grounds, Gardens, Ruin. Existing on site before construction of Manor; ancient weathered marble columns in Doric style, line black & white weathered marble tile walkway, covered w/ cracked earthenware roof tiles. Some columns & portions of roof left to collapse, artfully. From these spots, Gardener is apparently allowing wildflowers & vines to bloom.
Amphitheatre: Estate Grounds, Gardens. Small open-air stage built at bottom of gently sloping hill. Seating on the slope; audience looks down at stage. Mostly unused, apart from occasional travelling theatre troupes passing through... however if you go on moonlit nights, might just witness an otherworldly performance. Be warned though, it may not be to your taste... (u/Zawoopdoop)
Garden Ambulatory or Loggia: Estate Grounds, Gardens. Located few dozen yards away from Main House is rubble & freestone structure w/ stone slate roof, six bays of arched columns, flagstone lined arcade filled w/ comfortable looking wicker furniture. In crest of each arch, crude medallions of several different figures, now weathered & worn beyond easy recognition.
Old Treehouse: Estate Grounds, Gardens. Small hut in branches of reat oak, hideout of noble child long since grown up. Accessed via rope ladder; within shouting distance of manor, it's rather peaceful once inside. Wooden building, still holding strong, contains only simple chairs & table, tattered rug, some forgotten toys. Perhaps there is secret item hidden within - an old child-treasure, or someone else taking advantage of abandoned space. (u/Zawoopdoop)
Coin Tower: Estate Grounds, Gardens. Given fancy name, Folly guards one outer-entrance to Manor-grounds. Miniature castle tower, complete w/ battlements & arrow slit fortifications; only two stories tall. Metal-clad door w/ slot sized for gold-piece; place one piece inside & it locks main-gate to toy-tower via clever clockwork mechanism. Gate & anyone inside is locked in for 12 hours. Locking coin box on the inside holds deposited coins.
Dungeon of Wayward Toys: Estate Grounds, Gardens. Inside Garden Folly that looks like miniature castle tower; guards one outer-gate to the Manor, small alcove w/ rusted jail cell, palatially sized for several small creatures or v. cramped adult. The moldering remains of several stuffed animals & children's toys locked in or chained to the wall w/ rusty, miniature manacles... the toys have been long forgotten. Close inspection might reveal the mummified or skeletal remains of poor animal too.
Overgrown Polo Field: Estate Grounds, Gardens, Ruin. Off in a corner of the estate, long overgrown by woods & ivy. Tournaments held here regularly some one or two generations ago but the sport's popularity decreased, & so did this once well manicured plot's use. It is rumored that the field is inhabited by feral polo horses left in the stables to rot & anyone who enters the green must be ready to face their wrath! (u/Win5get1free)
Trucco-ground & Terrace Estate Grounds, Gardens. Soft green square for leisurely form of ground billiards played w/ heavy balls; brilliant beds & borders of small brick-walled gardens, gray flags of great terrace; rows of little orange trees, once heavy w/ flower & fruit, set in blue delft-ware tubs; now cracked and dying. Oriented to catch the last light of sun & remain warm in early evening. Lit at night during parties by great copper braziers & torches. Big Portugal Laurel grows in the back corner, conceals secret entry into the house.
Decrepit Mews: Estate Grounds, Wilderness, Ruin. Just beyond estate-walls, still within the watchful, downcast eyes of smoke-stained windows; a modest hillock. In days past affluent gentlemen of the Manor took fancy to falconry, doting on birds like dearest children. In those days the mews was fine building constructed mostly of wood & wire mesh cage; playfully built miniature clone of the larger estate. Time has lain itself upon the estate like a smothering blanket; little remains of this once proud roost. One of the walls has rotted through, eaten away by termites until the whole of the tiny house sagged to the side, a precarious arrangement of warped wood & bending metal. The falcons are gone, replaced by the occasional dirt-feathered barn owl or nest of starlings. (u/Knightheart777)
Ye Olde Dovecote: Estate Grounds, Ruin; Back in the day, one of the Estate Lords decided they liked the taste of roast pigeon & doves, as well as using them as reliable message carriers, they decided to breed them. Homing, Roasted, Boiled, Baked, & Stewed; the dovecote was the home-roost of these flexible multi-purpose birds. Now-a-days, chicken & pheasant is tastier, & the roost is in disarray; feral pigeons infest the place like winged rats!
Wind-Swept Sea-Cliff: Estate Grounds, Wilderness. Battered by waves, where else will forlorn lovers throw themselves to their doom?
Wrack & Ruin: Estate Grounds, Wilderness. Wave wracked sea-cliffs at base of Manor; brutal & often site of beached wreckage & powerful currents. Who knows what poor soul has met demise here?
Common Pasture: Estate Grounds, Wilderness. Vast, rolling field of un-farmed grasslands & moors; nearby villagers pasture animals for small fees to Estate. Sheep are common, as is occasional howl of a spectral & terrifying black hound at night!
Wheal & Woe: Estate Grounds, Wilderness, Ruins; Ancient coal or tin & copper-mine sprawls beneath Estate. Don't fall into one of many unmarked, open shafts or pits! Known Hazard, scary.
Old Pumphouse Engine: Infrastructure, Ruins; Rusting clockwork & steam powered pump-engine w/ tall brick chimney; maybe powers Estate, or maybe used to pump out Old Mines beneath, if it can be made working again. Ghosts of several rage-filled engineers no-doubt guard it; must be exorcised before repairs begun.
Oak Forest: Estate Grounds, Wilderness. Where bulk of Estate’s wood comes from. Home to wild boar & truffles; also a well groomed section w/ lone-giant tree, twelve foot trunk; stone benches & small swing.
Common Right of Way: Estate Grounds. Locals are still furious Old Lord enclosed Right of Way; posted “No Trespass” on old trail that runs thru Estate & Oak Forest; short journey to Mines & Coast is now made longer by several miles!
Game-keeper’s Shack: Estate Grounds, Outbuilding, Ruin. Built in hidden ravine, deep in Oak Forest. Shack built on huge fallen log; straddles small but swift flowing stream. Also here: decrepit smoke-house, abandoned kennel for hunting hounds, & vacant, rotting butchery. Rotten animal hides hang on rusty hooks inside, literally every surface coated by thick layer of sprayed blood, gore, & viscera. No clue if it is human-blood, it is gory nonetheless.
A River Runs Thru It: Estate Grounds, Wilderness. Fast flowing brook, w/ gravel, & large rocks perfect for trout, salmon, etc. Just deep & wide enough for small boats or canoe to navigate it, out to sea. Several small ponds connect, including one large pond from Old Abandoned Mill. Sportsman’s Paradise.
Old Abandoned Mill & Bridge: Estate Grounds, Wilderness, Outbuilding. Used by villagers, large mill-pond, spillway dam from Old Mill, & Bridge. Pond is several dozen acres, near Commons; large enough for locals to boat on, even fish when given permission by Lord. Mill has seized, hasn’t been repaired for three generations. Bridge across Spillway is stone w/ several arches. Children play games by dropping sticks off one side, racing them to the other. V. Scenic.
Lonely Sea Wall: Estate Grounds, Outbuilding, Wilderness, Infrastructure. Long wall blunts majority of sea's rage; protects v. small harbor, dock, & boathouse. At end of brick & stone structure, former estate owner installed an ever-burning torch & large brass bell. When wind blows strongly, bell rings by itself. No doubt several former estate owner's family have been brought to sad end here.
Groundskeeper's Shed: Estate Grounds, Outbuilding, Infrastructure; filled w/ rusty tools & pots for wintering plants. Rusty nails & hooks, no doubt able to give one tetanus, simply by looking too long at them.
Old Courtyard Wellhouse: Estate Grounds, Outbuilding, Infrastructure. 100 feet of dark, dangerous shaft down to water table; in disrepair, unused for years, & possibly poisoned. Hidden cavern connected to who-knows-where. Large covered house w/ locked iron gate protects pulley; keeps fools from falling in.
New Wellhouse: Estate Grounds, Outbuilding, Infrastructure. Provides fresh water for Estate, w/ aqueduct & pump to rest of village too. Clockwork or wind-powered. Brand new, 100 years ago! Up on hill in copse of trees behind House. Probably not poisoned.
Great Oven: Estate Grounds, Servant’s Wing, Gardens, Infrastructure. Fire-brick, the size of a building; detached from House because of prodigious heat, w/ small awning to keep out rain. Large enough to cremate bodies, it has several openings. Used by Estate daily; bread & baked goods. Privileged members of Village who charm Chief Cook may use.
Hot Water Cistern: Infrastructure. Made of wood & iron, several thousand gallons of boiling hot water, in Attic, kept at temperature by Fiery Furnace in Basement below. At least one servant's children, playing around, have fallen in & boiled themselves to death over last 100 years. Occasionally leaks onto Servant's Quarters one or two levels below.
Galvanic Array: Infrastructure. New-fangled Storage Battery, charged via generator or magic. Used to provide power to House, or for current/former Lord's magical or scientific experiments. Serious risk of electrocution; pay no attention to creepy hunchback.
Garden Privy: Infrastructure. Gardeners & groundskeepers have to go somewhere, you know. They say that 3rd Earl's grandfather was brutally murdered & unceremoniously buried in muck here, a hundred years ago, their ghost still haunts it!
Enclosed Kailyaird: Servant’s Wing, Estate Grounds, Gardens. Don't let Gardener touch the Turnips. Chief Cook of Manor has claimed enclosed garden behind Kitchens as their own secondary kingdom. Whatever they grow there is incorporated in fine cooking Kitchens produce. Some kitchen staff are convinced several foolish scullery maids have been murdered & buried in back, as fertilizer.
Sewer Catchment: Infrastructure. “We all Float Down Here, Georgie”. Miles of rain-gutters, sink-drains, & indoor plumbing connect here. All that water from laundry’s got to go somewhere; into huge vaulted timber, stone, & iron septic tank underground before percolating into ground-water. Something has stashed at least 150gp of treasure inside.
Fiery Furnace: Infrastructure; burns copious amounts of fuel, provides steam-heat for estate. Connected to coal-chute, wood-storage area, or fuel-tank filled w/ bunker-fuel. Infrastructure.
Dumb-waiter: Infrastructure. One of several, also chute for Laundry. Used for sending food & drink up & down from stores, cellar, kitchen, etc. Not an elevator, but staff & drunken partiers often use it as such, occasionally get stuck, become laughingstocks.
Chief Cook: Overly portly, overly fond of pepper, loud & runs Kitchens like some sort of hyper-militant dictator. Could have even served in military in past.
Wheeze the Lost Groundskeeper: just like the polo field, a young groundskeeper who manicured the pitch was left behind. "We'll be back after a quick lunch!" They said, "just trim sidelines & clean the bleachers please!" & so he did... for decades. They never came back; his tools rusted long ago. His name is long forgotten; grasp on common language tenuous at best. Only companions feral equines that roam this place; they too know what it's like to be abandoned like so many playthings. He is one of them, one of them now, more horse than man, some might say. (u/Win5get1free)
Garden Hermit: Crazed guy who, for some reason, lives in shack in secluded area of Estate, & is never bothered. Hermit never leaves place, or holds conversation w/ anyone for at least the last seven years! During that time they've neither washed, nor cleansed themselves in any way whatsoever, letting their hair & nails on hands & feet, grow as long as nature permits them. Used to be a hit at fancy parties, when previous Lord would show them off to party-guests as a prank!
Eldritch Hobb: Pile of filthy rags in corner of Laundry. Laundry Urchin steers well clear of it & & any drainage catchments, complaining of “red eyes glowing” & alternatively “face of dead sibling”, “red balloon filled w/ blood”, or “harlequin w/ painted face”. IT has taste for nicking shiny jewelry, there is well over 150gp worth in catchment, & Lady of House’s prized earrings were found hidden under pile of rags, years ago; footman was blamed for it & sacked. (u/mr_earthman)
Mad Muckbang: Finias Arquist Muckbang is youngest son of Knight that had been in the Lord's service decades ago. No one bothers him much these days. Alchemist & Inventor, rents use of cave on the Estate for sometimes dangerous experiments. (OwenMcCauley)
Father Ted: Local priest, lives in Vicar's Cottage. Secretly views this posting as punishment for misusing church funds, although such knowledge isn't widely known.
Game-keeper: Ghost particularly reported around Old Vegetable Garden; elderly gentleman in old-fashioned clothing carrying flintlock or blunderbuss; seen late in evening during October; vanishes if approached. Linked to Gamekeeper wrongly executed for murder of a servant to former Lord.
Gardener Wyllet: Getting on in years, losing their sight, hearing, & barely able to swing scythe or turn hoe in order to keep Grounds from turning to weeds; still has knack for finding & tending to medicinal herbs. Mostly found in Gardener's cottage these days.
Laundress & Urchin: Short, powerful, arms likely to bend steel bars, & fists like iron. Shrill voice & accent that can peel paint. Skin & face red & peeling from caustic soda, she’s only 24, but “ain’t got time for suitors or no guff like that -- she has Laundry book to finish before sunset, thank you very much.” She, her 10 yr old urchin cousin, & whatever housestaff she can wrangle away from other duties, crew Laundry from dawn till dusk; for only 25p/day plus food & lodgings in Manor. Urchin is somehow terrified of pile of filthy rags in corner & walks well clear of drains & catchments, foolishly complaining of glowing red eyes within.
Lost Maiden: Haunts Estate; often spotted standing alone in corridors, rooms, or wherever w/ a confused look upon her face. Wears fine, but dated, gown w/ silver lacing. Sometimes only seen in corner of one's eye, other times right in view. However; whenever anyone tries to communicate w/ her, she steps out of sight & is gone! It is said that on occasion, she may look right at you. When she does, you suddenly find yourself, too, lost for just moment before World seems to bounce back into place. (u/Rigaudon21)
Nurse Trunchible: Nasty, strict, & hates children. Doses laudanum & arsenic to get 'em to sleep & to keep that healthy waxy pallor. Sleeps in set of v. small rooms off Nursery & Children's Quarters. Has feud going w/ Head Housekeeper or Butler.
The Twins: Pair of gangly youths, one deaf, one mute; children of an Estate Widow. Rapidly outgrown their rough clothes; aim to serve Estate, in order to survive. Live in Widow Row.
Younger Wyllet: Gardener's niece or nephew. Too young to do much work, even though they try to take up slack for far-too-old-to-be-working relative, Gardener. V. precocious; studying herbology & plans to be master arborist one day. When they aren't trying to weed garden, can be found in Gardener's Cottage.
Unfortunate Son: “Deformed”, or “Mad” Lunatic trapped up in the Attic Garret. “Fresh” slop bucket twice a week. Chained, or straight-jacketed, and basically ignored.
Lupine Publishers | Water Quality Assessment in Sindh, Pakistan: A Review
Lupine Publishers | Open Access Journal of Environmental and Soil Sciences Abstract Increasing detrimental impacts of water pollution on environment and serious health issues, this review aims to investigate water quality status of Sindh, Pakistan.it also help us to determine current and future water demand of the province as well as adverse impact on human health in regards with water borne disease. To conclude, some recommendations are also outlined. Keywords: Water borne disease; Quality assessment; Water supply; Water contamination; Sindh; Pakistan Introduction Although surplus amount of water is available on the planet of earth, but only small portion is available for human utilization. Overall population wholly depend upon the water sources mainly consist on groundwater and surface water. Currently, countries around the world are facing water pollution as well as water scarcity problems. Following the report of UN, the total populace increases exponentially while accessibility of water decline with time. WHO announced that by 2025, half of the total populace will live in water-stressed zones? Unfortunately, water pollution stresses the remaining small portion. During last decades, Urbanization and industrialization further added burden on water resources around the globe. Quality of water around the world has been deteriorated with chemicals discharged into water bodies directly and improper dumping of solid waste. According to Joint Monitoring Programme (JMP) report 2017 on “Progress on drinking water, sanitation and hygiene” 2.1 billion people lack access to safe drinking water at home. Globally, 448 million lack to have basic drinking water services from which 159 million individuals are those who rely upon surface water. According to speech of UNO secretory on world water day 2002, each year 5 million people died of water disease i.e.10 times more than people died in war. Furthermore, several studies have documented various contaminants such as organic (Pesticides), inorganic (heavy metals), minerals (arsenic and chromium) and microbial (pathogens) are responsible for water pollution. Recently, water contaminated with arsenic has been documented around the world, especially in Asian countries including Pakistan, Bangladesh, India, Cambodia, Vietnam, China, Taiwan, Hungary, Chile and Argentina [1-4]. Pakistan has been blessed by natural resources i.e. surface as well as groundwater resources. Sudden rise in population, industrialization and urbanization have brought huge stress on water resources of country. The country once has surplus amount of water is not including in water stressed zone. Most of the population belong to different cities of country rely upon groundwater for survival. While, current water supply is about 79% in Pakistan. Pakistan has experienced six noteworthy floods between 2000- 2015, which killed many people and posed negative impact on groundwater through salinization CRED [5]. Furthermore, Per capita availability of water has been decreased from 5,600 cubic meters in 1947 to 1,038 cubic meters in 2010. It is expected to decrease further to 575 cubic feet in 2050 [6,7]. In addition to this, quality of water resources has been declined due to intermixing of municipal sewage with water supply line and direct release of industrial wastewater into water bodies. Pollutants such as heavy metals, pathogens and other dangerous chemicals have been found in different regions of the country. Only 20% of the population have accessibility to safe drinking water while 80% is compelled to consume unsafe water for drinking. Each year 2.5 million deaths from endemic diarrheal disease has been reported [8-13]. Pakistan ranks 80th, out of 122 nations of the world, on the basis of water quality [14-16]. According to a Worldwide Fund for Nature (WWF) report titled, “Pakistan’s Waters at Risk”20-40% health centers are filled with the patients of water borne disease which include diarrhea, gastroenteritis, typhoid, cryptosporidium infections, giardiasis intestinal worms, and some strains of hepatitis [17]. Quality of drinking water in Sindh province is unfit like other provinces of Pakistan. Large portion of water available is contaminated with pathogens, chemicals and toxic materials. Several studies have documented that the four major contaminants are responsible for water quality deterioration in Sindh i.e.69% bacteria, 24% arsenic, 14% nitrate and 5% fluoride. According to the report of Inquiry commission appointed by Supreme Court of Pakistan “78.1 % of all water sample tested were found unsafe for drinking”. The aim of this review is to analyses the status of water quality in different divisions of Sindh, Pakistan. It also describes the impacts of water quality on human health as well as outline some recommendations. Study Area Sindh is second most populated province (Figure 1) with population of 30.44 million situated in south-eastern part of Pakistan. It is stretched from 66°8’ East Longitude to 71°, lies between 24°4›N to 28°7’N and covers about 46,569 miles2 . Province is bounded by the Thar Desert to east, the Kirthar Mountains to the west, and the Arabian Sea in the south. It is divided into six divisions namely Karachi, Hyderabad, Sukkur, Shaheed Benazirabad, Mirpurkhas and Larkana. Karachi i.e. the capital of Sindh province ranked at the top with 14.91 million and Hyderabad ranked the 8th most populated with 1.73 million population among the list of 10 most populated cities of Pakistan. Large number of populations of the province depend upon the fresh water for domestic and irrigation purpose. Indus basin is the major source of water provision in the area. In Sindh Province, only 10 % of land area had availability of fresh groundwater and occurs in shallow aquifers [18]. Following high average annual temperatures, semi-arid climate, sea water intrusion and high rate of evapotranspiration shallow aquifers are highly saline [19]. Irrigated land i.e. almost 78% of the province rely on saline groundwater which is not fit for irrigation. As the ground water is saline in most areas, rural population is also depending on supplies from the canal system. According to the survey conducted by Pakistan Council of Research in Water Resources (PCRWR) in 22 districts of Sindh province out of 1247 surveyed water supply schemes only 529 (42%) were functional with average duration supply of 5 hrs/day. From which only 25% water samples were fit for drinking while remaining are contaminated with microorganisms and arsenic. Current Demand and Future Requirement of Sindh In next 20 years, Province will undergo demographic change. Current population of 33 million is expected to increase to 52.6 million and urbanization will increase from 50% to 64% in 2025. Currently, Karachi’s demand for water supply is about 1,220 MGD against which has an allocation of 34,000 l/s (1,200 cusecs) from the Indus water which is expected to increase 65,460 l/s (2,320 cusecs), with increased population to about 23 million in 2025. Likewise, water demand for other urban cities will also increase which will put burden on water resources. In addition to this, rural population of about 18.8 million will need an additional about 7,125 l/s (250 cusecs) for drinking purposes. Hence, total municipal water requirement of the province in 2025 will be of the order of 94,000 l/s (about 3.300 cusecs). Besides municipal water requirement, water requirements for agriculture would also increase by about 50%. Current water use is about 52.6 Bm3 (42.6 MAF) which means an additional 26.3 Bm3 (about 21.3 MAF) required to meet the future demand of agriculture products (FAO). Water Quality Alarming increase in population is the single important driving force affecting the water sector and cause water scarcity problem in the province. Water pollution is another major problem which is deteriorating the quality of remaining small portion of water. According to Director General of Sindh Environmental Agency Baqa Ullah Unar “every day almost 500 million gallons of industrial waste and human consumption falls into Arabian Sea”. 80% samples from 14 different districts of Sindh are not safe for drinking as well as 78% of water used in hospitals is above standard limits. 90% of water had bacterial contamination and not fit for drinking in Karachi only (PCRWR). Several studies have been conducted in different cities of Sindh, Pakistan (Table 1) [20-29]. Abdul Hussain Shar [30] analysed the samples from Rohri for the presence of total coliform (TC), E. coli (Ec) and heterotrophic plate count (HPC) which result the contamination of all samples with TC (100%), Ec (41.6%) and with HPC (100%). In Hyderabad bacteriological tests on drinking water has been conducted by PCRWR found that 15 monitored sources as unfit for drinking mainly due to bacteriological contamination (93pc), excessive levels of iron (47pc) and turbidity (93pc). Mashiatullah [31] carried out a study on Malir and Lyari rivers, he analysed different Physiochemical and biological parameters. The coliform contamination i.e.156-542 per 100 ml in high tide and 132- 974 per 100 ml in low tide were observed which exceeded WHO guidelines. Aziz et al. [32] reported a study for drinking water quality in Pakistan including both urban and rural areas which results that total coliform and fecal coliform were 150–2400/100 ml and 15–460/100 ml respectively. The investigation reported the presence of anthropogenic activities which resulted. Mahmood et al. [33] measured the physical, chemical and microbiological parameters for the different groundwater samples collected from Thatta in pre-monsoon and post-monsoon seasons, respectively. It was observed that concentration of heavy metals were; As (0.0045 to 0.0055 mg/l), Cd (0.15-0.22 mg/L), Zn (0.040 to 0.046 mg/l), Pb (1.40-1.49 mg/l) and Cu (0.001- 0.87 mg/L) in both the seasons and were in order of Pb > Cu > Cd > Zn > As in premonsoon and Pb> Cd > Cu > Zn > As in post- monsoon respectively. Other parameters Electrical conductivity (233-987 μs/cm), pH (6.9-8.9), TDS (161.1-690.9 ppm), Temperature (24-33°C), chloride (81.79-131.78 ppm), total hardness as CaCO3 (124.40-188.81 ppm), nitrate (2.10-5.20 ppm) were within prescribed standard limits. Some common diseases were found to be nausea, vomiting and kidney damage. Suresh Kumar Panjwani [34] collected Thirty-five groundwater samples and analysed for 22 different parameters including physicochemical parameters and bacteriological contamination. Three drinking water samples (9%) contain Fluoride as 1.83 mg/l to 0.44 mg/l which exceeds WHO limits. Two water samples (5%) were contaminated with nitrate–nitrogen i.e. 23.61 mg/l to 0.97 mg/l. (45%) 16 water samples were contaminated with E. coli ranges from 01-too numerous to count CFU/ml exceeding the prescribed limit by WHO (0/100ml). None of the drinking water samples (0%) were found bacteriological safe for drinking purpose. In 2014, another study examined water quality in Thatta, Karachi and Hyderabad found presence of heavy metals that exceeded the WHO drinking water guidelines [35]. Outbreak of Water Borne Disease Improper treatment and dumping of waste in water bodies accounted for rise in water borne disease. Deteriorated quality of water in Sindh province had badly affected the human health. More than 20,000 children die annually in Karachi only, from which majority of deaths caused by drinking contaminated water. Outbreak of water borne disease have been noticed in different parts of Sindh including typhoid, cholera and diarrhea. According to Zahid J [36] areas surrounded by poor households, children with mothers married in early ages, children having small size at birth and ages less than 24 months and children belonging to uneducated mothers are found most vulnerable where prevalence of diarrhea found non-ignorable. In Sindh, Tando Allahyar (46%), Matiati (50%), Hyderabad(44%), Badin (40%), Mirpur Khas (40%) Karachi East (40%) and Karachi South (52%) have highest rate of cases while lowest rate found in children from rich house holds’ of Larakana (6%) and Jacobabad (8%). In some areas including Gadap, Kathore and coastal areas 30-35% of people have been found infected with viral hepatitis. While 20-25% of the population is infected with the deadly viral disease said by Dr Shahid Ahmed, consultant gastroenterologist and patron of the PGLDS on World Digestive Health Day 2018 (WDHD 18). Recently, a drug-resistant typhoid strain identified first in Hyderabad, spread from the city to various parts of the country. 5,274 cases of XDR typhoid have been reported by Provincial Disease Surveillance and Response Unit (PDSRU) from 1 November 2016 through 9 December 2018.69 % (3658) of cases were reported in Karachi only, following 27% (1405) in Hyderabad, and 4% (211) in other districts of the province. On 9th July 2017, outbreak of acute watery diarrhea and abdominal pain in village Mir Khan Otho, District Shaheed Benazirabad were reported to the DG Health Office Sindh in Hyderabad. A total of 30 cases were identified (22 through active case finding) and n=16 (53.7%) were females. Mean age was 25.3 years (range: 1-50 years). Overall attack rate was 23%. People aged 21-30 years were the most affected (n=10; AR 43.5%). Apart from diarrhea, abdominal cramps (n=28; 93%) was the most common symptom. On bivariate analysis, consumption of water from the hand-pump near the swamp was significantly associated with the disease (OR=8.4, 95% CI: 3.1-22.7) [37]. In 2016, 22,000children have been hospitalized and more than 190 have died in Tharparkar district due to drought-related waterborne and viral diseases. According to the Joint UN Needs Assessment, water scarcity has been severely affected several districts (62% in Jamshoro and 100% in Tharparkar) which resulted in reduced harvest by 34-53% and livestock by 48% UNICEF [38]. According to local media, the total under- 5 deaths were rising from 173 in 2011, 188 in 2012, 234 in 2013, 326 in 2014, and 398 in 2015. According to the provincial health secretary, 450 children lost their lives in 2017, 479 died in 2016 and 398 in 2015 while reasons for the deaths vary. Furthermore, According to authorities in Tharparkar district, Sindh province, 99 children and 67 adults (43 men and 24 women) have reportedly died in Tharparkar since the beginning of 2014 as well as an outbreak of sheep pox occurred which has killed thousands of small animals (Pakistan: Drought - 2014-2017) [39]. Furthermore, three months after floods began in Pakistan, 99 cases of cholera were reported from across the floodaffected areas of the country (WHO). In 1994, first ever case of dengue has been reported in Pakistan, sudden rise in cases first occurred in Karachi in November 2005. Since 2010, Pakistan has been encountering dengue fever that has caused 16 580 affirmed cases and 257 deaths in Lahore only also about 5000 cases and 60 death confirmed from other parts of the country (WHO) [40]. The three provinces have faced the epidemic are Khyber Pakhtunkhwa, Punjab and Sindh. In Sindh province, 2088 dengue positive cases had been reported as well as two people had died of dengue in Karachi city in 2018. Currently, according to the weekly report issued by Prevention and Control Programmed for Dengue (PCPD) in Sindh, from January 1 to January 7, 2019 a total of 38 dengue positive cases were detected. From which 36 were reported in Karachi only while two were in other districts of Sindh (PPI). Contamination Sources Climate Change For water resources, climate change is a long term and unmitigated risk. Water demands is expected to increase up by 5 percent to 15 percent by 2047 due to climatic change. In the upper Indus Basin, climate change will increase the risk of flood outbreak by accelerate glacial melting while in the lower Indus Basin, sea level rise and increases intensity of coastal storms also exacerbate seawater intrusion into the delta and into coastal groundwater. Furthermore, in coastal Sindh, groundwater quality will further be deteriorated and also impact the ecosystems, and irrigation productivity of the province. In addition to this, Sediment dynamics in the Indus sourcing, transport, and deposition have been significantly altered by water resources development. Past floods in Pakistan not only posed physical damage but also affected human lives in terms of flood-related death and illness as well as clean water and sanitation facilities. The flood destroyed 54.8% of homes and caused 86.8% households to move, with 46.9% living in an IDP camp. Lack of electricity increased from 18.8% to 32.9% (p = 0.000), lack of toilet facilities from 29.0% to 40.4% (p=0.000). Access to protected water remained unchanged (96.8%); however, the sources changed (p=0.000) [41]. Since 2013, Tharparkar has been influenced by a drought‐like circumstance affecting employments, nourishment and wellbeing conditions. In south-eastern Sindh, low rain fall throughout 2016 in districts including Tharparkar, Umerkot and Sanghar sharply reduced the cereal production also causes loss of small animals due to diseases and severe shortages of fodder and water. Moreover, it has aggravated food insecurity and caused acute malnutrition [42]. Poor Water Supply and Sanitation USAID reported that in Pakistan about 60% of the total number of child mortality cases are caused by water and sanitation-related diseases. Pakistan Strategic Environmental Assessment of the World Bank, 2006 stated that about 2,000 mgd of wastewater is discharged to surface water bodies in Pakistan. 13,000 tons of municipal waste daily generated in Karachi only, following 3,581 in Hyderabad while 48 million tons a year around the country. Water and sanitation sector have the highest financial cost to Pakistan from environmental degradation at Rs112bn a year as reported by WB. This is based on health cost of only diarrhea and typhoid and accounts for 1.81 per cent of the GDP. While figures for Sindh are not available. According to the media (The news) “More than 50 per cent of the people were suffering from diseases related to water and sanitation due to the lack of proper sanitation in the Sindh province” speakers told on‘ World Toilet Day with the 2018 theme ‘Toilets and Nature, the Pathway to Neat and Clean Sindh’. In Karachi, 42 percent of the city’s total population have no access to a proper toilet and appropriate sanitation system and live in 539 slums. Furthermore, Karachi Metropolitan Corporation and Cantonment boards have public toilets at only 13 places. Poor Water Management According to Rubina Jaffri, the general manager of Health and Nutrition Development Society (Hands), only 440 MGD is being filtered out of 640 MGD of water supplied to Karachiat seven filtration plants. A recent survey accounted that 40% water samples collected from different parts of Karachi were not properly chlorinated. In Karachi, long transmission route also causes leakages and water thefts problems which account for the loss of almost 30% of the city’s water supply, said by Jawed Shamim, former chief engineer at KWSB (The Karachi Water and Sewerage Board).Moreover, Parallel water supply and sewage pipes currently lead to cross contamination and corrosion. Chief Minister Syed Murad Ali Shah, in Sindh there were 2,109 water filtration plants, including 1,620 RO plants, and 818 of them were non-functional. He also added that there were 5,091 water supply and drainage schemes and 2,494 of them were non-functional and 244 of them had been abandoned (PPI). Agriculture sector consumes up to 90% of the available fresh water of the country. About 70% of the canal water is lost from river to the end user. The larger portion of canal water (35%) is wasted at field level which needs proper attention of the policy makers. furthermore, 30 MAF is equal to 10 trillion gallons which can feed a population of more than 500 million people has been dumped into Arabian sea instead of storage. Problem is the absence of efficient conservation, storage and usage of water [43-50]. Recommendations a) Basic filtrations units and 24 hours water quality monitoring stations should be established b) Proper usage, efficient storage and conservation strategies are utmost practices to deal with water scarcity problem c) Rearranging of water supply line to deal mixing of municipal sewage into water supply d) Latest and technical irrigation strategies to use water efficiently such as drip irrigation and sprinkling. e) Proper waste management system and treatment of industrial effluent should strictly implement f) Institutional capacity management in order to operate and maintain the water supply schemes g) Proper design of water distribution network to deal with the water loss. h) Education on the water conservation and utilization practice should be provided to people by arranging seminars and utilizing media i) Water thief and corrupted people should be deal according to law and regulations j) Construction of new water reservoirs and proper check in balance on old ones to enhance storage capability by resolving siltation problem k) Encouragement of new polices and proper implementation as well as check in balance l) Awareness campaign should be encouraged about water quality and water borne disease m) Basic health care and relief facilities should be provided at doorsteps when needed to reduce death related to water borne disease n) Involvement of community to reduce water pollution by providing basic knowledge and changing lifestyle. o) Proper check in balance on water filtration plants to provide safe drinking water to communities. p) Mitigation strategies to improve the response to climate change-induced effects on health and agriculture Conclusion Conclusively, water quality status of Sindh Pakistan has been reviewed. Most of the water in different areas of the province is contaminated with bacteria which causes outbreak of waterborne disease including, diarrhea, cholera, hepatitis and typhoid in many cities and caused millions of deaths simultaneously. Arsenic is the second hazardous chemical found in water of Sindh mostly in coastal areas. Fluoride and nitrite are other metal which pose threat to human lives in Sindh Pakistan. Thus, many policies have been established and many schemes were organized by provincial government to deal with the water crisis but still some gaps related to implementation exist that needs to be executed. Moreover, new reservoirs and flow distribution line should be constructed to deal with water scarcity and water loss problem of the province. https://lupinepublishers.com/environmental-soil-science-journal/pdf/OAJESS.MS.ID.000156.pdf https://lupinepublishers.com/environmental-soil-science-journal/fulltext/water-quality-assessment-in-sindh-pakistan-a-review.ID.000156.php For more Lupine Publishers Open Access Journals Please visit our website: https://lupinepublishersgroup.com/ For more Open Access Journal on Environmental and Soil Sciences articles Please Click Here: https://lupinepublishers.com/environmental-soil-science-journal/ To Know More About Open Access Publishers Please Click on Lupine Publishers Follow on Twitter : https://twitter.com/lupine_online Follow on Blogger : https://lupinepublishers.blogspot.com/
NeXus Cafe, Chicago, IL Friday, July 11th “Calm down, everyone!” Shaun Sr. shouted over the almost two-hundred people crowded around the cafe’s lounge. “After creating your character, make sure you find Jonathon, Jr. or Julie. We will try and organize everyone as fast as possible for the various tasks once we know what we’re dealing with. If you’re not going to be a team player, please leave now. I have a waitlist of those who are biting at the bit to play Outbreak with our group.” Shaun Sr. said in a lower voice once everyone got quiet. The NeXus FIVR cafe was a hive of excitement. In less than an hour, they would be logging into Outbreak. Everyone would be playing for twenty-four-hours inside Outbreak during each eight-hour session every night. The new upgrades Shaun had installed into their now hundred-ninety-two capsules would allow everyone to experience the full spectrum of senses in their games, as well as experience the time compression technology available in Outbreak. Shaun Sr. had set up a signup list for Outbreak on the cafe’s intranet. Everyone currently here had opted to prepay a week’s time in advance to join the group. The only exceptions were the chippers who had their Neurolink Delve Implant already. The chippers would be using cots to sleep while they delved into Outbreak. Shattered Helix had hinted at rewards for the winning groups in each of the fifty regions, getting everyone in the cafe excited to be the group who won. They would be one of the larger groups getting organized for Outbreak. They made sure to tell everyone in the Chicagoland area that if they wanted to join them, they could. The stipulation was they had to get to their base from where they would spawn in and follow their rules. [I’m still upset that I can’t play with you, Kyle. I can’t even log into Fantasy while you’re in Outbreak. I was hoping to teach Than’ro my Fast-Ball Special before we logged in and started traveling north.] “Yea, I can understand your frustration, Bob. You never know what they’re going to do with the game. I mean, there aren’t many AIs right now who can say they play games.” [You're correct.I’ll be here if you need my help.] Everyone in the cafe sat around talking and guessing what would happen when they finally logged into Outbreak. The time slowly crawled forward until it was five minutes to launch. The assembled players then finished talking, eating, and drinking before heading to their assigned capsule for the evening. Shaun Sr. and Jr. helped everyone into their pods, ensuring everything worked for each user. With the help of Terica, father and son settled into their capsules. She would be the sole attendant for the cafe every night, as Terica wanted nothing to do with zombies. Kyle McCoy, and the five who had their delve chips, went into the back office to get comfortable on the provided cots. Laying his head on the pillow and kicking his shoes off, Kyle mentally initiated his delve, bringing him to his MicroWorld. Not seeing the new monolith under his pavilion, he walked into his Japanese style modern house and found his AI, an orange and white Persian cat sitting on the couch watching Stargate SG-1 and eating popcorn. “I don’t think anyone would believe me if I told them my AI spends all of his time watching TV inside my MicroWorld.” Bob, the cat, looked over at Kyle, now Flea the Gnome, and shrugged, causing the Gnome to laugh. “Well, you enjoy your TV. I’m going to go murder me some zombies.” Flea walked back out onto his massive deck and over to the pavilion. The Gnome had to wait just another minute before a large grey monolith materialized next to Fantasy’s shiny-black standing stone. Walking up to it, he could see what looked like hundreds of cracks in the grey stone, with some of the corners missing and chipped. Carved into the stone’s center above the dark red door was the word Outbreak, with what looked like neon yellow liquid dripping from a couple of the letters. Flea tentatively reached for the door handle, opened it, and walked through. Coming to the other side, he found himself immediately growing back into his human form. Looking around, the bright white room he found himself in seemed to be a padded room for people with mental health conditions. To his right was a single tall mirror. Kyle also noticed there was no exit door in the room. Well, I guess they have a thing for mirrors for their character creation. Walking over to the mirror, Kyle was not surprised to see himself in it. Tapping its surface, he found it was, in fact, the character’s customization system. At first, he was surprised to find he could only change the hair on his head and face. It soon occurred to him; Shattered Helix wanted people to play as themselves for this game. Kyle decided to keep everything the same except dying his hair a royal purple. Kyle sat with his back against the padded wall and waited for the remaining twenty-eight minutes to tick away. Shaun Sr. said everyone had thirty minutes to finish their characters’ customization, and much to his chagrin, it took him less than two. As the time finally hit the thirty-minute mark, the mirror changed into a door and opened into a bright light. “And away we go!” Kyle stepped into the light and found himself in the park behind the cafe. Looking around, he was shocked at how the game looked so much like the real world. Of course, the one big difference was the city of Chicago was dead. The usual sounds of the city couldn’t be heard around him. It was an eerie experience. Before he could ponder more on the subject, someone materialized fifty feet in front of him and then immediately another fifty feet to his right. Looking around now, Kyle recognized most of the people porting in were players from the cafe. One of them began to run towards the back of the cafe, and people started to follow. Five minutes later, many of the players were now inside the NeXus. The inside itself looked nothing like Kyle had expected it to be. Instead, the walls were a plain light grey, with no furniture and none of the capsules or other hardware. The entire building was just an open space. “Oh my god. Everyone, come outside and look!” someone yelled. Following the mass of players outside, Kyle looked up to where people were pointing. Most of the eastern sky was dominated by a large planet. Some smaller planets also dotted the heavens. “Is that Mea?” someone said behind Kyle. “Is this the Earth they showed in the Fantasy trailer?” another person asked. That would be a safe bet. Kyle thought. The group sat around talking. No one could see any zombies or figure out what the game wanted them to do next. Thirty minutes passed before a ringing in Kyle’s ears got his attention. A prompt popped up a foot in front of him, hanging in the air as they did in Fantasy. Welcome to Outbreak!You have one hour to find other survivors and create a group. The group leader will gain 100 AP and a single territory claim token. The leader must claim the group’s territory within the hour limit. Once the territory is claimed, your group has three additional hours to find supplies. At the end of those three hours, the first event begins the outbreak. In a few moments, Kyle got a prompt asking to join the ‘NeXus’ group by Shaun Sr. It took the man almost twenty minutes to get everyone in the area into their group. Once everyone seemed to be sorted, Senior went inside the cafe to claim the territory. The group ‘NeXus’ has claimed the territory ‘43,752.’ Your leader has renamed territory ‘43,752’ to ‘The NeXus.’ NeXus has 2:59:57 to find supplies. Kyle watched as the timer slowly ticked down. Senior immediately started organizing people into groups, with orders to go out and find supplies. Waiting around for a few moments, Senior spotted him and beckoned the teen over. “Ok, Kyle. You, Junior, and Julie grab a few people and scout the area. Find out what’s different around here, and if there are any special locations or even anything that catches your notice.” “Alright, we can do that,” Kyle responded. Kyle and Junior grabbed two people each, growing the group to seven, and then headed out. “What are we looking for, Kyle?” asked Julie. “Honestly, not sure. I’d hazard a guess we are trying to find anything out of place. Like a building or structure that shouldn’t be there or is different from the ones in real life,” Kyle said. “You mean like that shack over there?” said one of the guys tagging along. Kyle looked to where the new guy had been pointing, and there next to the taco joint was a large wooden shack. The small structure reminded him of the old retail kiosks, some of which still existed as landmarks in the city. A cloaked person stood behind the counter. Drawing even closer, they could see a plethora of familiar items and guns behind the man. “Ah, my first customers!” the man said with a toothy grin. “What do you trade for?” asked Kyle. “Cores, and only cores.” “Where do cores come from?” asked Junior. “Anything alive...or undead,” he grinned as he said it. “Thank you for your time. We’ll be back soon,” said Kyle. “Yeah...that wasn’t creepy at all,’ commented Junior once they were out of earshot. The group left the shack and continued to walk down the street. Around them, other small parties from their group were ducking into each building and coming out a few moments later empty-handed. Kyle’s group had barely made it to the corner when they heard some shouting from ahead. One of the scavenger teams on the next block were yelling for everyone to come help collect supplies. Drawing closer, Kyle looked into the local convenience store and saw it was filled with stocked shelves. On each, food, as well as other items, lined them. A few of the others found bags and started filling them with the supplies, then carrying them off towards the NeXus. “Alright, guys, let’s keep scouting. If we find other stores like this, we’ll send someone back with the location,” said Kyle. The team would walk down two blocks, then down the next set of two making a sweeping pattern through the streets. They found one other store with items in it and sent one of the random guys to report its location. They had just begun walking down the next two blocks when Julie squealed and ran off. Running to catch up with her, they watched as she bent down in front of a truck tire on the side of the street. Standing up and turning around, they could see she held a white kitten that looked half dead. “Aww, look at him, Shaun. He’s nothing but skin and bones. We need to find some food and water for him,” said Julie. “It’s just a cat inside a video game. How did you even see him?” said Shaun. “I saw him pop his head up for a sec... OWW!” Julie yelped as she let the cat go. The cat hit the pavement and ran into an alley; no one bothering to follow. “He scratched my arm really good. Damn, that hurt. The sensations in this game are crazy. He must have been scared by so many people and wanted to get away.” “Let me see your arm,” said Kyle. She had four red scratches going down her arm. They looked a bit swollen, but nothing major. “Looks like we don’t heal fast. I’m betting we need to find medical supplies for injuries. I doubt we can make healing potions like in Fantasy,” said Kyle. “There should be a hospital a few more blocks down that way. We should see if it has supplies before others ransack it,” said Shaun. “That’s a good idea. Let’s head there now. I know we haven’t seen any yet, but keep an eye out for any kind of vehicle. That’s going to help us out with the time limit.” The group of six began walking towards the hospital, still peeking into every building as they went. [ Previous Chapter ] - [ Next Chapter ] [ Discord ] - [ Patreon ] - [ RoyalRoad.com ] - [ ScribbleHub.com ] Author’s Note Thank you for returning to read the beginning of Shattered Helix’s third volume. As mentioned two weeks ago, I've created a Patreon to help me push my dream of becoming a full-time writer to the realms of possibility. Those who choose to help support the story of Flea, Barricade, and Ginka will be rewarded with extra chapters and an exclusive side story each month. I want to thank everyone again for all the feedback and comments I've gotten over the past three months since starting to publish. [Discord Link] - [Patreon Link]
NeXus Cafe, Chicago, IL Friday, July 11th “Calm down, everyone!” Shaun Sr. shouted over the almost two-hundred people crowded around the cafe’s lounge. “After creating your character, make sure you find Jonathon, Jr. or Julie. We will try and organize everyone as fast as possible for the various tasks once we know what we’re dealing with. If you’re not going to be a team player, please leave now. I have a waitlist of those who are biting at the bit to play Outbreak with our group.” Shaun Sr. said in a lower voice once everyone got quiet. The NeXus FIVR cafe was a hive of excitement. In less than an hour, they would be logging into Outbreak. Everyone would be playing for twenty-four-hours inside Outbreak during each eight-hour session every night. The new upgrades Shaun had installed into their now hundred-ninety-two capsules would allow everyone to experience the full spectrum of senses in their games, as well as experience the time compression technology available in Outbreak. Shaun Sr. had set up a signup list for Outbreak on the cafe’s intranet. Everyone currently here had opted to prepay a week’s time in advance to join the group. The only exceptions were the chippers who had their Neurolink Delve Implant already. The chippers would be using cots to sleep while they delved into Outbreak. Shattered Helix had hinted at rewards for the winning groups in each of the fifty regions, getting everyone in the cafe excited to be the group who won. They would be one of the larger groups getting organized for Outbreak. They made sure to tell everyone in the Chicagoland area that if they wanted to join them, they could. The stipulation was they had to get to their base from where they would spawn in and follow their rules. [I’m still upset that I can’t play with you, Kyle. I can’t even log into Fantasy while you’re in Outbreak. I was hoping to teach Than’ro my Fast-Ball Special before we logged in and started traveling north.] “Yea, I can understand your frustration, Bob. You never know what they’re going to do with the game. I mean, there aren’t many AIs right now who can say they play games.” [You're correct.I’ll be here if you need my help.] Everyone in the cafe sat around talking and guessing what would happen when they finally logged into Outbreak. The time slowly crawled forward until it was five minutes to launch. The assembled players then finished talking, eating, and drinking before heading to their assigned capsule for the evening. Shaun Sr. and Jr. helped everyone into their pods, ensuring everything worked for each user. With the help of Terica, father and son settled into their capsules. She would be the sole attendant for the cafe every night, as Terica wanted nothing to do with zombies. Kyle McCoy, and the five who had their delve chips, went into the back office to get comfortable on the provided cots. Laying his head on the pillow and kicking his shoes off, Kyle mentally initiated his delve, bringing him to his MicroWorld. Not seeing the new monolith under his pavilion, he walked into his Japanese style modern house and found his AI, an orange and white Persian cat sitting on the couch watching Stargate SG-1 and eating popcorn. “I don’t think anyone would believe me if I told them my AI spends all of his time watching TV inside my MicroWorld.” Bob, the cat, looked over at Kyle, now Flea the Gnome, and shrugged, causing the Gnome to laugh. “Well, you enjoy your TV. I’m going to go murder me some zombies.” Flea walked back out onto his massive deck and over to the pavilion. The Gnome had to wait just another minute before a large grey monolith materialized next to Fantasy’s shiny-black standing stone. Walking up to it, he could see what looked like hundreds of cracks in the grey stone, with some of the corners missing and chipped. Carved into the stone’s center above the dark red door was the word Outbreak, with what looked like neon yellow liquid dripping from a couple of the letters. Flea tentatively reached for the door handle, opened it, and walked through. Coming to the other side, he found himself immediately growing back into his human form. Looking around, the bright white room he found himself in seemed to be a padded room for people with mental health conditions. To his right was a single tall mirror. Kyle also noticed there was no exit door in the room. Well, I guess they have a thing for mirrors for their character creation. Walking over to the mirror, Kyle was not surprised to see himself in it. Tapping its surface, he found it was, in fact, the character’s customization system. At first, he was surprised to find he could only change the hair on his head and face. It soon occurred to him; Shattered Helix wanted people to play as themselves for this game. Kyle decided to keep everything the same except dying his hair a royal purple. Kyle sat with his back against the padded wall and waited for the remaining twenty-eight minutes to tick away. Shaun Sr. said everyone had thirty minutes to finish their characters’ customization, and much to his chagrin, it took him less than two. As the time finally hit the thirty-minute mark, the mirror changed into a door and opened into a bright light. “And away we go!” Kyle stepped into the light and found himself in the park behind the cafe. Looking around, he was shocked at how the game looked so much like the real world. Of course, the one big difference was the city of Chicago was dead. The usual sounds of the city couldn’t be heard around him. It was an eerie experience. Before he could ponder more on the subject, someone materialized fifty feet in front of him and then immediately another fifty feet to his right. Looking around now, Kyle recognized most of the people porting in were players from the cafe. One of them began to run towards the back of the cafe, and people started to follow. Five minutes later, many of the players were now inside the NeXus. The inside itself looked nothing like Kyle had expected it to be. Instead, the walls were a plain light grey, with no furniture and none of the capsules or other hardware. The entire building was just an open space. “Oh my god. Everyone, come outside and look!” someone yelled. Following the mass of players outside, Kyle looked up to where people were pointing. Most of the eastern sky was dominated by a large planet. Some smaller planets also dotted the heavens. “Is that Mea?” someone said behind Kyle. “Is this the Earth they showed in the Fantasy trailer?” another person asked. That would be a safe bet. Kyle thought. The group sat around talking. No one could see any zombies or figure out what the game wanted them to do next. Thirty minutes passed before a ringing in Kyle’s ears got his attention. A prompt popped up a foot in front of him, hanging in the air as they did in Fantasy. Welcome to Outbreak!You have one hour to find other survivors and create a group. The group leader will gain 100 AP and a single territory claim token. The leader must claim the group’s territory within the hour limit. Once the territory is claimed, your group has three additional hours to find supplies. At the end of those three hours, the first event begins the outbreak. In a few moments, Kyle got a prompt asking to join the ‘NeXus’ group by Shaun Sr. It took the man almost twenty minutes to get everyone in the area into their group. Once everyone seemed to be sorted, Senior went inside the cafe to claim the territory. The group ‘NeXus’ has claimed the territory ‘43,752.’ Your leader has renamed territory ‘43,752’ to ‘The NeXus.’ NeXus has 2:59:57 to find supplies. Kyle watched as the timer slowly ticked down. Senior immediately started organizing people into groups, with orders to go out and find supplies. Waiting around for a few moments, Senior spotted him and beckoned the teen over. “Ok, Kyle. You, Junior, and Julie grab a few people and scout the area. Find out what’s different around here, and if there are any special locations or even anything that catches your notice.” “Alright, we can do that,” Kyle responded. Kyle and Junior grabbed two people each, growing the group to seven, and then headed out. “What are we looking for, Kyle?” asked Julie. “Honestly, not sure. I’d hazard a guess we are trying to find anything out of place. Like a building or structure that shouldn’t be there or is different from the ones in real life,” Kyle said. “You mean like that shack over there?” said one of the guys tagging along. Kyle looked to where the new guy had been pointing, and there next to the taco joint was a large wooden shack. The small structure reminded him of the old retail kiosks, some of which still existed as landmarks in the city. A cloaked person stood behind the counter. Drawing even closer, they could see a plethora of familiar items and guns behind the man. “Ah, my first customers!” the man said with a toothy grin. “What do you trade for?” asked Kyle. “Cores, and only cores.” “Where do cores come from?” asked Junior. “Anything alive...or undead,” he grinned as he said it. “Thank you for your time. We’ll be back soon,” said Kyle. “Yeah...that wasn’t creepy at all,’ commented Junior once they were out of earshot. The group left the shack and continued to walk down the street. Around them, other small parties from their group were ducking into each building and coming out a few moments later empty-handed. Kyle’s group had barely made it to the corner when they heard some shouting from ahead. One of the scavenger teams on the next block were yelling for everyone to come help collect supplies. Drawing closer, Kyle looked into the local convenience store and saw it was filled with stocked shelves. On each, food, as well as other items, lined them. A few of the others found bags and started filling them with the supplies, then carrying them off towards the NeXus. “Alright, guys, let’s keep scouting. If we find other stores like this, we’ll send someone back with the location,” said Kyle. The team would walk down two blocks, then down the next set of two making a sweeping pattern through the streets. They found one other store with items in it and sent one of the random guys to report its location. They had just begun walking down the next two blocks when Julie squealed and ran off. Running to catch up with her, they watched as she bent down in front of a truck tire on the side of the street. Standing up and turning around, they could see she held a white kitten that looked half dead. “Aww, look at him, Shaun. He’s nothing but skin and bones. We need to find some food and water for him,” said Julie. “It’s just a cat inside a video game. How did you even see him?” said Shaun. “I saw him pop his head up for a sec... OWW!” Julie yelped as she let the cat go. The cat hit the pavement and ran into an alley; no one bothering to follow. “He scratched my arm really good. Damn, that hurt. The sensations in this game are crazy. He must have been scared by so many people and wanted to get away.” “Let me see your arm,” said Kyle. She had four red scratches going down her arm. They looked a bit swollen, but nothing major. “Looks like we don’t heal fast. I’m betting we need to find medical supplies for injuries. I doubt we can make healing potions like in Fantasy,” said Kyle. “There should be a hospital a few more blocks down that way. We should see if it has supplies before others ransack it,” said Shaun. “That’s a good idea. Let’s head there now. I know we haven’t seen any yet, but keep an eye out for any kind of vehicle. That’s going to help us out with the time limit.” The group of six began walking towards the hospital, still peeking into every building as they went. [ Previous Chapter ] - [ Next Chapter ] [ Discord ] - [ Patreon ] - [ RoyalRoad.com ] - [ ScribbleHub.com ] Author’s Note Thank you for returning to read the beginning of Shattered Helix’s third volume. As mentioned two weeks ago, I've created a Patreon to help me push my dream of becoming a full-time writer to the realms of possibility. Those who choose to help support the story of Flea, Barricade, and Ginka will be rewarded with extra chapters and an exclusive side story each month. I want to thank everyone again for all the feedback and comments I've gotten over the past three months since starting to publish. [Discord Link] - [Patreon Link]
The following is a list of hazardous materials, or items that may contain hazardous materials. Many of these are considered hazardous waste, and in most cases, may not be disposed of in the dumpster, landfill, or sewer. When spilled or leaked, most of these materials need to be disposed of as hazardous waste. Be sure to fully evaluate waste materials and contact the appropriate University Hazardous Materials and Waste Management Plan - 2014 Revised 4.24.2014 PURPOSE The purpose of the Hazardous Materials and Waste Management plan is to provide an environment for patients, staff, students and visitors safe from the hazards associated with the handling, storing, transporting, using and disposing of hazardous materials and waste Hazardous Materials (HAZMAT) Checklists. Promote the safe handling of hazardous materials and help prevent HAZMAT incidents. Jump to featured templates . Get everyone on the same paperless page. Rated 4.6/5 stars on Capterra from 76 ratings. Available on iOS, Android and Web. Provides information on the Control of substances hazardous to health (COSHH). Using chemicals or other hazardous substances at work can put peoples health at risk. 2 hazardous chemicals in health care a snapshot of chemicals in doctors and nurses 3 This developed a number of materials to help hospital staff choose safer products and chemical alternatives. But the health care sector cannot manage this problem alone. As a student or intern working in a hospital for the first time, you’ll have a lot on your mind, and health and safety regulations may not be foremost in your thoughts. It’s understandable. Spending time with severely ill or injured patients can upset your emotional balance and cause you to forget the most basic […] Hazardous Materials Descriptions and Proper Shipping Names UN or NA Code Aerosols, flammable, n.o.s. (engine starting fluid) (each not exceeding 1 L capacity) 1950 Aerosols, non-flammable,(each not exceeding 1 L capacity) 1950 Aerosols, poison, (each not exceeding 1 L capacity) 1950 Air bag inflators, or Air bag modules, or Seat-belt pretensioners. Hazardous materials can harm you if they: Touch your skin. Splash into your eyes. Get into your airways or lungs when you breathe. Cause fires or explosions. Your hospital or workplace has policies about how to deal with these materials. You will receive special training if you work with these materials. Hazardous materials (hazmat) are any material that has properties that may result in risk or injury to health and/or destruction of life or facilities. Many hazardous materials (hazmat) do not have a taste or an odor. Some can be detected because they cause physical reactions such as watering eyes or nausea. The most common hazardous materials in healthcare facilities include mercury, pharmaceuticals, radiologicals, sterilants and disinfectants, cleaning chemicals, laboratory chemicals and pesticides. However, even simple construction debris can become hazardous in a healthcare setting.
This first of six videos will take you through fictional employee "Andy" and his first day on the job in shipping and receiving.The trainer demonstrates how ... Share your videos with friends, family, and the world Introduction to HAZ MAT. Produced by Nick James Productionshttp://NickJamesProductions.com#nickjamesproductions Hazardous materials situations require special training and equipment. OSHA and NFPA have created a list of competencies required to protect emergency responders in hazardous materials situations. https://www.safetyvideos.com/HAZWOPER_Hazardous_Materials_Labeling_Training_Vid_p/h10.htm This HAZWOPER training video focuses on HAZMAT Labeling. An importa... J. J. Keller® Hazardous Materials (Hazmat) Training Previews. Sign in to like videos, comment, and subscribe. Video intro to Sec 11.1, "Hazardous Materials," from the 11th Edition of the _ARRL Extra Class License Manual for Ham Radio._ Subscribe: https://www.youtube.... Comprehensive overview of the Department of Transportation (DOT) hazardous materials training requirements. The DOT Hazmat training requirements are found at... Share your videos with friends, family, and the world Enjoy the videos and music you love, upload original content, and share it all with friends, family, and the world on YouTube.
