Nerdland (2016)
M4ufree Movies - Watch Movie Nerdland (2016) Online
Director:	Chris Prynoski
Genre: Animation Comedy
Released: 14 Apr 2016
Starring: Paul Rudd Patton Oswalt Hannibal Buress
Storyline:  Nerdland (2016) NERDLAND is the story of two best friends, aspiring screenwriter ELLIOT and aspiring actor JOHN, whose dreams of super-stardom have fizzled. With their 30th birthdays looming and their desperation growing, John and Elliot decide that in this 24/7, celebrity-obsessed world of over-shared navel-gazing, there are more ways to become famous -- or infamous -- then ever before. So why not become famous TODAY? NERDLAND is that day. Making up for what they lack in brains and talent with abundant, witless enthusiasm, John and Elliot troll Los Angeles on a fame-grab journey, encountering and abusing friends both new and old. Navigating their hyper-stimulating landscape of consumerism gone wild, our two consumers want desperately to be consumed -- and they will have their FAME, no matter what the cost
# Tags:	Paul Rudd Patton Oswalt Hannibal Buress
A Long Way Off
A Long Way Off (2014)
A Long Way Off (2014) In this modern day retelling of the timeless Prodigal Son Parable, young Jacob is tired of living on the family farm, submitting to the rules of his Father, Mr. Abraham. One day he demands an early inheritance from his father, who shocks his young son by agreeing to give it to
Texas Across th
Texas Across the River (1966)
Texas Across the River (1966) The Louisiana wedding of debutante Phoebe Ann Naylor to Don Andrea de Baldasar, El Duce de la Casala is stopped by the Cavalry over a matter of honor. Don Andrea flees across the river to Texas, where he meets up with Sam Hollis and his Indian sidekick, Kronk, who are c
Cruel World (20
BRrip - 3.9
Cruel World (2005)
Cruel World (2005) Reeling from his dismissal from a reality show, a deranged runner-up holds a group of co-eds hostage on the set of his own fictitious show, where losers suffer a deadly fate.
Knut und seine
Knut und seine Freunde (2008)
Knut und seine Freunde (2008) This documentary shows the early life of polar bear Knut that had to be hand fed by Berlin zoo employee Thomas Dörflein after its mother Tosca refused the baby in 2006.
Trinity and Sar
Trinity and Sartana Are Coming (1972)
Trinity and Sartana Are Coming (1972) Trinity and Sartana
Marooned (1969)
Marooned (1969) After spending several months in an orbiting lab, three astronauts prepare to return to earth only to find their rockets wont fire. After initially thinking they might have to abandon them in orbit, NASA decides to launch a daring rescue. Their plans are complicated by a hurricane he
Curse of La Llo
Curse of La Llorona (2007)
Curse of La Llorona (2007) A troubled family must unite to save their young niece from the sinister forces of La Llorona, an evil spirit that inhabits an abandoned house.
The Rare Event
The Rare Event (2018)
The Rare Event (2018) Five people - Five stories The Rare Kind is a meditation on the unique story of us - human beings. The documentary explores the strength and hope of people as they do this dance we call 'life'.
A Gentle Breeze
A Gentle Breeze in the Village (2007)
A Gentle Breeze in the Village (2007) In "A Gentle Breeze in the Village," Soyo Migata (Kaho) is a quirky 8th grade student who resides in a tiny rural village somewhere in Japan. The village is small enough where there's only 6 students that attends their school (from 1st grade through 8t
Campfire Kiss (
Campfire Kiss (2017)
Campfire Kiss (2017) Feeling disconnected with her teenage son, a protective mother decides to step outside of her comfort zone and take him camping. But as soon as she arrives, she begins butting heads with her handsome cabin neighbor, a single father and outdoorsman who is also in search of a conn
Its a Bet (1935
Its a Bet (1935)
A young English reporter makes a bet with a wealthy publisher that he can disappear for a month In his absence the publisher makes much of the mysterious disappearance in an attempt to boost the circulation of his newspaper
Downton Abbey (
Downton Abbey (2019) The continuing story of the Crawley family, wealthy owners of a large estate in the English countryside in the early 20th century.
Lisbon (1956)
Lisbon (1956) High stakes battle of wits and morals between gentlemen crooks, set in beautiful Portugal. A smuggler is hired to kidnap the rich husband of an American woman who's just arrived in Lisbon, Portugal.
Impasse (1969)
Impasse (1969) Adventurers search for World War II gold in the Philippines.
The Twins Killi
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A Scottish missionary arrives to live among African tribes who practice twins infanticide and human sacrifice. She crusades to stop these practices and preach the Christian gospel. It's a daunting mission that will not be easy.
Evil Come Evil
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Evil Come Evil Go (1972) A religious fanatic murders people who are engaging in sex.
Jasmine (2015)
Jasmine (2015) A year after his wife's murder, once-successful Hong Kong businessman Leonard To (Jason Tobin) is still reeling from the tragedy. Having lost his job, friends, and all sense of order in his life, Leonard becomes obsessed with a mysterious stranger he sees at his wife's grave, believin
Detained (2017)
Detained (2017) A young Syrian refugee Lara, fights to maintain her innocence when she's detained by U.S. Homeland Security after her father is identified as the suicide bomber of a terrorist attack at an airport in London.
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Sloss Furnace
Sloss Furnace is the only blast furnace in the U.S to be preserved and opened for public use. It is currently a museum and holds various functions such as a nationally recognised metal arts centre, a barbecue cookoff and various stage shows and concerts. Today the furnace is a fun and memorable place to visit, but its history didn't tell quite the same tale.
A man named James Withers Sloss started his own furnace company and built the Sloss facility on 50 acres of land which was donated by Elyton Land Company for industrial development.
The furnace was a rather advanced structure in its day, and it employed hundreds of workers from the surrounding area to come and operate it. The furnace was a resounding success and in its first year alone produced 24,000 tons of high quality iron, and it even won an award at the southern exposition in 1883.
The furnace continued to operate until 1969 when it was sold to the Jim Walter Corp. who closed it down due to the outdated workings and the availability of cheaper ores from overseas.
The furnace even holds an annual fright night ghost event, but please contact the venue directly for details.
Is Sloss Furnace Haunted?
The man who was resposible for construction of Sloss furnace was known as a ruthless buisnessmen, and was often refered to as James "slag" Sloss, and incase you're not sure "slag" is a glass like useless by-product of the smelting process.
Work at the mines was highly sought after, even though everyone was aware of the conditions and risks. At the time there was no government body which protected the rights of the workers here, and knowing this Sloss highered many former slaves on a pityful wage to work long hours in these terrible conditions.
Apart from the workers being incredibly hot and enduring back-breaking work the furnace also claimed many of their lives in the time it was operating. Everything from steam blasts to people falling into vats of molten iron were responsible for the loss of life here, but there is one story of the death of a worker which out shines the others in terms of gruesomeness.
In the furnace there were many large cogs on many of the machines, and one day one of the workers was unlucky enough to catch his clothing in one. He was slowly dragged into the machine screaming for his life until the giant circle of metal crushed him through to the other side. His work mates were all present to witness such a horrible event, and each time the wheel turned there was a little bit less of their former co-worker.
Deaths such as this make an excellent basis for a haunting, and this place has more than enough nasty endings to qualify, but it isnt its history that makes it known for being one of the most haunted places in the state, but the huge amount of activity that goes on here.
Visitors to the site tell of everything from the normal orbs and sounds, to very bold claims about being phsically attacked or full on apparitions of workers writhing around in pain before suddenly vanishing. There are simply to many stories and claims to list here, but the most well known and famous ghost is that of James "slag" Sloss himself.
The story goes that one day he went to the top of the highest blast furnace known as Big Alice and fell into the huge pot of molten iron. Apparently he never went up to the top of that furnace in all his time of running it until that day, and the most popular version is that he was actually pushed in by one of the workers, though no one was charged for his death.
His presence has been making itself known since the early 1900's when people reported being violently pushed by unseen hands, and there is even a story of how 3 workers were found knocked out in a store room, though they couldnt say how it happened.
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UofT ranks Top 20 internationally.
UofT hosts the 2020 World Academic Summit
Kasia Proce - Staff Writer
Nour Saqqa
This year the University of Toronto hosted the Times Higher Education's World Academic summit for the first time. This year also brings with it another milestone for the prestigious event as it was the first summit to be held online due to the COVID-19 pandemic.
The summit followed the theme of "the power of place," focusing on how the geographical and cultural environment of universities have an impact on the schools and how, in turn, the universities impact their communities both near and far. The summit's theme also explored whether the digital realm has replaced the physical aspect of campus, which U of T President Meric Gertler discussed later on.
U of T has a lot to celebrate. The university was not only selected to host the summit this year but also kept its top 20 spot internationally and number one in Canada across all major university ranking publications. Compared to years prior, where U of T was ranked 19th and even 21st on the list, it is an accomplishment to remain as 18th for two consistent years now. The recent Times Higher Education publication ranked U of T as eighth for world rankings, and third for North America. U of T has also been selected to host the summit again next year in 2021.
In his speech, U of T President Meric Gertler discussed how the university has benefitted from being located in the Toronto area, especially as a leverage point for students deciding where they want to study. "More often than not, it was the quality of the city that helped tip the balance in our favour," said Gerler.
Location has become even more important with the onset of the COVID-19 pandemic since many students are now required to stay home, rather than take advantage of the opportunities life in the Toronto region may provide.
Professor Susan McCahan, the vice-provost of innovations in undergraduate education, also spoke at the summit, particularly about how the pandemic has created an accelerated shift in online education.
"In 2018-2019, we had about 150 online courses at the University of Toronto. This coming year, we will have several thousand," she stated. McCahan went on to predict that the future of higher education will result in "the blending of the virtual with the real and in-person."
Considering how many courses are being delivered via online methods this year, McCahan's point hits close to home for many students.
Moreover, with the assistance of digital media, recent events regarding systemic racism have gained more attention and are being recognized for the critical issues they are. President Gertler said that universities must work on challenging systemic racism through both faculty and student channels.
President Gertler also mentioned that the university administration is putting in more effort to reach out to larger numbers of racialized students by co-operating with public schools in disadvantaged areas, hiring more Indigenous and Black faculty, and dismantling the unconscious bias in faculty search committees through targeted programs, which are yet to be announced.
Although the U of T administration was proud of the outcomes of this year's summit, President Gertler pointed out that universities the world over still have a lot of work to do to remain the respected institutions they are revered to be.
2020 World Academic Summit
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The Listeners By Walter De La Mare Critical Analysis
Early research into New Hampshire wards and towns which used Diebold's AccuVote Optical-Scan voting machines during last week's Primary reveals that chronic problems continue with the company's.
UPDATE, 6:18 pm: In reaction to Rick Davis' comments about the election not being about issues, Barack Obama campaign manager David Plouffe released the following statement: "We appreciate Senator.
The Listeners" is narrative poem centering a traveler's encounter with the supernatural. It was first published in London in 1912 by Constable and Company in The Listeners and Other Poems, a collection of Walter de la Mare's verses.
If 95, 96 or 97% of scientists say that human activity is driving the world temperature higher, why is it that some people reject the view of the overwhelming majority? Stephan Lewandowsky has studied.
The Listeners study guide contains a biography of Walter de la Mare, literature essays, quiz questions, major themes, characters, and a full summary and analysis. Though named for the mysterious "Listeners," the poem opens with a spoken question from its main character, described only as "the Traveler." He has arrived, traveling on. These papers were written primarily by students and provide critical analysis of The Listeners by Walter de la Mare. Admittance.
Walter de la Mare [1] (də lə mâr), 1873–1956, English poet and novelist. The Listeners and Other Poems. M. E. Coleridge: An Appreciation. de la Mare: A Critical Study by Forrest Reid, 1929; de la Mare: An Exploration by John Atkins, 1947; de la Mare: A Study of His Poetry by H.C. Duffin, 1949; de la Mare by David.
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Children's Laureate Michael Rosen has said government literacy policy is having a "disastrous" effect on poetry. He spoke out after an Ofsted report said poetry was taught well in two-thirds of.
Walter de la Mare's 'whispered incantation' echoes on in the memories of countless readers from the late nineteenth century onwards, J. H. Prynne, in an apparently impromptu poetry reading on Chinese national television in 2014, chose de la Mare's 'The Listeners' for his text. Especially in the last decade, there has been increasing critical appreciation for the breadth and significance of his oeuvre.
RESULTS: Judged against critical questions about autism. However, they might have difficulty recognizing their listener's perspective, realizing meaningful implications of what is said, and.
16 Sep 2018. Through an analysis of The Listeners, articulated with Bernard Stiegler's notion of the digital pharmakon, this. John Cayley's piece takes its name from a 1912 narrative poem by Walter de la Mare (1873-1956), published in.
Walter John de la Mare OM CH was an English poet, short story writer, and novelist. He is probably best remembered for his works for children, for his poem "The Listeners", and for a highly acclaimed. For children, de la Mare wrote the fairy tale The Three Mulla Mulgars (1910, AKA The Three Royal Monkeys), praised by the literary historian Julia Briggs as a. Includes the poem itself and analysis.
Get an answer for 'Attempt a critical appreciation of the poem "The Listeners" by Walter de la Mare.' and find homework help for other The Listeners questions at eNotes.
27 Mar 2013. Free Essay: Justin Gonzales A Promise to Return Poetry Analysis Essay 3-1- 2013 A Promise to Return "Is there anybody there? said. "The Listeners" by Walter Del La Mare is a dark and spooky poem with an unexpected ending. Critical Analysis of The Garden As with many of his poems, Andrew Marvell wrote The Garden to put forward his point of view and then argue it logically.
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"I remember landing under sniper fire. There was supposed to be some kind of a greeting ceremony at the airport, but instead we just ran with our heads down to get into the vehicles to get to our base.
'The Listeners' by Walter de la Mare describes the actions of a Traveller who knocks at the door of a seemingly deserted home at night.
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walter d Walter de la Mare is one of England's best known writers, producing great works that were often atmospheric, slightly scary and with a touch of mystery. He was probably given much encouragement by his mother, Lady Sophia, to follow a literary career. of a man by an 18th century pirate and he followed this up with a successful collection of poems called The Listeners, published in 1912.
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Free Essay: 'The Listeners' by Walter De La Mare is a narrative poem. It tells us. This proposed research work was a qualitative research in its very nature of data collection and analysis. Critical listening is analysis, thinking, and judgment.
Rosowsky, Andrey 2018. Globalisation, the practice of devotional songs and poems and the linguistic repertoires of young British Muslims. Culture and Religion, Vol. 19, Issue. 1, p. 90.
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The Background "The Listeners" is a unique poem written by Walter De La Mare. The poet devoted the later part of his life to writing in 1908. He wrote diverse poems both for kids and adults. The Structure The poem is written in 36 lines with.
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9 Jun 2006. Although Walter de la Mare's gothic whimsy and goblin language was at odds with the realism of his. in music and meaning such as occur in the lines that conclude the poem "The Listeners": "And how the silence surged softly backward, Naomi Royde-Smith was the literary editor of the Saturday Westminster Gazette, where she praised and published De la Mare whenever she could,
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And in this world devoted to reality, this fantastical respite comes in the form of Walter De La Mare's poems. Born in England in. But the strongest gothic element comes to this poem in the form of the "Phantom Listeners." De La Mare very deftly uses. But it was also this very aspect that garnered him criticism. He was often.
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Dive deep into Walter De la Mare's The Listeners with extended analysis, commentary, and discussion. (Critical Guide to Poetry for Students). What is the summary and theme of the poem "The Listeners" by Walter de la Mare? traveler.
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appraisal of de la Mare's poetic genius can hardly ignore the other relatively. detailed analysis of the poems of de la Mare, including his own points of view on. Megroz, R.L. Walter de la Mare : A Biographical and Critical Study. (London : Hodder and. The Listeners and Other Poems London : Constable and Co., 1912.
Empiricism Semantics And Ontology Week 1: Jan. 7, 9 Overview of course aims and introduction; Natural Philosophy Week 2: Jan. 14, 16 Early modern metaphysics, physics, and systematic natural philosophy. Jason Brennan, a professor of philosophy at Georgetown, is the author of the new book Why Not Capitalism?, which argues that capitalism works because of humanity's inherent lack of
23 Jan 2019. Walter de la Mare published "The Listeners" in 1912, as the title poem of his second collection of poetry. "The Listeners" draws much of its eerie quality from the fact that its meaning is rather opaque; the poem in many ways.
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Walter de la Mare (1873–1956), roughly a contemporary of Robert Frost but by temperament more akin to Thomas. And, of course, other volumes of his verse ( The Listeners, Motley, The Veil, The Fleeting) are not concerned with. into an English phrase that also would generate literary resonance, he turned to the last line of a poem of de la Mare's for. Whisper their syllablings till all meaning is gone,
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It's been nearly two years since the pandemic hit Ireland. Since March of 2020 we've seen a government fail again and again to get things
Editorial – Bill limiting protests not the way to deal with far-right mobs outside people's homes
With the news that Fianna Fáil senator Malcolm Byrne is introducing a bill that'll ban protests outside of people's homes more than a few politicians
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Media debating people's rights isn't balance. It's abhorrent.
There are some elements in Irish society who need to think deeply about how they use their platforms. For anyone concerned about social justice it
Election Special – Voters will trounce Justin Barrett and Dolores Cahill. But that's not the point.
There's just over a week until voters in Dublin Bay South (DBS) go to the polls in an unexpected by-election. Conspiracy theorists and members of
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Editorial – The virus may be losing its grip but extremism and conspiracy theories are here to stay
As Ireland heads towards the fifth month of lockdown, COVID denialists and anti-lockdown activists are becoming more emboldened. Their message hasn't been dulled throughout the
Why do I care about anti-maskers? In a word, ableism!
Webster's dictionary defines the word ableism as….Okay. Relax. This isn't a leaving cert essay! "But", you cry, "Therese (Because that's my name!) what the actual
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Editorial – Forces similar to those that attempted insurrection in Washington aren't unknown to Irish shores
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Editorial – Ireland is unexceptional when it comes to the pandemic and the far right
Ireland is not special. This has been hammered home for many in the last year. We were, like every other country on the planet, hit


Nintendo Direct Highlights – 4th September 2019
by Rob Pritchard, September 6th, 2019
For many years, video game players all over the world have received exclusive information about upcoming games for Nintendo consoles via their Nintendo Direct presentations. The latest of these live streamed events has now arrived, bringing with it a vast catalogue of news about previously announced titles, as well as a handful of all new games for the Nintendo Switch family of systems.
To start things off with a bang, the fan favourite third person shooter Overwatch is at last making it's way onto Nintendo Switch. The game will run at a very respectable 30fps, and will arrive worldwide on October 15 2019.
After the relative success from Kirby Star Allies, Nintendo fans will be delighted to learn that Super Kirby Clash, an all new free to start fighting game starring the pink mascot will be available later today.
Little Town Story
Although they are best known for developing the Pokemon series, Game Freak are no strangers to developing other software. Their newest RPG, Little Town Story, is set to offer a fresh experience set in a village where every resident can offer a helping hand to defend it from monsters.
Super Smash Bros Ultimate
It was announced at E3 that Banjo and Kazooie would be coming to Super Smash Bros Ultimate, and during the Nintendo Direct, it was revealed that the dynamic duo will be available for Fighters Pass owners and individual purchase later today.
On a further note, it was announced that the next challenger will be Terry from the Fatal Fury series.
Tokyo Mirage Sessions ♯FE Encore
With so many ports of Wii U titles coming to Switch, it is pleasing to see that Tokyo Mirage Sessions ♯FE has made the cut. The port will include all new dungeons, playable characters and an all new performed by the game's cast. Tokyo Mirage Sessions ♯FE Encore will arrive on Nintendo Switch on January 17th 2020.
Pokemon Sword and Shield
During the latest Direct, the Galar region has been announced to be the home to all new mechanics for the Pokemon series, such as cooking curries together with various ingredients found around the region and building a camp site for your Pokemon to explore.
The latest entries in the Pokemon RPG series are still in course to be released in November.
SNES Games On Switch
When it was first launched last year, Nintendo Switch Online provided a small library of NES classics to play as long as you are a subscriber. From September 6th, it is now possible to play SNES games such as Super Mario Kart, Super Mario World and The Legend of Zelda: Link to the Past.
The final announcement to be made during the Nintendo Direct was that a remastered version of the original Xenoblade Chronicles will be coming out next year. The graphics have been upgraded to match the recently released sequel, and content cut in the original release will be included in the game.
If you would like to see the rest of the Nintendo Direct, a YouTube link to the full version of the showcase can be found below.
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Developing Your Child's Self Esteem
Sometimes it's easy to notice when kids seem to feel good about themselves — and when they don't. We often describe this idea of feeling good about ourselves as "self-esteem."
Kids who have healthy self-esteem tend to:
feel valued and accepted
feel confident that they can do what's expected
feel proud of a job well done
think good things about themselves
feel prepared for everyday challenges
Kids with low self-esteem often:
feel self-critical and are hard on themselves
feel insecure, or not as good as other kids
focus on the times they fail rather than the times they succeed
lack confidence
doubt their ability to do well at things
Why Self-Esteem Matters
When children feel good about themselves, it sets them up for
success — in everything from school to friendships. Positive feelings like self-acceptance or self-confidence help kids try new challenges, cope with mistakes, and try again. Taking pride in their abilities and accomplishments helps kids do their best.
By contrast, kids with low self-esteem might feel unsure of themselves. If they think others won't accept them, they may not participate as often. They may allow themselves to be treated poorly and have a hard time standing up for themselves. Kids who don't expect to do well may avoid challenges, give up easily, or be unable to bounce back from mistakes.
Having low self-esteem can block success. It can leave kids distracted by the stress of how to deal with everyday challenges.
How Self-Esteem Develops
Contrary to what some might think, self-esteem does not come telling kids they're wonderful, special, and great (even though they are!). Giving every child a trophy doesn't help kids' self-esteem. Indeed, it's possible for kids to feel good about themselves even when they fail.
When children compete — win or lose — they see that their own hard work and practice can make a difference. Earning a prize contributes to self-esteem only when a kid knows he or she earned it.
Self-esteem is the result of experiences that help a child feel capable, effective, and accepted.
When kids learn to do things for themselves and feel proud of what they can do, they feel capable.
Children feel effective when they see that good things come from efforts like trying hard, getting close to a goal, or making progress. For example, kids who take part in a service project feel good about themselves when they see how their actions matter.
When kids feel accepted and understood by a parent or someone close, they are likely to accept themselves, too. Their good feelings about themselves multiply as parents praise good behaviors, help when needed, and give encouragement and support.
How Parents Can Nurture Self-Esteem
Self-esteem develops over time. And if it's low, it can be raised. Here are things parents can do:
Help your child learn to do things. At every age, there are new things for kids to learn. Even during babyhood, learning to hold a cup or taking first steps sparks a sense of mastery and delight. As your child grows, things like learning to dress, read, or ride a bike provide perfect opportunities for self-esteem to take root.
When teaching kids how to do things, show and help them at first. Then let them do what they can, even if they make mistakes. Be sure your child has lots of opportunities to learn, try, and feel proud. Don't make new challenges too easy — or too hard.
Praise your child, but do it wisely. Of course, it's good to praise kids. Your praise is a way to show that you are proud, too. But research shows that some ways of praising kids can actually backfire.
Here's how to do it right:
Avoid over-praising. Praise that doesn't feel earned doesn't ring true. For example, telling a child he played a great game when he knows he didn't feels hollow and fake. It's better to say, "I know that wasn't your best performance, but we all have off days. I'm proud of you for not giving up." Add a vote of confidence, "Tomorrow, you'll be back on your game."
Praise effort rather than fixed qualities. Avoid focusing praise on results (such as getting an A) or fixed qualities (such as being smart or athletic). This kind of praise can lead kids to avoid challenges that may threaten the good 'reputation' they get praised for most.
Instead, offer most of your praise for effort, progress, and attitude. For example: "You're working hard on that project," or, "You're getting better and better at these spelling tests," or, "I'm proud of you for practicing piano — you've really stuck with it."This kind of praise encourages kids to put effort into things, work toward goals, and try. When kids do that, they are more likely to succeed.
Be a good role model. When you put effort into everyday tasks (like raking the leaves, making a meal, cleaning up the dishes, or washing the car), you're setting a good example. Your child learns to put effort into doing homework, cleaning up toys, or making the bed.
Modeling the right attitude counts, too. When you do tasks cheerfully (or at least without grumbling or complaining), you teach your child to do the same. When you avoid rushing through chores and take pride in a job well done, you teach your child to do that, too.
Ban harsh criticism. The messages kids hear about themselves from others easily translate into how they feel about themselves. Harsh words ("You're so lazy!") are harmful, not motivating. When kids absorb negative messages about themselves, they feel bad about themselves, and act accordingly.
Focus on strengths. Pay attention to what your child does well and enjoys. Make sure your child has opportunities to develop these strengths. Nurturing strengths is better than focusing on weaknesses if you want to help kids feel good about themselves and succeed.
Reviewed by: D'Arcy Lyness, PhD
Date reviewed: September 2016


Chai With Shai: Writers are the most neglected and underpaid lot – Jyoti Kapoor
by mattshai.In Chai With Shai.2 Comments on Chai With Shai: Writers are the most neglected and underpaid lot – Jyoti Kapoor
If the dialogues of Sholay or Mr. India are still popular then you remember the faces mouthing them. When Bajrangi Bhaijaan or Bahubali is applauded for their sheer performance at the Box Office and also connecting with the audiences than Salman Khan and Rajamouli takes the credit so on and so forth. If I have to give you examples then it will take reams and reams of cyberspace.
In the star-driven industry the most exploited creative people are the writers. And who else other than me (a writer) can vouch for it? The saddest thing for any creative person to face is his / her work being passed off as somebody else's or someone plagiarizing their work. Few months ago one person stuck her head high and challenged one of the most prominent directors of the industry on charges of plagiarism and pleasantly won the case against him in court, giving a ray of hope to the oppressed and over-exploited writer community. Yes friends I am talking about Jyoti Kapoor, the 'Iron Lady' of writer community who won the plagiarism case against the mighty Kunal Kohli. Sitting right next to me sipping a cup of hot Chai we talk about the controversy that shook the industry and also about movies in general. Here are some excerpts from our conversation.
Welcome Jyoti to my web series Chai With Shai (smiles).
Thank you Shaiju for inviting me over (smiles) 'Iron Lady of Writer Community' huh? That's a new one (beams).
I am sure there might be few more flattering titles given to you by the media (smiles). Anyway, let's begin with you being in the news lately for winning a case against director Kunal Kohli for lifting your story idea and turning it into a movie – Phir Se. So how are you feeling about the victory?
Relieved, (smiles) much relieved! I have stopped having nightmares, my appetite is back and I can concentrate on work again (laughs).
(Laughs) That's nice to hear. Moving on… Plagiarism is a common thing in the industry, why do you think reputed directors resort to such tactics when they can very well hire the original writer and get the script done?
Because they think they can get away with it (frowns). Some of the 'reputed' directors have built their careers on stealing. The ghosts of the original writers will come and haunt them if they don't stop this stealing business (giggles).
I am sure it will happen one day (laughs). After the case was judged in your favor, Kunal went on record saying that he didn't want to harm the movie's release therefore he agreed for an out of court settlement. How far is it true?
I'd say he's becoming a better actor by the day. I wish him all the best for his second innings (winks).
Kunal also went on record that going forward he will never entertain a new writer ever and if he does then he will make sure the meeting is recorded. What are your thoughts about the same?
I am actually worried if any writer 'OLD OR NEW' will ever entertain him. I think having meetings recorded is a brilliant idea. Every writer should carry a camera hidden in their script/ purse/ chappal/ eyes/ hands/ underwear, basically wherever they can squeeze it in (laughs). I think, journalists should also have lie detectors fitted in their mics, especially when interviewing 'reputed' people (smiles).
What have you learnt from this incident?
Always fight for what is rightfully yours and don't listen to naysayers.
How has the industry reacted to you? Has this incident done any harm to your career?
So many colleagues have reached out to me with good wishes, strangers (from the industry) have hugged me when they got to know that I was the same person who had fought this case (pauses). I receive so many messages from fellow writers from all over the country who are stuck in similar situations and need guidance with the legal course of action. I've been overwhelmed with support from all over and I'm thankful to everyone for that (crosses fingers).
As far as this incident affecting my career is concerned, I can only say that nothing can harm your career if you are good at what you do. If people see any value in your work, they will always work with you.
Absolutely! (Smiles) Do you think writers as a lot is hugely neglected and underpaid in Bollywood?
YES! Put that in Capital Letters (smiles).
Jyoti with husband Harsh Wardhan
Why is it that Indian movies have not experimented in genres that Hollywood has excelled? We still have the stereotypical movies being made. Whom do you blame – the writer / the director / the audience?
Firstly, I think Hollywood is overrated. In terms of experimentation, their TV content is way better than their films; a majority which, by the way, are not any less formulaic than the ones we make. Also, why do we need to conform to the western idea of experimentation? Our films are born out of Indian ethos and are unique in their own way. Bollywood, however, is not the true and only representative of Indian cinema. The Indian Independent cinema, which has always co-existed, is slowly and steadily finding its bearings. Sadly however, we don't get to see these films as much as we should. The filmmakers are perpetually struggling with their shoestring budgets and don't have enough backing, especially when it comes to marketing their films. There are a few producers who are putting their money where their mouth is but we are still way behind. In that respect, I think Hollywood is more sorted. You'll see mainstream actors/producers supporting small content driven films even as they continue to produce their big budget movies.
As far as the mainstream Indian films go, we are "mostly" churning out the same done to death, run of the mill movies except a few gems like 'Dum Laga Ke Haisha'. I don't know whom to blame. But in a star driven system where everything revolves around a handful of Ks – from the epiglottis (say animatedly and giggles) I don't see things changing anytime soon. Having said that, there's no dearth of scripts. There aren't enough people ready to take a risk. And ever since the studios have taken over, things have only worsened (grim). Films have taken a back seat. It's projects that are made now (frowns).
So True! Anyway let's go back to how you started your journey in Bollywood? (Rubbing my hands) This is one of the most favorite part I like to ask my guests (smiles).
Okay…(laughs). I was a journalist for almost 4 years before I packed my bags and landed at the Film and Television Institute of India. I wanted to go beyond the facts, beyond the five W's and one 'H' (What, When, Where, Who, Why and How) of journalism. After completing my course in screenwriting in 2005, I shifted back to Mumbai and have been working as a screenwriter ever since. My training in screenwriting has definitely helped me understand the craft better but my first teacher will always be the fieldwork in journalism.
Okay… One thing I am very curious to know about is, Habib Faisal is a wonderful writer himself, so dow did you get to write Daawat-E-Ishq for him?
Even the best of writers need collaborators. Plus, Habib has collaborated with newer writers in the past. I met him at one of our screenwriting study circles and was quite impressed with his approach towards writing. Post that I shared one of my scripts with him, which he liked and asked me if I'd be interested in collaborating with him on his next script. He is a wonderful mind to collaborate with.
How I wish such interesting incidents happen with me too (frowns animatedly).
Awww (laughs).
A still from Daawat-E-Ishq
Anyway moving ahead… Did you get to learn anything new with your association with Habib?
Yes, lots. Habib is a hard taskmaster. He will keep pushing you until you have explored all the possibilities in your story, which I think is how we should always approach it. Another thing I like about his writing is his ordinary, everyday, endearing characters, which I could completely relate to.
Why do you think Daawat-E-Ishq failed to connect with the audience?
Nobody can predict what will work and what won't, especially when it comes to movies. I think we should just keep at it (writing) without second-guessing the audience. The most we can do is to try and enjoy the process of writing and hope that some of that excitement passes on to the audience as well. Too much of analysis makes Jack a dull boy (giggles).
You are looked as a new-age crusader for writers in Bollywood. Any tips for your fellow writers?
My case came out in the open for various reasons that were beyond my control but it was certainly not the first one. There have been so many writers before me who have taken on the big guns and won. Urmi Juvekar for example, who took on CNN-IBN and Kapil Chopra who fought against the Bhatts, won their respective cases among others.
To my fellow writers, my two cents:
a) Do not doubt yourself – except may be two days a week (winks)
b) Do not take yourself too seriously
c) You cannot control the fate of your script, so just enjoy the process.
d) You will always be the unsung hero, so get used to it
e) You will always need to take up commissioned work to sustain yourself but try and take out some time for stories that make you happy, that you are passionate about. Or you'll get burnt out before you know.
f) Keep your family and friends VERY close to you. On days you are suicidal, they will help you sail through it.
g) Don't take shit from anyone. Nobody is giving you a break here. People are working with you because they are getting something out of it.
h) Lastly and most importantly, Bollywood is not the be all and end all. It's just one of the platforms where we can showcase our work. As long as you are writing, whether that's a book, a play, a story or a poem, you are fine. Diversify, as much as you can.
Wow! Those were really some pearls of wisdom (smiles). Accha… it is normally seen that eventually every writer at some point of time wants to turn director. Do you have any such aspirations?
In an ideal world, I'd rather be a writer; write quietly in my cubbyhole and not deal with too many people and their big egos. However, with each passing day I am realizing that you can't trust many people with your stories and it's frustrating to see your work getting butchered. So unless you find that perfect collaborator, you are left with no choice but to go ahead and direct your scripts yourself. So yeah, never say never! (Smiles).
So what's the future ahead for you?
A movie each with Junglee Pictures and Landmarc Films which are in the pipeline (smiles). I'm hoping that my projects see the light of day soon.
It will I am sure (smiles). Okay Jyoti I think we have done a lot of serious talking and we need to brighten up. What do you think?
True… so what's in store for me next?
Haha! If you are a regular reader of my series then you will know that next is where I will throw few questions at you and you have to answer in short (grins).
Interesting (smiles)
In the industry there are no permanent friends or foes. So will you work with Kunal in the future?
Only if I can manage to carry a hidden camera inside! (winks and burst out laughing)
Funny (joins laughing)… Okay… YRF or Dharma the best production house to work with?
Haven't had a chance to work with Dharma. So can't really say.
So for now YRF huh?
The most underrated actor in Bollywood?
The most overrated actor in Bollywood?
Oh there are so many!
Come on… One name, please…
You will put me in trouble… so no comments (giggles)
The most underrated director in Bollywood?
Shimit Amin
The most overrated director in Bollywood?
Prabhudeva
Actor / Actress to watch out from the present lot?
Radhika Apte looks promising among the newer lot.
Parineeti Chopra or Priyanka Chopra the better actor?
Parineeti
On a wild date whom would you like to go with?
TV or Films?
Any advice to upcoming writers?
That's Interesting (laughs). Alright Jyoti it was a pleasure chatting up with you.
Same here (smiles).
I wish you all the very best for your future and I hope you inspire more and more budding as well as established writers to stand for their rights and the situation definitely changes for the writer community of which even I am a part of (smiles).
Hopefully (fingers crossed).
BahubaliBajrangi Bhaijaanbollywoodchai with shaiDaawat-E-ishqHabib FaisalHollywoodJyoti KapoorKunal KohliParineeti ChopraPhir SePriyanka Choprasalman khanshaiju mathew
Gajanan Patki says:
Intresting and insightful conversation. Good job Shaiju..
mattshai says:
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Home » News » Redwood Coast Land Conservancy buying 112 acres near Gualala River and regional park
Redwood Coast Land Conservancy buying 112 acres near Gualala River and regional park
by Mary Callahan, The Press Democrat, November 4, 2019
A 112-acre swath of land just inside the mouth of the Gualala River, including 13 acres of river frontage adjacent to Gualala Point Regional Park, is on its way to permanent preservation for public recreation and habitat conservation.
Long sought by the community to improve public access to the river and ensure the natural scenery remains intact, the Mill Bend property has been acquired by the local Redwood Coast Land Conservancy through the help of a secret benefactor — an interim buyer who has pledged to hold title for two years, ostensibly long enough for the nonprofit to pay for the $1.8 million purchase.
. . . But there remains a significant fundraising task ahead, which includes securing grants from the state and federal wildlife agencies, the California Natural Resources Agency and the California State Coastal Conservancy, whose representatives all have toured the land, Chasey said.
To read the entire article, visit The Press Democrat:
Redwood Coast Land Conservancy buying 112 acres
near Gualala River and regional park
The yellow lines in this photo show the approximate boundaries of the Mill Bend (lower left) and Lower Mill Bend properties. Photo courtesy the Mill Bend Coalition.
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Jimmy Kimmel Asks Pedestrians If They Watch Porn At Work
Jimmy Kimmel Live / YouTube
Trending News: People Get So Awkward If You Ask Them About Watching Porn At Work
After a recent revelation from NBC4 in Washington DC that 100 federal employees had been caught or admitted to watching pornography while at work in the last five years, ABC talk show host Jimmy Kimmel decided to do a little social experiment of his own.
As part of his Pedestrian Question series, Kimmel's team stopped people on the streets and asked them if they had ever watched porn while on the job, and the answers were somewhat surprising.
After each passerby was asked the question, the Jimmy Kimmel Live! audience was asked to guess their response from the expression on their face, but nobody could have predicted some of these responses.
From the less than convincing reply of "I don't think so" to two clearly unrepentant "yes" answers, the segment seemed to demonstrate that X-rated content and the workplace don't have to be kept separate.
Especially if you work from home, as one man triumphantly declared that he kept his adult viewing for home, rather than work, before admitting that he works from home.
The highlight of the video is a woman who admits watching porn at a call center before being tricked into naming the employer. Luckily she insists she doesn't work there any more -- she certainly doesn't now!
A 2014 survey by Proven Men Ministries found that nearly two thirds of men admitted to watching porn while at their desk, while 36% of women also confessed to sneaking a look at some very NSFW content during working hours.
Interestingly, the most likely workers to look at porn were men between 31 and 49 or men who earn over $75,000, where the percentage increased to 75%.
Gives a whole new meaning to the phrase 'working hard'.
Drop This Fact
GQ reported that a Baltimore man was fired in May 2015 after it was discovered that he watched 39 hours of porn at work, including one day when he managed to enjoy a whopping 6 hours and 46 minutes of adult content at his desk.
Office Politics Pornography entertainment news


Mikaela Åhlin-Kottulinsky claims first win of scandinavian TCR
Swede Mikaela Åhlin-Kottulinsky converted a pole position into victory in the first round of TCR Scandinavia.
Ph credits: PWR Racing-Joakim Åström
What a weekend it was for women in motorsport.
Exciting news started to come on Friday, as Mikaela Åhlin-Kottulinsky had conquered her first ever pole position, in the inaugural race of the TCR Scandinavia in Knutstorp, Sweden.
But it was just the beginning, as the the young Swede was then able to convert her qualifying result into race 1 victory after a masterful drive on very difficult track conditions.
Light snow, rain then a drying track: those were just some of the challenges Kottulinsky had to face in her pursuit of the top step of the podium.
After a good start, she was able to gradually pull away from her experienced teammate Robert Dahlgren and, without missteps on the damp circuit, she took her Seat Cupra to the finish line completing a 1-2 for PWR Racing.
The second race was won by Andreas Wernersson and saw Åhlin-Kottulinsky forced to retire in the early stages following contact with Brink.
It was nonetheless a memorable weekend for the 26-year old, who now sits third in the standings, just 6 points behind the leader Wernersson.
" Race one was a good one 🤩 🤜🤛 From pole to win, and a P1 and P2 finish for the team! Race 2 didn't play out well, but all in all happy with our speed this weekend, can't wait til Anderstorp! Rock on 💥 "


Find a Doctor/Psychiatry/CA/San Marino
Dr. Daniel Suzuki, MD
Psychiatry, NeurologyPsychiatry | Neurology
San Marino, CA
San Marino Psychiatric Associates2400 Mission StSan Marino, CA 91108
Dr. Suzuki's Background
Dr. Suzuki, MD is a practicing Psychiatrist in San Marino, CA. Dr. Suzuki graduated from University of Medicine & Dentistry of New Jersey Robert Wood Johnson Medical School in 1984 and has been in practice for 34 years. He completed a residency at U S Department of Veterans Affairs. Dr. Suzuki also specializes in Neurology. He currently practices at San Marino Psychiatric Associates and is affiliated with Las Encinas Hospital. Dr. Suzuki accepts multiple insurance plans including Aetna, Medicare, and Blue Cross of California. Dr. Suzuki is board certified in Psychiatry. Dr. Suzuki also practices at San Marino Psychiatric Associates A Medical Group in Pasadena, CA.
Dr. Suzuki, MD is a practicing Psychiatrist in San Marino, CA. Dr. Suzuki graduated from University of Medicine & Dentistry of New Jersey Robert Wood Johnson Medical School in 1984 and has been in p...Dr. Suzuki, MD is a practicing Psychiatrist in San Marino, CA. Dr. Suzuki graduated from University of Medicine & Dentistry of New Jersey Robert Wood Johnson Medical School in 1984 and has been in practice for 34 years. He completed a residency at U S Department of Veterans Affairs. Dr. Suzuki also specializes in Neurology. He currently practices at San Marino Psychiatric Associates and is affiliated with Las Encinas Hospital. Dr. Suzuki accepts multiple insurance plans including Aetna, Medicare, and Blue Cross of California. Dr. Suzuki is board certified in Psychiatry. Dr. Suzuki also practices at San Marino Psychiatric Associates A Medical Group in Pasadena, CA. More...Less
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U S Department of Veterans Affairs
University of Medicine & Dentistry of New Jersey Robert Wood Johnson Medical School
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The Serious Risks of Untreated Depression
Super-salesman Zig Ziglar once said, "The first step in solving a problem is to recognize that it does exist." But it's the second and third steps (or even more) that actually solve ......Read More
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Care For Vulnerable Populations during COVID-19 Pandemic
This CME focuses on liver injury in COVID-19, care for maternal and child health in primary care and palliative care during COVID-19
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Maternal And Child Health Services During Covid-19 Pandemic At Health Clinics – Embracing The New Normal
Presentation slide by Dr. Rozita Binti Zakaria, KK Persint 18, Putrajaya.
Classroom content
Liver injury in COVID-19
Presentation by Dr.Tan Soek Siam, Senior Consultant, Hepatology Department, Hospital Selayang
Hospice Persists During Coronavirus Pandemic And The New Norm
Presentation by Dr. Vanitha A/P R. Thangaratnam, Senior Hospice Doctor, Kasih Hospice
Serving Our Community During a Pandemic: A Sharing experience
Presentation by Sunita Kaur A/P Manmohan Singh, Senior Hospice Nurse
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Self Assessment Questionnaire
Participants who have completed the self assessment quiz with passing marks 60% and above will receive a certificate of completion which translate into 1 CPD point under the MMC CPD (new guideline 2020) category A7 Self-directed Learning for medical doctors and category A8 for other healthcare professionals and allied health team.
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This is a self-paced CME focuses on liver injury in COVID-19, care for maternal and child health in primary care and palliative care during COVID-19.
This CME is open to all healthcare professionals and allied health personnel.
Dr. Rozita Binti Zakaria
Head of Service Family Medicine, MOH Malaysia and Family Medicine Consultant
Dr. Rozita Binti Zakaria is the Head of Service Family Medicine, Family Medicine Consultant, Klinik Kesihatan Presint 18, Putrajaya
Dr. Tan Soek Siam
Senior Consultant Hepatologist, Department of Hepatology, Selayang Hospital.
Dr. Tan Soek Siam is the Senior Consultant Hepatologist, Department of Hepatology, Selayang Hospital. She was the head of department and head of hepatology service in MOH up until 2017. Dr. Tan graduated from Trinity College, Dublin (Ireland) with honours in Medicine and conducted her housemanship and senior housemanship in Ireland. After passing her postgraduate exams she returned to serve as a clinical specialist at both Ipoh Hospital and Kuala Lumpur Hospital (Malaysia), in the latter hospital she started her training in Hepatology. She did her fellowship in hepatology in the Institute of Liver Study at King's College Hospital, United Kingdom and also received training in Queen Mary Hospital, Hong Kong and University of Michigan, USA. She had received several awards for her clinical service and her research work from local and international bodies.
Dr Tan is the immediate Past President of Malaysian Society of Gastroenterology and Hepatology, Deputy Chair and Scientific Co-Chair (Hepatology) of Asian Pacific Digestive Week (APDW2020), Kuala Lumpur. She is also a member of APASL ACLF Research Consortium (AARC) and a member of Editorial Board of Hepatology International.
Dr. Tan's research interests include acute liver failure, acute-on-chronic liver failure, chronic hepatitis B and C, autoimmune liver disease, non alcoholic fatty liver disease and liver transplantation. She is the principal investigator of numerous viral hepatitis B and C and non alcoholic fatty liver disease clinical trials. She had won several grants for research and clinical trial funding. She is a member of the Asia Pacific Association for the Study of the Liver (APASL)-ACLF working party, the APASL-ACLF Research Consortium (AARC). She had authored thirty publications in peer review journals, a few book chapters and a reviewer for several peer review journals. She has experience as organiser and faculty member of several clinical and research meetings at national and international conferences.
Dr. Vanitha A/P R. Thangaratnam
Senior Hospice Doctor in Kasih Hospice Care Society, Petaling Jaya
Dr. Vanitha A/P R. Thangaratnam is a Senior Hospice Doctor, working with Kasih Hospice Care Society in Petaling Jaya, which is a non governmental organization providing free medical, psychosocial, emotional and spiritual support for patients with life limiting illness. Dr Vanitha has been working with Kasih Hospice Care Society for the past 12 years and is in charge of the medical team.
Sunita Kaur A/P Manmohan Singh
Senior Hospice Nurse, Kasih Hospice.
Sunita Kaur A/P Manmohan Singh is the Senior Hospice Nurse, Kasih Hospice. She joined Kasih Hospice 6 years ago. Prior to this, she was a head nurse in King Fahad Military Medical Complex in Saudi Arabia.


The Same Quality at One-Tenth the Cost
By John Goodman Filed under Health Alerts on October 31, 2008 with 22 comments
Sundays at the Goodman household tend to include the New York Times crossword puzzle, the Dallas Cowboys football game….and (not to be missed)….an e-mail press release from Health Affairs, describing their latest, most interesting and most newsworthy offerings.
Yet by far the most interesting, informative and valuable article [gated, but with abstract] I've ever read in Health Affairs didn't make it into any press release. Nor did it get covered in any of the mainstream health policy media outlets. It was an article about a country with institutions that produce health care quality as good or better than what we have, at a fraction of the cost! It describes how and why this happens and what institutions keep similar innovations from occurring in the United States.
So why the news blackout? Hard to say. As in art, food and sex, perhaps in health policy there's no way to explain the diversity of human interests.The country is India, where fewer than one in seven people purchase health insurance. Yet two-thirds of Indian households rely on private medical care — a preference that cuts across classes and even extends to rural and paramedic care. Not to put too fine a point on it, but India appears to have the largest free market for medical care found anywhere in the world.
Because Indian patients are paying for health care out-of-pocket, providers necessarily compete on price and quality. Because even middle-class incomes are quite low, Indian hospitals have to keep costs down to make care affordable. Because these hospitals also compete in an international marketplace, the quality must be very high. The result: open heart surgery that would cost $100,000 in the U.S. is offered for $6,000 at Indian hospitals that rival their U.S. counterparts on quality measures.
How do they do it? By using the same continuous quality improvement techniques capitalist entrepreneurs employ in other businesses around the world:
Keeping services patient-centered by importing routines from the hotel industry.
Redefining job descriptions to delegate tasks to nurses and physicians' assistants where M.D.-level skills are not required.
Maximizing the use of capital equipment — through continuous use, say, of scanning devices and efficient operating room turnover.
Managing the supply chain by finding the lowest-cost items (subject to quality control) in a world market.
Vertically integrating where appropriate, including one hospital group that manufactures its own stents and diagnostic catheters.
Investing in information technology and telemedicine.
Using real-time monitoring of provider behavior to reduce unexplained variations in clinical practice.
Above all, these institutions have discovered that cost reduction and quality improvement often go hand in hand. Minimizing adverse events achieves both objectives. As one executive explained, "we can't afford to have complications."
So, what's keeping the United States from copying the Indian experience? Government. Insurance companies. Pete Stark. Trial lawyers. All the usual suspects.
Does the U.S. Spend More?
Medical Tourism Reversing Course
Laissez Faire Medicine
A Socialist Idea We Applaud
Health Savings Accounts Come to India
Joe S. says:
The reason for the media blackout is that the article shows that in hospital care, markets work if they are allowed.
For some people, that is an abhorant thought.
Good post. This should be required reading for all health policy types.
A great Medicare reform (not that it will ever happen) would be to offer gainsharing opportunities to seniors who went overseas for surgery. Split the savings with the Treasury 50/50, for example. It would be great to see a Congressman introduce such a bill.
Apparently, India is going in the opposite direction as China is going. China is re-socializing its health care system. It will be an interesting and contrasting experiment.
I saw something about this earlier and it was quite interesting. Shouldn't there be a link to a serious discussion of the pro's and con's of this approach. The first, obviously, that comes to mind is the source of much of our high expense: remedies for damages from incompetent care. How does the Indian system treat screw-ups and how many screw ups are there? If it's my leg they mistakenly took off, I lose interest in the fact that the cohort is doing pretty well.
Larry C says:
Markets work. Incentives work. Self interest works. All this is an anathema to most health policy wonks. No wonder there is a news blackout.
Ron Masters says:
There is a great expansion of this topic in today's (Sunday November 2) Los Angeles Times business section. First page. Included in the article are listings of medical organizations involved and international medical travel firms. According the reporter quoting souce Deloitte Consulting, this is a burgeoning market. John's observations are signifcantly amplified by this times article.
Here is what you should have said but did not: The average income in India is very low. Even highly skilled medical personnel can be hired more cheaply in India than in the United States.
However, lower wages alone connot explain India's costs advantages. Other countries also have low wages but have not done what India has done. So the hospitals described in the Health Affairs article really are pushing the envelope on efficiency.
BClay says:
This is an interesting and important observation. A point that might be included in this discussion, especially as it pertains to keeping costs down, is the aspect of personal liberty in choosing a route to healing. In India, the protocols and substances that we in the US call 'alternative' are routine (i.e. Ayurvedic System of Healing) Dietary ingredients, stress management through yoga, homeopathy and acupuncture are all typically first lines of care. There are studies that show spices in the diet such as curry can prevent cancer.
We have a lot to learn about returning a balance to personal choice, personal responsibility and the role of government in paying for health services.
Joseph Mehan says:
Realize it is LATE, LATE but what's the chance of getting this into a full page spread in say Chicago, Atlanta, Philadelphia. Boston, Cleveland and New York.
All well and good that one reply said if it is his leg–but our system "wants the best" for each of us, BUT no treatments that have not been approved by the gate keepers-such as acupuncture. My wife had to have two ops on her feet–10+ yrs apart, 1st in Doctor's office==2nd in hospital with any more people & much more cost
Jack Tatom says:
John very nice piece!
In the past, India heavily subsided the production of doctors (as it does with other education- intensive professionals). That may be one reason we have so many high quality Indian doctors practicing in the U.S. Competition may have pushed the salaries of doctors far below where they would have been without the subsidy and that may play a part in India's relatively low prices for health care. We make doctors more scarce, they make them more abundant.
Dr. William Pfeifer says:
Do telemedicine services provided to other countries like the US at a higher cost than India but lower cost than the US help subsidize their system?
David Seymour says:
Thank you very much for bringing the Duke paper to my attention. Your readers might like to know that the paper is able to be downloaded for free via the link you provided.
D H Leavitt says:
YOUR LOGIC MAKES GOOD SENSE…
….SO SOMETHING MUST BE WRONG WITH IT.?
Marti Settle says:
This is why I respect the Indian intellect so much.
How did Americans get so dumb so fast?
Bob Corrigan says:
What a great article, do you have a source for a more expanded version of this report????
R E Carlson, MD says:
It's improbable that interventionist on the Left will permit the true prinicples enunciated to be implemented.
Regardless, meaningful tort reform would lead the way to the desired India experience. LOL with the new congress!
John Goodman says:
Per Bob's request,
You can read the expanded version of the report if you go to the address below and click "download." http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1277407
DaveBurris.com | Global Medical Economy says:
[…] From John Goodman: Because Indian patients are paying for health care out-of-pocket, providers necessarily compete on price and quality. Because even middle-class incomes are quite low, Indian hospitals have to keep costs down to make care affordable. Because these hospitals also compete in an international marketplace, the quality must be very high. The result: open heart surgery that would cost $100,000 in the U.S. is offered for $6,000 at Indian hospitals that rival their U.S. counterparts on quality measures. […]
Ralph Weber says:
John…just got back from Bangkok. Visited 8 hospitals. They are at least 50 years ahead of us in hospital care if not more. Everything I thought I knew about medical tourism has been turned upside down.
Devon Herrick, National Center for Policy Analysis says:
Recently Newsweek had an article discussing how health care is becoming a global marketplace. Firms in the Dallas-area are building hospitals in Mexico near the U.S. border to attract cash-paying Americans.
http://www.ncpathinktank.org/sub/dpd/index.php?Article_ID=17290
Health Alert: Why Can't WE…..Be More Like THEM? | John Goodman | NCPA says:
[…] what lessons can be gleaned from all this to guide health reform? As we previously reported here and Health Affairs reported here (but which is not even mentioned in the BRT study!!!): Although […]


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Authored by Dr Oliver Starr, Reviewed by Dr Laurence Knott | Last edited 24 Feb 2017 | Meets Patient's editorial guidelines
This article is for Medical Professionals
Professional Reference articles are designed for health professionals to use. They are written by UK doctors and based on research evidence, UK and European Guidelines. You may find the Rheumatic Fever article more useful, or one of our other health articles.
Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.
Rheumatic fever (RF) used to be a fairly common disease amongst children in developed countries until about the middle of the 20th century. It was a major cause of death in children until 1960 and a common cause of chronic structural heart disease in developed countries. In developing countries it still remains a major cause of death and heart disease.
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Pathogenesis[1]
The pathogenesis and immune mechanisms are not fully understood.
It is caused by Lancefield group A beta-haemolytic streptococci (GpA BHS) of which those with the M antigen are most likely to cause the disease (M types 3, 5, 18, 19, 24). However, RF and rheumatic heart disease have been discovered in communities where other responsible serotypes have been found[2].
It is thought that host susceptibility, virulence of the organism and the environment combine to determine the clinical manifestation and the severity in a particular individual.
The decline in RF is not just due to penicillin but also to improved social conditions and a reduction in virulence of the GpA BHS. It remains prevalent in other parts of the world, particularly developing countries[3].
The disease affects joints, skin, heart and nervous system.
Twin studies have shown a 44% monozygotic concordance but only a 12% dizygotic concordance, strongly supporting the idea of a genetic susceptibility to developing rheumatic fever after exposure to the bacterium, rather than a simple throat infection[4].
The features of the disease are thought to be the result of a hypersensitivity reaction caused in the main by cross-reacting antibodies. It is thought there is a combined humoral and cell-mediated immune response to the bacterium (pharyngitis or skin streptococcal infection) which may lead to infiltration of the heart valve endothelium by T cells cross-reactive with streptococcal M protein and cardiac myosin[1].
Pathological evaluation of the valves of patients dying from acute rheumatic fever (ARF) indicates microscopic disease in each of the four cardiac valves. Clinically, the mitral valve is involved in 90-95% of this group, in whom 20-25% also have aortic valve involvement. Isolated aortic valve, tricuspid valve or pulmonary valve involvement is much less common[5].
Different methods of collecting data can make comparisons of statistics very difficult. The incidence remains high where there is overcrowding and poor access to healthcare. In these populations with the highest incidence it is often most difficult to obtain reliable epidemiological data.
The incidence is highest in school-aged children. One study reported a median age of diagnosis of ARF of 10.4 years with an interquartile range between 8.7-14.3 years[6].
The incidence of RF in developed countries is low. The incidence of ARF has fallen in high-income countries to less than 1 per 100,000 population[2].
Even in developed countries, prevalence is a function of socio-economic status. The incidence is higher particularly when there is overcrowding and in the winter months.
The incidence in developing countries remains high. The indigenous populations of Australia and New Zealand have some of the highest incidences recorded in recent years with 374 per 100,000 per year in those aged 5-14 years. Around 60% of these patients develop rheumatic heart disease. Sub-Saharan Africa has been identified as a high-burden area, although accurate data are hard to collect[7].
At least 233,000 deaths are attributable to rheumatic fever or rheumatic heart disease each year[8].
Both primary and recurrent episodes of fever are equally common. Recurrence occurs most often in the first five years after the initial episode. The young are most at risk of recurrence. The risk of carditis and valve damage increases in subsequent attacks[9].
Overcrowding, poor hygiene and lack of access to medical services are all important. In hot countries, skin infection is a more important source of streptococci than pharyngitis. Young age is a risk factor[6].
Presentation[3]
Symptoms appear between one and five weeks after a sore throat, with an average of three weeks.
In recurrent cases this incubation period is shorter, in keeping with a faster immune response.
The diagnosis is based on major and minor criteria. In the acute disease the arthritis and toxicity are obvious but it can be more insidious with mild carditis. This probably accounts for only about half of those with typical rheumatic heart disease giving a history of RF.
Diagnosis is based on Jones Criteria that were devised in 1944, revised in 1992[10]and updated in 2015. The update included the role of echocardiography to detect subclinical valvular lesions[3]. They can be used to identify patients with a high likelihood of having RF.
Jones Criteria
A method of identifying patients with a high likelihood of having RF:
Evidence of recent streptococcal infection (eg, history of scarlet fever, positive throat swab or rising or increased antistreptolysin O titre (ASOT) >200 U/mL or DNase B titre).
Plus two major criteria; or
One major and two minor criteria.
Definitions of these criteria are set out below.
Major criteria
Arthritis:
The most obvious presenting feature is a flitting or migratory arthritis affecting large joints like the knees, ankles, wrists and elbows.
The joints are hot and red with decreased range of movement. Typically, one joint is exquisitely painful and inflamed while another is improving.
Usually one or two joints are affected at any time with each being only involved for between a few hours and a few days.
Aspirin has been the traditional treatment but nowadays other non-steroidal anti-inflammatory drugs (NSAIDs) might be considered in view of Reye's syndrome. If it fails to respond, consider an alternative diagnosis.
Carditis (occurs in 40% of patients):
There is a pancarditis affecting the pericardium, myocardium and the endocardium.
Endocarditis leads to valvular heart disease which, along with myocarditis, is fatal in about 1%.
Examination of the pulse will show tachycardia beyond that expected for the temperature.
A murmur of aortic regurgitation is common in older children or young adults.
Auscultation of the heart may reveal a pericardial rub. It is present in 40-60% without chorea and 20-30% with chorea.
Carditis has characteristic findings on Doppler echocardiography. The mitral valve is the most common to be involved at 65-70%, with the aortic valve second at 25%. Aortic valve disease, unlike most other manifestations of this disease, is more common in males. The tricuspid valve is affected in barely 10% and involvement of the pulmonary valve is very rare.
Nearly all acquired mitral valve disease is rheumatic in origin. Certain characteristic murmurs have acquired eponymous names:
Carey Coombs' murmur is a soft, short diastolic filling murmur due to vegetations on the mitral valve.
Austin Flint's murmur is from aortic regurgitation as the vibration of the anterior leaflet of the mitral valve is buffeted simultaneously by the blood jets from the left atrium and the aorta.
Chorea (also known as Sydenham's chorea and 'St Vitus' Dance'):
Occurs in 10-30% of patients.
It usually presents in children between 7-12 years, with a female preponderance.
There are both psychological and physical features. It causes rapid and purposeless movements, particularly of the face and upper extremities.
Paediatric autoimmune neuropsychiatric disorder associated with streptococcal infection (PANDAS) and Tourette's syndrome are other varieties of movement and neurological disorders described.
It may stop when the patient sleeps.
Subcutaneous nodules:
Occur in 10% of patients.
They are infrequent and appear over the extensor surfaces of the elbows, knees, ankles, knuckles, scalp and spinous processes of the lumbar and thoracic vertebrae.
They are firm, painless lumps from a few millimetres to 2 cm in size.
They are normally in crops of three or four, appearing 2-3 weeks after onset of fever.
The histology resembles Aschoff bodies found in the heart and they are indicative of severe carditis.
Erythema marginatum (also known as erythema annulare)
It occurs in about 5-15% of patients.
The rash comprises pale-red macules or papules between 1 cm and 3 cm in diameter on the trunk and proximal limbs but never on the face.
The rash occurs early in the disease and remains long past the resolution of other symptoms.
It is exacerbated by heat and fades when the patient is cool.
Minor criteria
Fever:
This is present in 90% of cases. It is usually over 39°C, stays high for a week and is lower for the following two weeks.
In pure chorea the patient may be apyrexial.
ESR and serum CRP are very raised.
Arthralgia (but not if arthritis is one of the major criteria).
Prolonged PR interval (but not if carditis is the major criterion).
Other clinical scenarios
There are three other clinical scenarios that are not part of the Jones criteria but merit attention:
Chorea may occur late and be the only feature of the disease.
Low-grade carditis may present too late for diagnosis of the RF.
Newly ill patients with a history of RF, especially with heart disease, who have supporting evidence of a recent streptococcal infection and who have either a single major or several minor criteria.
The paper looking at the revision of the Jones Criteria also addresses the question of excessive diagnosis[10].
Differential diagnosis[13]
Arthritis - consider:
Rheumatoid arthritis (including Still's disease in children).
Henoch-Schönlein purpura.
Reactive arthritis.
Erythema nodosum.
Heart disease - consider:
Cardiomyopathy.
Kawasaki disease.
Infective endocarditis.
Rash (erythema marginatum) - consider:
Drug reactions.
Lyme disease.
Chorea - consider:
Drug reactions (especially in young people) to: metoclopramide, oral contraceptives, phenytoin, haloperidol or amitriptyline.
Huntington's disease. This does not usually present until at least the age of 30 years (peak age 35-45).
Chorea gravidarum may occur in pregnancy.
Wilson's disease.
Investigations[5, 13]
Throat swabs are usually performed but may fail to grow streptococci by the time symptoms of RF appear.
Clinical features begin when antibodies are at a peak. Antistreptococcal antibodies are especially useful in patients with only chorea. Sensitivity can be improved by testing for several antibodies:
Check antibody titres two weeks apart for a rise[14].
The most common antibodies tested include ASO and anti-DNase B, antihyaluronidase, antistreptokinase, antistreptococcal esterase and anti-nicotinamide adenine dinucleotide (anti-NAD).
Generally, the antibodies rise during the first month after infection and then plateau for 3-6 before returning to normal levels at 6-12 months. ASOT peaks 2-3 weeks after the onset of clinical disease and there is a sensitivity of 80-85%. Anti-DNase B has a slightly higher sensitivity at 90%.
ECG may show a prolonged PR interval and possibly other features too. Tachycardia is usual, although some children develop bradycardia. ST elevation suggests pericarditis.
CXR may show features of heart failure.
Doppler echocardiography is more sensitive than clinical assessment in the detection of carditis in acute RF and can contribute to earlier diagnosis. The use of handheld echocardiography is being explored in low resource settings[15].
RF should still be considered as a likely diagnosis, even if criteria are not fully satisfied, when there is chorea or carditis without apparent cause and recent streptococcal infection, or when the patient has had previous RF and has symptoms of a recurrence.
Management[5, 13]
The main aims of management are to:
Eradicate the streptococcal infection if infection is still present (usually a pharyngitis).
Suppress inflammation arising from the autoimmune response.
Provide supportive treatment, particularly for cardiac complications such as congestive cardiac failure.
This is one of the very few conditions in which bed rest is enforced even if the patient feels well enough to be up and about. Full activity should not be resumed until markers for inflammation and infection (acute-phase reactants) have returned to normal.
Penicillin is given to eradicate any organisms still present. In allergy to penicillin, erythromycin or a cephalosporin is recommended. Penicillin appears to be the drug of choice both in initial infection and to prevent recurrence. The World Health Organization (WHO) recommends that this should be given intramuscularly unless there are issues of compliance, in which case oral treatment may be given[16]. Other authorities recommend oral therapy first-line with a single injection of benzylpenicillin reserved for patients unlikely to complete the course[17].
For recurrent pharyngitis a second 10 days of penicillin may be given but carriage is difficult to eradicate with conventional penicillin therapy. Oral clindamycin is recommended.
Aspirin usually relieves arthritis within a few days. High doses are required and other NSAIDs like naproxen may be safer[18]. There is no evidence that NSAIDs, steroids or immunoglobulin reduce the severity of heart disease but trials are rather old and newer methodology would be valuable[2, 19].
Heart failure will require diuretics, angiotensin-converting enzyme (ACE) inhibitors and digoxin. If this fails, consider cardiac surgery - even in acute failure. Mitral valve repair or replacement may be life-saving[2].
Chorea is often self-limiting but is likely to need suppression with diazepam. Chorea may be treated with haloperidol, although this drug can cause extrapyramidal effects.
The most important complications and sequelae derive from:
Carditis.
Mitral stenosis.
Congestive cardiac failure.
Rheumatic heart disease occurs in 30-45% of patients with acute RF[20]. Severe chronic valvular disease is associated with severe carditis and recurrent RF[21]. Patients need long-term follow-up of cardiac status and myocarditis leaves the myocardium weak for life. Most recurrences occur within five years of the original episode[9].
Clinical features of RF resolve inside 12 weeks in 80%[13].
Chorea can occasionally continue in remitting fashion for years. Mortality is rare in industrialised countries but is about 1.5% per year globally[5]. Penicillin is said to have significantly reduced the rate of valvular heart disease[22].
Secondary prophylaxis requires that every patient should start a long-term programme of regular antibiotics to prevent further GpA BHS infection[2]. The duration of prophylaxis is the subject of some controversy:
This should be continued for at least five years or until age 21 years, whichever is longer.
This should be for ten years for RF with carditis but no valvular disease (or well into adulthood, whichever is longer).
However, with substantial valvular disease this should be continued longer. In severe valvular damage, or with valve surgery, prophylaxis should be continued for life (or at least ten years or until age 40 years, according to the American Heart Association)[2, 17].
A vaccine against RF is possible in theory but has not yet been developed[23]. Prophylactic antibiotics before dental or surgical treatment (to prevent infective endocarditis) are no longer recommended for patients with acquired valve disease.
Historical perspective[24]
This often dramatic disease has been recognised for centuries. Baillou (1538-1616) realised that the arthritis was different to gout. Sydenham (1624-1668) famously described the chorea. The association of RF with sore throat was made in 1880 and the association with scarlet fever in the early 1900s. The arrival of antibiotics in the 1940s heralded the start of treatment and preventative strategies. The incidence in developed countries has declined since. Unfortunately, developing countries have not benefited very much from the progress made.
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Further reading and references
Saxena A, Kumar RK, Gera RP, et al; Consensus guidelines on pediatric acute rheumatic fever and rheumatic heart disease. Indian Pediatr. 2008 Jul45(7):565-73.
Ralph AP, Fittock M, Schultz R, et al; Improvement in rheumatic fever and rheumatic heart disease management and prevention using a health centre-based continuous quality improvement approach. BMC Health Serv Res. 2013 Dec 1813(1):525. doi: 10.1186/1472-6963-13-525.
Cunningham MW; Streptococcus and rheumatic fever. Curr Opin Rheumatol. 2012 Jul24(4):408-16. doi: 10.1097/BOR.0b013e32835461d3.
Cilliers AM; Rheumatic fever and its management. BMJ. 2006 Dec 2333(7579):1153-6.
Webb RH, Grant C, Harnden A; Acute rheumatic fever. BMJ. 2015 Jul 14351:h3443. doi: 10.1136/bmj.h3443.
Engel ME, Stander R, Vogel J, et al; Genetic susceptibility to acute rheumatic fever: a systematic review and meta-analysis of twin studies. PLoS One. 20116(9):e25326. doi: 10.1371/journal.pone.0025326. Epub 2011 Sep 30.
Kumar RK, Tandon R; Rheumatic fever & rheumatic heart disease: the last 50 years. Indian J Med Res. 2013 Apr137(4):643-58.
Sudeep D et al; The Descriptive Epidemiology of Acute Rheumatic Fever and Rheumatic Heart Disease in Low and Middle-Income Countries, American Journal of Epidemiology and Infectious Disease, 2013, Vol. 1, No. 4, 34-40.
Zuhlke LJ, Steer AC; Estimates of the global burden of rheumatic heart disease. Glob Heart. 2013 Sep8(3):189-95. doi: 10.1016/j.gheart.2013.08.008. Epub 2013 Sep 26.
Carapetis JR.; Rheumatic heart disease in developing countries. N Engl J Med. 2007357:439–441
Carvalho SM, Dalben I, Corrente JE, et al; Rheumatic fever presentation and outcome: a case-series report. Rev Bras Reumatol. 2012 Mar-Apr52(2):241-6.
No authors listed; Guidelines for the diagnosis of rheumatic fever. Jones Criteria, 1992 update. Special Writing Group of the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young of the American Heart Association. JAMA. 1992 Oct 21268(15):2069-73.
The Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (2nd edition); RHD Australia, 2012
Steer AC, Vidmar S, Ritika R, et al; Normal ranges of streptococcal antibody titers are similar whether streptococci are endemic to the setting or not. Clin Vaccine Immunol. 2009 Feb16(2):172-5. doi: 10.1128/CVI.00291-08. Epub 2008 Dec 3.
Ploutz M, Lu JC, Scheel J, et al; Handheld echocardiographic screening for rheumatic heart disease by non-experts. Heart. 2016 Jan102(1):35-9. doi: 10.1136/heartjnl-2015-308236. Epub 2015 Oct 5.
Antibiotic use for the Prevention and Treatment of Rheumatic Fever and Rheumatic Heart Disease in Children; World Health Organization (WHO) 2008
Seckeler MD, Hoke TR; The worldwide epidemiology of acute rheumatic fever and rheumatic heart disease. Clin Epidemiol. 2011 Feb 223:67-84. doi: 10.2147/CLEP.S12977.
Hashkes PJ, Tauber T, Somekh E, et al; Naproxen as an alternative to aspirin for the treatment of arthritis of rheumatic fever: a randomized trial. J Pediatr. 2003 Sep143(3):399-401.
Cilliers A, Adler AJ, Saloojee H; Anti-inflammatory treatment for carditis in acute rheumatic fever. Cochrane Database Syst Rev. 2015 May 28(5):CD003176. doi: 10.1002/14651858.CD003176.pub3.
Guilherme L, Cury P, Demarchi LM, et al; Rheumatic heart disease: proinflammatory cytokines play a role in the progression and maintenance of valvular lesions. Am J Pathol. 2004 Nov165(5):1583-91.
Meira ZM, Goulart EM, Colosimo EA, et al; Long term follow up of rheumatic fever and predictors of severe rheumatic valvar disease in Brazilian children and adolescents. Heart. 2005 Aug91(8):1019-22.
Gerber MA, Baltimore RS, Eaton CB, et al; Prevention of rheumatic fever and diagnosis and treatment of acute Streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics. Circulation. 2009 Mar 24119(11):1541-51. doi: 10.1161/CIRCULATIONAHA.109.191959. Epub 2009 Feb 26.
Good MF, Batzloff MR, Pandey M; Strategies in the development of vaccines to prevent infections with group A streptococcus. Hum Vaccin Immunother. 2013 Jun 289(11).
Kadri SM; Diagnosis of Rheumatic Fever, Indian Journal for the Practising Doctor, 2005
Sydenham's Chorea
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Next Review 23 February 2022
Document ID 2731 (v24)
Author Dr Oliver Starr
Peer reviewer Dr Laurence Knott
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