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tv   After Words  CSPAN  October 12, 2014 9:00pm-10:01pm EDT

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stealing the country and there was a great university but nobody was paid. there was no electricity. so people were denied some basic opportunities and i cannot explain why i was bitten by the virus.
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>> .. >> >> the book cover has a piece of grass on the cover and has so much potential
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and he has a famous quotation i decrease myself from the grass that i love. what does that mean to you and why is it on the cover? >> it is a biblical reference. and it refers to the idea that we come from something fertile. and then in the process of writing this book "being mortal" i think is terrific by the way one of the few times but did it hit your stride q. i will not be around forever? and then doing the research for this have an effect on you? >> guest: all lot.
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it was the story impact it was having even in my own practice with the very successful job. by the end of the '90s radically 17% of the population died in the home 83 at institutions no chance to say goodbye are hooked up to machines. and try to preserve some quality of life but it was clear that this was not what people wanted. so i began to interview patients and interviewed over 200 patients about their experience. and then enter the scores with the hospice workers in the nursing homes and i
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learned what some of them do with a really successful office and began to try that than my father was diagnosed with a brain tumor in the brain stem and best buy no accord in by an expected be needed to use what i was learning. >> host: that was a tough time personally? >> guest: yes. it was. having the chance to understand those that were more effective as family members or clinicians' what they do made it less tough. but what came out was people have priorities besides with being laundered -- living longer the second part was
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the most reliable benefit if i was not asking. not even my own dad. so when his condition began to deteriorate and it is said to merge to make him a quadriplegic and he faced options of surgery and radiation and chemotherapy i would ask the questions. what are your priorities? what trade-offs are you willing to make? hard questions to ask. but yet change the step along the way. >> you describe your grandfather. who lived to be 110 years old. and in a village in india.
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tell me what you learned from his side. >> guest: he is fascinating it is the kind of old age we think we want to. the last 20 years he needed 24-hour care but yet did not have to check into a nursing home like he did today but surrounded by family. and then a vice who they should marry and was respected. could live a good of life as possible to the end. as a society. that is why they are leading reynaud break above that extended family it is
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occurring for young women that provide that care and on top of that his son's. there waiting to inherit the wind remember your economic future dependent on your dad. finigan is other people's freedom they can live and work can marry when day one toward take different lines of work or leave the elderly's -- the elders behind. we did not have a plan in the 19th century for those who are left behind. china does 90 there. that medicine will take care of. turnover to health care. >> guest: my dad is having trouble with memory or falls
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but then take him to the doctor. they say we have a procedure. but there's some problems we cannot fix, and they throw up our hands. or we can go see another specialist. there are things to fight for besides living longer or to repair and repairable problems. >> host: when we go through school, medical school it attracts good people the type of high-school student that once to be a nurse is a remarkable person. and those from medical school but then they come out in a dilemma it is a
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confusion, preparedness, a sense this is out of my league? then they have such great people going into the profession then they deal with the problem that is out of their league? >> a few things happened. i have a geriatric office by bill my clinic and for years i never knew what they did. 97% of medical school does not teach geriatrics and i said let me hang out with you for one day and he would recognize the most life-threatening things for patients over 80 is they could fall then they have been only average of six months to survive if they are miserable. more important than the colonoscopy or mammogram was the falling component he
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knew how to examine the beat so the calluses and toenails could make someone and steady and then have a podiatrist address that and then make them take off their socks and observed because it told them something about their abilities of the care at home. then he went further to recognize if they have drugs have a much higher risk of falling. >> he could do that because they were not necessary? >> guest: there were not addressing the priorities that was as good a life as possible for as long as possible. >> seven making different choices it did not matter even if she was alive to do
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what she wanted to do her priority was to keep her home. sova risk factors the likelihood of falling and the most important things we could do we don't know. we did not teach people along the way innocency or medical school what is the skills required to help people achieve the best possible outcome? and through medical technology has it is different goals and our medical values are health they stand survival recognizing our well-being is bigger but then the
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second course is 92 were the lowest paid in our profession? not the surgeons the public debt care doctors primary care physicians because these professions take time to talk to people to allow the people to have the time to get an understanding of what matters then make plans accordingly. it does not remotely pay as well. >> i did not know there was a medical school in geriatrics. did you? >>. [laughter] they were still specializing in infectious diseases.
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as i think about what is going on with geriatrics today queer training fewer people in geriatrics than one decade ago and it has reached the point the geriatrics profession itself is that we're so far behind the eightball the country is ignoring the fact we don't train or paid the geriatric doctors there will be enough and we have to train the basic skills to the internist and medical students we have to make these basic skills what is the checklist. >> what has to be executed for those people that are aging and address their
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particular health risk. but also even hire them that to get some skills and improvement how to ask about priorities in life effectively just because you talk about the worst-case scenario does not mean that you say i'm giving up on you. >> host: medical school, i may be overly reducing its but the equivalent of learning so many foreign languages the only way to memorizes two-parent. diagnosis treatment. diagnosis treatment. to come up with a reflex. and you can learn all this knowledge but what is concerning is missing out on
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the appropriateness. it seems to be the focus or the issue around the end of life. when is it appropriate? when do we treat high cholesterol? >> then that medication makes them dizzy then they fall. >> are they confuse it with another. >> guest: how do we do that? people have a great fear. it means it is no longer about my choice. it is the evolution of what it means to be a doctor. 50 years ago a paternalistic doctor knows best. they would tell you what you were going to get. might to or might not tell
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you what is going on but not the options. and also it was our job not to worry. we would rebel in the '70s and '80s and '90s. we were trained to me dr. informative. go through all the options and pros and cons and which one do you what? then they say what would you do? we are taught to say it is not my decision. this is your decision to make. and what is evolving is the recognition when i follow the geriatricians they play a role of counselor. the counselor says i need to ask you a few questions to
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understand your life to have guidance. >> host: they what options also guidance. >> guest: understanding from their priorities. and then to say what is the a understanding of your health? what are your worries for the future what are the outcomes and based on that if they don't work option may not work we have to make up a solution she said my priority is to get to a wedding this weekend.
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five. >> pa '02 we get her to -- how do we get her to that wedding? that is when it gets cool to be a doctor. that is great. >> host: the first time you had to break bad news to a patient? >> i remember it as an intern would be asked to get the comfort -- informed consent or go consent them. he would be explaining this operation and talking about risk and benefits infection and it would raise their eyebrows nobody said anything about that. we all have our way to
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alleviate it. then they say this is just the form. don't worry about it. how can we know with the complications are like but how can we cancel people? it is legalese. i met the people that are good at walking through a conversation of the do not resuscitate order, they treat it the same way that people treated teaching us how to do the operation. they broke it down. they studied the component parts and recognize you need to use questions. you should be talking wesley of 50 percent of the time.
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and i was talking 90% the patient would not then you get to the end. deal understand? yes. that was our conversation. how would you break that news to some one? there is good and bad ways. give the facts none of the meaning. here is the data. the effective conversation is here is what i know and i am worried about these complications did you. i am not worried about the others. i unlawful about certain things but i wish as is i a worry i hope i wish. i wish it were true.
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i hope that we can buy you more time. i am worried you may end up back in the hospital again. and i tell the story of my dad to the end "this is it". then he woke up. [laughter] and he had three more days. [laughter] >> host: as you say those phrases i am concerned it reminds me of the importance of the art of language as the doctor as mentors told me down as patients are you taking your meditations? they will be defensive but ask people have a tough time
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taking them how had he been doing with it? it was amazing. with one set there is alienation and then when you phrase that a certain way it is cited by the a conversation. >> words matter. had in the stories matter. parts of writing a book like this a journalistic investigation. with the nuances and complexities when you do a randomized trial look at what everybody has in common in a case study. to recognize that they tell
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you we are ready to recognize those are important contributions. >> host: i was in a trauma day and a patient died and was told the mother is next door. that her mother is happy and says how was my son doing? and therein is massive demotions mad at myself for not thinking through this ahead of time then maddow my training for completing -- completely missing this part. when you were researching and of life care did you
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feel how could this be missing? >>. >> you also deal with every patient having to have this discussion only some of mine are worried are potentially at the end of life. and it would strike me all along one of the first essays that i wrote as a 23 year-old subsequent times i have written about family members how are we supposed to cope? you break bad news all the time pancreatic and to see a lot of them die. is this the billiard? or ddc things that were new to you?
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>> host: things were new because you did a tremendous amount of research with observations and encourage myself to ask whether your goals as a patient? this week 81 and frail beating pancreas surgery but instead i said wait to. whether your goals? she said i want to spend time with my husband if we can get another year i will be happy so it was clear to accomplish the goal. >> guest: one of the things that words matter. asking them their goals that is hard for people. they don't have clear goals but asked about what your priorities what are the outcomes that you would find unacceptable? what you really hope for
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here? so what if your treatment doesn't work? another is whether your fears and worries? that you have some understanding where to make a turn on the pathway. >> host: we will take a quick break and then continue the conversation.
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>> host: the cdc updated the numbers on life expectancy no the life is 79 if you make a two-stage 65 you live to age 83 for a man and 86 as a woman. most of the health statistics are better except the suicide rate has gone up. do you think depression of is under appreciated under recognized problems? how does that connect to the issues? as people age they are happier as they get older
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compare a 300 live 70 year-old they're more likely to be happy like to have more complex emotions until you incarcerate. into nursing homes asking when they can go home. when it is possible to have a great life to live
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independently with knee replacements there is no better time to be elderly in history but when we are dependent you have falls or your memory is going then suddenly it turns the tide and we're put into institutions that no longer are under what we have been a whole which our choices and economy. five with institutions is the goal is health and safety. we are an incredibly safe place for your parent but we don't talk about kim the parent simply go to the refrigerator to get what they want to eat whenever they want? no.
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fisker is the schedule time to wake up. the pill line and addressed at a certain time is of the staff schedule. they look more like hospitals built around the nursing station. >> it is not about the nurses and is about being at home in the kitchen people are allowed to you get what they want you know, how controversial that is? just a little bit of autonomy like that. but an alzheimer's patient should only eat the pureed diet may go get a cookie. it is fascinating you see the writing upset patients violating the rules.
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the most common reason people are written up is they violated the food rules. the ability what they sacrifice they have histories their teachers, policemen, doctors. and if they care about the focuses. with the pioneer who came
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into nursing homes battling regulations even those with dementia had something to care for that purpose and reason to live. they woke up. they became active in life. less medication. the even live longer. >> host: is the autonomy symbolic is that apart of the happiness describing your mother-in-law that she liked to wear certain shoes was part of her identity and then for safety reasons she did not want to wear the shoes. [laughter] have we taken away dignity later in life and a certain context in places as you describe where people are
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incarcerated? >> guest: yes. there are places are getting the idea this task to change than the culture of change in nursing homes with assisted living it is one of the most amazing sources right now there's a revolution of this care is provided. and allows people to have a lock on their door. that's the workers have to knock to respect privacy. when in our lives since college to we have to live with the unknown make that may be appalled by? crazy making sounds and noises and the homes that
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exist the people that they market to was not the parent but to the kids. safety is what we want for those we love but autonomy is what we want for ourselves. we ask what is the safety record? we don't ask how to ensure they have a purpose in their day? are they lonely? how engaged can they be with the world and what is important to them? are we getting to learn or pursue things? also a 94 year-old man
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trouble with memory, and then describes the things he could get to do for the first time in my life i was not afraid. >> host: you nicely point out with this sense of autonomy and companionship that contributes. but increasingly with of life this is the first time in civilization and most people live along they have a person of this or that with devices their personal subscriptions, it is a personal and individualize
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society this is why we see a convergence of the shared culture but like uber that are businesses that say we are a community. to create more of a community level than of facility or shared activities or in anticipation. >> guest: given a choice many would provide with the least contact with a human being. i don't want to have to connect if i don't have to. it is manifested in interesting ways but with social security the first thing the elderly did was move doubt they would rather
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live alone been in the family of their kids to be under their rules. did not want to live by their rules the son and daughter don't want to live by their rules. so we live increasingly added intimate distance. we are hungry but french ships that people do not always get along to retreat to space is absolutely necessary. the hard part of aging is when you can no longer be independent to retreat to your own corner because you need human beings to help you to manage anything from
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had a right changed the label to where you want to go and the frustration i have to wait. how do i navigate that world. that we have assumed you don't have a life worth living anymore because you are not independent. what growth could there be? there is a huge amount that's possible that we can still make contributions along the way. >> host: how do we get nursing homes? it is an amazing institution to charge a function they're not doing well to get people
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institutional life but not the autonomy they need for happiness or the companionship for the pet program but your book has a lot of positive things in it in ways you have been inspired by what would you have seen with individuals. >> guest: it is turning upside down the reason why we created these places. when i started researching you would think people would live longer we would come up with a rational way to make sense had retake people do different phases of their life. we built a ton of hospitals in the 1950's as the results of a law that passed we had technological capabilities
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every community could build a hospital in they filled up with elderly people whose problems could not be fixed. the hospital said what do we do? has medicare was created there is financing allowing people to go to a nursing home for about 60 days that he would nurse them back to health not they you could not get them back to health. but 50 is important any of these places were firetraps people were dying or neglected they had to be there but not with the understanding this is the well-being home. there's the people back to health may not happen bet nursing back to well-being can happen regardless of
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what we face. these and other wines we do not cross this is what we now need to discover. now hitting the age we have parents are thinking those issues and we think of those issues and this generation will not put up with the wards of the nursing stay. [laughter] >> host: end of life is the tough subjects to talk about it because it is polarizing because of individual experiences or someone on a ventilator far longer than someone would have wanted or under treated.
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to discuss the difficult issues that also focus on life not just a good death to achieve what you want to achieve what inspired you to take a positive approach to a very polarizing subject that has not evoked those reactions you would think. >> guest: i even talk about assisted suicide. here is the fear that people have the discussion of the end of life it is all about what you take away. that they are giving up sooner. that meeting people it is about fighting for a set of goals that are different and the goal is not a good
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death. number one death is messy and not entirely in zero or control. -- our control latinus moment at that end but it is life and living as you face tremendous constraint and looking closely at the field but it also gets us out of the box of incredibly polarized debate of the death panel. >> host: we've -- what is a test panel? >> guest: isn't clear. of mobile a specific notion that by allowing there is a
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discussion to encourage a possibility discussions of the end of life to hasten people end. rationed care. it is important to understand the fundamental mistake we have made studies show looked at terminal lung cancer patients was only 11 months to live at the time of the steady. half of them got usual oncology care the other half given oncology care plus meetings with the pilots said care specialist discussing goals and priorities for the remaining time. those that had discussions choose -- would stop there p earlier fewer days in the hospital less likely to die in the hospital started hospice sooner less
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suffering at the end and it lived 25 percent launder even with less chemotherapy. indicates we're making fundamental mistakes with court decision making that when we had that fourth or fifth round of chemotherapy is out of the unwillingness to recognize we could sacrifice quality of life or fighting just to have a good day now instead of more time and not worrying about how much time their baby it does not share in profits lengthened. the failure to recognize a number of studies those who start on hospice sooner they
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live equally long or longer. it just reflects about what the evidence is showing and a lack of evidence why this might be. then we listen to what priorities they have and why that might be. >> is a positive attitude part of the reason why people live longer from those that have leaked -- less chemotherapy? >> guest: i don't think so there are reasonably good studies over pessimistic and optimist and they don't. the major difference is when you try the last ditch operation or chemotherapy or other aggressive treatments, a ventilator, a feeding tube, when you give
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these approaches you have the toxicity toxicity, pain, suffering, c omplications with very little benefit to the point that the harm outweighs any potential benefit. their beaten down by the toxicity and less of the psychology. we did a study. the week you're most likely to have surgery is the last week of your life the day is the last day of that week. now we don't know of things will turn out well or not. but it had dealing with terminal illness, last-ditch effort not discussing priorities we your sacrificing not just quality
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but also there two sons of survival and we're getting it wrong more than likely. it is a wake-up call for us in medicine and patience -- patients. if you to recognize or priorities to push short clinician to make them understand what they are besides living longer what you do not want to sacrifice it is important we communicate that. >> host: this longevity run you will hear patients say there is no infection my mom had back and her mother had that. to what extent can we explore that genetics'? >> guest: i tell people my grandfather died at 110. then i will say my
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grandmother died at 30. from malaria. [laughter] so there are interesting studies about genetics how tall you are they% is determined genetically from the height them identical twins but the average difference in the length of survival is 15 years but there is a difference in 15 years. >> host: people have wisdom later in life as they would disclose things to their doctor or put a knife to their skin because you are the surgeon. what have patients shared with you?
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about time spent with family or betty? >> guest: i thank you are referring to research done by as stanford psychologist who has studied by asking people ages 18 through 94 now going on two decades and ask them to record their emotions, experiences and have done studies if you have an hour of time with you rather spend it with your sister or family member or this movie star? the young tend to choose that they want to take options that lead to achieve the more comic getting more, accumulating more, more stuff, and meet more people, they love the
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possibility going to a loud bar at 2:00 a.m. to the hopes but then the older signature says i would rather spend time with my sister they narrow the people they focus on and want deeper relationships and more connections. more focused on being to make sure contributions to be anonymous and small. the fascination is as people age the thought is evergreens are changing. then she discovered some of the folks had a terminal illness it was on the west
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coast the early-- said hiv/aids and those patients had a shift to having the older signature then she did as steady during and 11. when the world became uncertain and fragile you were not sure, everybody moved to a signature i want to be with family and be connected with those i love to make a difference. and that was revealing. as time goes on, when we are unaware of our mortality, we focus on getting having achieving. when we are in your or become aware of the limitations of the uncertainty of an atmosphere it would be ebola. or to be connected with
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others. the list of is a manifestation to have perspective on where we are in life. >> host: interesting. patients told me they wish they spend more time with their family but i never heard anyone say i wish i spent more time at work. >> guest: as kids off to college they would say don't want to focus on work. leah not sure that is the a good idea. it is prospective. if they think they have at least 20 years we behave as if we are immortal we are willing to sacrifice time now to have delayed gratification but that makes no sense if there is a finite amount of time. it is perspective to have that perspective of where
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you are in your place and time. >> host: great to see you again. congratulations on your book "being mortal" and look forward to continuing the conversation. >> guest: thank-you. you can also watch after words online go to go to after words of the series a and topics list of the upper right side of the page. >> with the movie contagion coming out of nowhere and we did not know until 2002 that
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fruit bats have a whole spectrum of viruses. we knew the rabies virus is were carried by vampire bats in south america. but that is all we knew. then suddenly we think it is influence said that it is not. then it about three weeks it turns out in the end of virus that came out of bats through little italy and southern china coming out of the forest area.
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it was an ally bid will market infecting humans then spread very quickly to hong kong and singapore and toronto. those are the main areas affected. the only area out of asia was toronto. but still it killed a hundred people. 25 for 40,000 people die with the influence of this was a hundred total it was a new infection not identified initially people were dying horribly and those in hospitals and medical personnel there was a great deal of fear. it costs $50 billion and people not traveling or not using hotels. it was a major economic problem that was the fact
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that respiratory infections can be extremely dangerous. so we have to take them seriously. also convinced it is not just up for -- the port. it is one of the reasons why we took the h1 virus seriously but with contagion we have the virus that affects the pig that has been butchered. the chef will shake hands with women's poll trop even though she is not feeling too will -- well she stops in chicago it has a liaison thing goes back to her family in indianapolis. this virus is worse than any we have seen anybody gets
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infected and dies. the most hideous virus in the world. it is in the film of infectious disease. in the actual control of the science is from columbia university. but they're killing hundreds of thousands of people their dying horribly. but it shows the cdc at work what is really important is to maintain the stature of public health because that is extremely important.
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s. citizens with local democracies those are the sorts of things by cost cutters if something goes wrong with the real problem. . .
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the author of inventing freedom. he's the recipient of this year's book award. in the book he discusses how how english-speaking people created the modern world. the book award ceremony and lecture are about an hour.


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