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Sunday, April 29, 2012

Sustainable Water Supply is Key to Urban Growth and Development


Nairobi is experiencing a water crisis of the kind that lures environmentalists into fits of gloomy Malthusian prognostications on demand and supply. For Nairobians, running taps and showers are almost luxuries of a past they remember with nostalgia.

The water situation in Nairobi is scourge on our national pride. It undermines the livability and attractiveness of the city. The nickname “The Green City in the Sun” now invites sniggers.

Less than 50% of Nairobi’s residents have direct access to piped water and only 40% have daily access to water. Only 22% of residents of the informal settlement, home to 60% of Nairobi’s residents, have access to piped water. Furthermore, Nairobi is insanitary; only 40% of Nairobi residents with access to the city’s water and sewerage network water-borne sewage.

The bulk of water supply for Nairobi comes via an old pipeline network from Ndakaini in Thika, Sasumua in the upper ridges of the Aberdares, Kikuyu springs and Ruiru in Kiambu. These sources are insufficient. The current demand for water exceeds supply by about 377,000 cubic meters per day. The supply deficit is exacerbated because 40-60% of the water destined for Nairobi is unaccounted for, lost.

The government, with funding from the French Development Agency and the World Bank undertook a study to identify new water resources within a radius of 70km of the Nairobi. The report, “Feasibility Study and Master Plan for Developing New Water Sources for Nairobi and Satellite Towns”, recommends groundwater development, abstraction and diversion of three rivers to supply additional water to the Thika reservoir by 2017.

Sadly, these new water resources will add a paltry 203,040 cubic meters per day, raising the supply to 685,980 cubic meters per day in 2017, against a projected daily demand of 1 million cubic meters. Moreover, additional diversions, abstractions and inter-basin transfers proposed between 2018 and 2030, but are unlikely to meet the projected conservative demand of 2.5 million cubic meters per day by 2030.

The solutions proposed in the feasibility study and master plan – increasing supply bulk volumes of portable water from outlying rural districts – were first developed and applied in Europe in the 19th century. Cutting and pasting solutions for Europe and North America from two centuries ago will not solve the problems of a dynamic Kenyan city.

Meeting urban water needs in the 21st century will require a paradigm shift. 19th century supply side solutions alone will not balance the ever-growing demand for water driven by rapid urbanization, shortage of surface and ground water due to climate change and competition from agriculture. Conventional approaches to urban water needs are unlikely to support sustainable communities and sustainable urban growth. The development of sustainable technologies and demand management measures are urgently needed.

Cities are hotspots of water consumption. But cities also have a huge potential to reduce their water footprint. Simple, low cost distributed innovations can deliver phenomenal reductions on urban water demand while creating new jobs in green plumbing and ecological engineering, improving environmental quality and creating exquisite habitat for urban flora and fauna.

I propose an approach that would reduce demand for centralized portable water through water use efficiency, reuse, recycling and purification of domestic wastewater, roof catchment and the abundant urban storm runoff.

Use of flush toilets (at 10-13 liters per flush) consumes nearly 40% of domestic water. Mandating the installation and use of low flush toilet would reduce water use per flush by 50%. Vacuum toilets use 0.5 liters of water per flush to transport the same volumes of human waste. Besides delivering outstanding water use efficiency, a dedicated vacuum sewer network connecting hundreds of households of can generate biogas as produce fertilizer for agricultural use. Furthermore, ecological sanitation approaches, which promote dry sanitation by separating solid and liquid human waste, offer low cost, low-tech non-polluting effective sanitation solutions for low-income urban households.  

Greywater – wastewater generated from showers, baths, hand basins, laundries and kitchens – is relatively easy to reuse. With minimal treatment, in the form of physical filtering and settling, greywater can be reused for toilet flushing and gardening. An ecological engineering approach through the application of constructed wetlands and wastewater aquaculture can be used effectively to for the treatment and purifying of wastewater and contaminated roof and urban storm runoff.

Water quality cascading, an approach that aims to match water quality to water use, is an important demand managing measure. Diversion of grey water from hand washbasin, washing machine and showering to toilet flushing is an example of water quality cascading.

Overall, national policy and institutional resources must focus on providing a framework for an integrated understanding of the multiple approaches to sustainable urban water and promote distributed, rather than centralized than water and sanitation strategies. Such decentralized infrastructure will play a vital role in water supply and demand while enhancing service quality and accountability.

Saturday, April 21, 2012

Holding Educators Accountable

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A report published by Uwezo, an education advocacy organization based in East Africa revealed that only 75% of pupils in class five could read and add at the level expected of a class two pupil. This report raised, unsurprisingly, the questions and debate on weather our kids were learning, and what they were learning.  

In my opinion the question of weather learning is occurring must be asked at all levels of education. I think we must direct our focus to what is going on in our universities, especially the quality and caliber of our graduates.  

We must think about how to hold our professors accountable to the modest but considerable public resources we spend on higher education.

In an Op-ed piece published April 19 in the NYTimes, David Brooks writes that there is fragility hanging over America’s colleges. This fragility Brooks writes comes from the fact that colleges are charging high tuition but it is not clear what benefits they provide.  

Brooks cites the seminal work by Arum and Roska in their book, “Academically Adrift”, in which they found that nearly half the students showed no significant gain in critical thinking, complex reasoning and writing skills during the first two years in college.

Here is an excerpt of David  Brooks column, Testing Teachers.

“In 1961, students spent an average of 24 hours a week studying. Today’s students spend a little more than half that time.  This is an unstable situation. At some point, parents are going to decide that $160,000 is too high a price if all you get is an empty credential and a fancy car-window sticker.

One part of the solution is found in three little words: value-added assessments. Colleges have to test more to find out how they’re doing.  Colleges and universities have to be able to provide prospective parents with data that will give them some sense of how much their students learn.

In 2006, the Spellings commission, led by then-Secretary of Education Margaret Spellings, recommended a serious accountability regime. Specifically, the commission recommended using a standardized test called the Collegiate Learning Assessment to provide accountability data. Colleges and grad schools use standardized achievement tests to measure students on the way in; why shouldn’t they use them to measure students on the way out?

The challenge is not getting educators to embrace the idea of assessment. It’s mobilizing them to actually enact it in a way that’s real and transparent to outsiders. The second challenge is deciding whether testing should be tied to federal dollars or more voluntary. Should we impose a coercive testing regime that would reward and punish schools based on results? Or should we let schools adopt their own preferred systems?

Given how little we know about how to test college students, the voluntary approach is probably best for now. Foundations, academic conferences or even magazines could come up with assessment methods. Each assessment could represent a different vision of what college is for. Groups of similar schools could congregate around the assessment model that suits their vision. Then they could broadcast the results to prospective parents, saying, “We may not be prestigious or as expensive as X, but here students actually learn.”

This is the beginning of college reform. If you’ve got a student at or applying to college, ask the administrators these questions: “How much do students here learn? How do you know?”

Wednesday, April 18, 2012

Toward a Sustainable Energy Future for Kenya


In his book, Hot Flat and Crowded, Thomas Friedman asks how we will know when Africa stands a chance to climb out of poverty. Friedman volunteers an answer to his question, “ it is when I see Angelina Jolie posing next to a vast field of solar panels in Ghana or a wind farm crowded with turbines in Zimbabwe.“

Satellite pictures of the earth at night on Google Maps are incredible. The Americas, Europe and Asia are incandescent. But Africa is this vast pit of darkness, except for the glow in the Mediterranean and the Cape. The World Bank estimates that 75% of households in Africa have no access to electricity. In stark contrast to Egypt and South Africa, Kenya’s most fierce competitors, 85% of Kenyans have no access to electricity. Only 4% of Kenya’s 78% rural population has access to electricity.

The high cost of grid power partly contributes to low connection among low-income households, especially in rural areas and among the urban poor. The cost of energy is US$ 0.15 per KWh, compared to US$ 0.04 in South Africa and 0.07 in China. Moreover, it costs approximately a family KES 35,000 (US$422) to connect to the grid.

The alternative to electricity is biomass. Wood, charcoal, dung and crop residue supply 76% of Kenya’s domestic energy needs. There is a strong correlation between exposure to biomass fuel and respiratory infections in children. A report published by the Ministry of Health in 2004 revealed that acute respiratory infections contribute to 70% of mortality in children aged under 5. According to World Health Organization, biomass energy as a cause of death ranks just behind malnutrition and lack of clean water and sanitation. 

Studies in Bangladesh have shown that study time for school children after sunset was 33 percent higher for those whose homes have electricity. Evidence from the Millennium Villages Program shows that access to electricity in rural public schools can provide access to additional online educational resources for both teachers and pupils, and help close the achievement gap between rural and urban schools.

The combined effects of rapid population growth, increased demand for food and declining soil fertility have made it clear that Kenya can no longer provide sufficient food by muscle power and animal dung. Moreover, climate change will constrain food production further, demanding intensive but energy and water efficient irrigation systems.

Every development challenge we face today is also an energy challenge. The high disease burden can be attributed to shortage of doctors and nurses, but also to a lack of energy to boil water, power diagnostic equipment, or refrigerate life saving vaccines. The weak manufacturing and industrial base is about skills shortage, but also unreliable and expensive energy. Food insecurity is about lack of high quality seeds, fertilizers, climate variability and shortage of power to operate efficient mechanization systems.

Access to energy is highly correlated with economic productivity. The Kenya government recognizes that energy is “one the infrastructural enablers” of the three pillars of Vision 2030. According to the World Bank, African enterprises report an average of fifty-six days of power outage, causing firms to lose 5–6% of sales revenue. For the informal sector, such losses could be amount to 20% of revenue annually. The frequency of power outages in Kenya is 33%, compared to 1% in South Africa, with production losses of about 9.3%

Novel and innovative policy and technological solutions are needed to deliver sustainable, competitive and equitable energy options for Kenya. However, the policy response as contained in various documents: Sessional Paper No. 4 on Energy; Least Cost Power Development Plan; and, the Renewable Energy Program are insufficient. These policy documents are long on conventional grid-based options that have led to the current failures. They are short on practical pro-poor low cost, distributed solutions that are critical to improving equity, reliability, sustainability, competiveness and energy security.

Never in our history has energy policy been so important, not only due to its role in powering social, economic development, but also because of its centrality in national security, environmental stability, climate change adaptation and mitigation and job creation. We owe it to the next generation to be audacious and farsighted in the goals we set today.

An audacious and futuristic energy policy should: specify targets for transition to a clean, reliable, secure and competitive energy supply; promote off-grid, distributed energy solutions for rural areas; set a fuel economy standard of 25 kilometers per liter for all cars by 2030, including tax incentives to purchase more fuel efficient vehicles; set a national energy efficiency target of 15-25% by 2030; reduce market entry barriers and provide high quality energy services; and, facilitate legislation to create a Renewable Energy Research Council to set priorities for energy research and integrate evidence-based energy policy across all sectors.

Tuesday, April 17, 2012

A Staggering Power Gap

Bridging the power gap is about the biggest challenge we have. 75% of Africa's population is has no access to electricity.



Friday, April 13, 2012

The End of Jobs: One Employee, a Robot and You


I think this is by far the best article I have read on globalization and the re-balancing of the world economy in a post recession phase. I think we have come to the end of notions like; local vs. global economy, made in country X and outsourcing. It is easy to understand why the American without a college degree will never get back into a job. 

Here is an excerpt of “How Did the Robot End Up With My Job?, an article by Thomas Friedman, published October 1, 2011 in The New York Times.

Pascal Lamy, chief of the World Trade Organization, argues that terms like “made in America” or “made in China” are phasing out. The proper term, says Lamy, is “made in the world.” More products are designed everywhere, made everywhere and sold everywhere. Indeed, there is no “in” or “out” anymore.

The term “outsourcing” is also out of date. There is no more “out” anymore. Firms can and will seek the best leaders and talent to achieve their goals anywhere in the world. Dov Seidman, is the C.E.O. of LRN, a firm that helps businesses develop principled corporate cultures, and the author of “How: Why How We Do Anything Means Everything.” He describes the mind-set of many C.E.O.’s he works with: “I run a global company with a global mission and one set of shared values in pursuit of global objectives. My employees are all over the world — more than half outside the U.S. — and more than half of my revenues and my plans for growth are out there, too. So you tell me: What is out and what is in anymore?”

In the last decade, we have gone from a connected world (thanks to the end of the cold war, globalization and the Internet) to a hyperconnected world (thanks to those same forces expanding even faster). And it matters. The connected world was a challenge to blue-collar workers in the industrialized West. They had to compete with a bigger pool of cheap labor.

The hyperconnected world is now a challenge to white-collar workers. They have to compete with a bigger pool of cheap geniuses — some of whom are people and some are now robots, microchips and software-guided machines. It is also both a huge challenge and opportunity. It has never been harder to find a job and never been easier — for those prepared for this world — to invent a job or find a customer. Anyone with the spark of an idea can start a company overnight, using a credit card, while accessing brains, brawn and customers anywhere.

There is no doubt that the main reason for our 9.1 percent unemployment rate is the steep drop in aggregate demand in the Great Recession. But it is not the only reason. “The Great Recession” is also coinciding with — and driving — “The Great Inflection.”

Picture this. You arrive at a major cable TV network studio in Washington. A contracted security guard signs you in. The same person will have your nose powdered, attach your microphone, position you in the studio chair before a robotic camera operated by someone in a control room in New York City and speak to whoever the host is and wherever.  That’s it: one employee, a robot and you.








Sunday, April 8, 2012

Educating the Next Generation of Africa’s Entrepreneurs

The global financial crisis, unemployment, rising inflation, rising food prices and the increasing income inequality has precipitated palpable global gloom. This has sapped confidence in our collective ability to attain the Millennium Development Goals, especially in Africa.

It is amidst such gloom and sagging confidence that we must draw upon our collective ingenuity and leverage academia and business to generate novel solutions, beyond “business as usual”. However, African universities offer a plethora of training programs, which prepare students for “business as usual” white-collar jobs in the public and private sectors.

But “business as usual” just won’t do! Now more than ever, Africa needs innovative solutions and new ways of operating to grapple with the most daunting challenges of our time. We are in uncharted territory and need human capital at all ages, who “think out of the box” to solve problems in paradigm changing ways.

The last half-century of Africa’s higher education and economic history shed light on why we are stuck with “business as usual” and the dearth of innovation. Inherited imperial structures of the colonial era, extractive industries and foreign aid have buttressed pervasive central control and stifled the emergence of functional civil institutions and enterprise in a majority of sub-Saharan Africa. Untrammeled executive control and state-owned monopolies have forestalled innovation and entrepreneurship.

The spoilt meat of aid to unaccountable regimes, the consequent public waste and corruption has begotten more poverty, which has in turn justified more aid. Consequently, the notion of entrepreneurship vaporized from international development discourse. In his book, The Elusive Quest for Growth: Economist’s Adventure and Misadventure in the Tropics, William Easterly argues that the mind-set of aid and help has imposed and enforced rules and regulations that have undermined both incentives and opportunities for entrepreneurship.


The convergence of globalization, technology, broadband internet, knowledge-based economies and demographic trends has led to a global focus on the potential for entrepreneurship to drive economic growth in developing countries. In 2010, US President Obama convened a summit on entrepreneurship. Following Obama’s leadership, global organizations such as United Nations Development Program, European Commission, the World Economic Forum and Global Entrepreneurship Monitor have produced extensive literature extolling the promise of entrepreneurship and the role of education.

According to the management expert Peter Drucker, the term entrepreneur was introduced by French economist Jean Baptiste Say to denote a special economic actor – not someone who simply starts a grocery business, but someone who “shifts economic resources out of an area of lower and into a higher productivity and greater yield”.

Joseph Schumpeter, twentieth century growth economist, characterized the entrepreneur as the purveyor of the “creative destruction” and systemic change necessary for a major economic paradigm shift, a game changer. By reimagining the computer as mass-market goods, Bill Gates and Steve Jobs “destroyed” dominant patterns, unleashing new business models and unprecedented leaps in productivity.

Africa’s educational institutions, at all levels need to adopt 21st century approaches to create the appropriate learning environment to encourage creativity, innovation and a proclivity to “think out of the box”. Combined with innovation, entrepreneurship provides an adaptive platform for grappling with Africa’s most daunting development challenges; high diseases burden, hunger, malnutrition, poverty and rapid population growth and unemployment.

Clearly, Africa needs a greater focus on entrepreneurship to help spur competitiveness, growth and job creation. However, low exposure to entrepreneurship, combined with the lack of role models, makes the barriers to entry in African countries significantly higher than in developed countries.

But can entrepreneurship be learned, or, more importantly, taught? Entrepreneurship, according to Peter Drucker¬ is not magic, has nothing to do with genes and like any discipline, can be learned. Education can undoubtedly, play a crucial role in molding the prerequisite attitudes, skills and culture – from the kindergarten level up. Entrepreneurship thrives in ecosystems in which multiple stakeholders play key roles. This requires collaboration and multistakeholder partnerships.

Entrepreneurship education is critical for developing the human capital necessary for the society of the future. But entrepreneurship must not be added into curriculum in a perfunctory manner. Candidate modules for embedding in the school curriculum should include: disruptive technologies and their potential economic and social ramifications; case studies of entrepreneurship in developing countries; comparative history of entrepreneurial progress; business literacy, including accounting, marketing, and financial skills; angel investors; and relationships, networks and social capital.

The modules could be taught and facilitated by an ensemble of international and local professors of entrepreneurship, economic history, case writers and experienced entrepreneurs, and professors of economic history. Excellent mentors and distinguished professors for such a program would include entrepreneurs like Mo Ibrahim of Sudan founder of Cel-Tel, Rwanda’s Miko Rwayitare who founded Telacel, co-founder of SoleRebels, Ethiopia Bethlehem Alemu and my compatriot and senior at Maseno School, Ayisi Makatiani, who founded Africa Online.

The advancement of entrepreneurship may seem tangential to universities committed to promoting science, humanities and the arts. However, entrepreneurs can help situate intellectual endeavors in reality by bringing novel knowledge to bear on urgent societal problems. Most importantly, universities have a pivotal role as intellectual hubs in an entrepreneurial ecosystem

Policy-makers have an important role to play in setting the appropriate fiscal and regulatory frameworks to encourage fundamental reform. Incremental change in education is inadequate in a globally competitive knowledge economy. Africa needs schools and universities that are entrepreneurial in their approach to preparing individuals for an unknown future. Also in dire need of rethinking is the way teachers are trained.

Thursday, April 5, 2012

Recruiting Africans Students into US Graduate Programs

Universities in the United States appear eager to enroll more Africans in their graduate programs. US universities view enrollment of African students as a way to diversify their classrooms and, at the same time, help fix Africa’s massive shortage of locals with graduate degrees.

In particular, two policies are part of the problem; the application of Graduate Record Exam (GRE) scores for evaluation of admission and a large requirement of coursework for graduate programs.

Countries such as the UK, Australia, Canada and France, which evaluate students based on their undergraduate transcripts, are more attractive choices for graduate studies. In contrast to undergraduate transcripts the GRE is a snap shot assessment of verbal, numeracy and analytical reasoning. For a majority of African students, the GRE is not in sync with their previous academic experience and taking the GRE often demands extraordinary effort in preparation.

The GRE by contrast is a one-time test of a student’s overall verbal, mathematical, and analytical reasoning. Africans perceive quite rightly that they will need considerable coaching and study to do well on this type of exam since it is foreign to their previous academic experiences. More specifically, a majority of African students who take the test perform poorly in the math section. Most high school and university curricular marginalize numeracy and mathematical reasoning that require algebra and geometry.

US graduate programs require many classes, and students must pass comprehensive exams.
The high coursework requirement of most US graduate programs means they take longer to complete compared to programs offered in Europe and Australia.

US graduate schools seeking to recruit students from English speaking Africa must address the GRE and coursework requirement. This will demand flexibility and an academic partnership framework with universities in Africa. Flexible admissions should allow potential students from Africa to demonstrate writing analytical and numeracy skills through scholarly work jointly supervised by a US and African professor. Another recruitment strategy would entail utilizing sabbatical time by US professors at an African university to head hunt and or mentor promising students.

Moreover, a proactive strategy is needed to address the duration required to complete graduate programs. A sensible approach would be to design a program that accomplishes the required course work and comprehensive examination in a US university, and undertakes through careful partnership, an African university to serve as a home for graduate research. Such an approach would ensure that African graduate students are working on problems relevant to their countries as well as building the professional networks they need to advance their careers. Similarly, this approach would help US universities expand the international reach of their research and graduate programs

It behooves African and US universities to develop a flexible platform for collaboration in graduate training and faculty research. This is imperative in an intensely competitive and globalized knowledge economy.

This article is adapted from an article by John D. Holm published in the Chronicle on April 4 2012.

Tuesday, April 3, 2012

Herbicides Can Induce Morphological Changes in Vertebrate Animals

Roundup, the world’s most popular weed exterminator can induce morphological change in a vertebrate animal. In a new study published in the Ecological Applications journal by Rick Relyea of University of Pittsburg shows that application of Roundup caused two species of amphibians to alter their morphology.

Relyea set up tanks of simple wetland communities containing leaf litter, algae, zooplankton and three species of tadpoles: wood frogs, leopard frogs and American toads. Some tanks contained caged predators i.e. dragonflies. Tadpoles were added to each tank and then exposed to a range of environmentally relevant herbicide concentrations of Roundup.

The tadpoles were removed from the tank after 3 weeks. The presence of dragonfly predators released chemicals known as kairomones, which induce defenses in the prey – larger tadpole tails. The ability to modulate development in the presence of predators is called predator-induced polyphenism.

The most intriguing finding of this study is that Roundup also induced development of larger tadpole tails. The similar morphological changes when exposed to Roundup suggest that the broad-spectrum herbicide may interfere with the hormones of tadpoles and potentially many other animals. These findings suggest that unchecked, application of herbicides may have far-reaching effects on non-target species, including humans, than previously thought.

In 1968 Waddington coined the term epigenetics, which is now defined as genetic mechanisms that create phenotypic variation without the base-pair nucleotide sequence of the genes. Epigenetic research is currently focusing on the mechanisms of phenotypic plasticity and on how changes in gene expression patterns mediated by the environment can cause diseases such as cancers and hypertension.

See full article: Rick A. Relyea. New effects of Roundup on amphibians: Predators reduce herbicide mortality; herbicides induce antipredator morphology. Ecological Applications Volume 22, Issue 2 (March 2012) pp. 634-647

Sunday, April 1, 2012

The Best Care Possible: A Physician's Quest to Transform Care Through the End of Life

With the proliferation of inpatient care services across the world and especially in the global south, a large majority of people die in hospitals. However, many people suffer poorly managed pain or other physical maladies and live out their final days feeling undignified and burdensome, especially to their loved ones.

Few of us have tried to imagine how different things might be when the end is nigh. Not many of us have grappled with the immutable fact of our mortality. When someone we love or ourselves is diagnosed with a life-threatening illness, the foremost thought we have is death. Few of us will have the bold confidence and privilege of Frank Sinatra to face the end “And now the end is here; And so I face the final curtain; I’ve lived a life that is full.”

Death is not the worst thing that can happen to us or our loved ones. The most troubling and painful thing is to see someone we love suffer and die painfully. In his book “The Best Care Possible: A Physician’s Quest to Transform Care Through End of Life”, Ira Byock attempts to provide candid insights to the dangers that confront seriously ill and dying people and coping with the pitfalls that trap so many.

Byock argues for the need to transform the way we care for seriously ill people and support caregivers. Byock observes that when it comes to caring for people with advanced and terminal illnesses, “our social systems are so broken and our health care system is so dysfunctional and, frankly, neglectful that it would be easy to become furious”.

Throughout history, mankind mostly died quickly and probably easily. Byock writes that dying has become a lot harder over the last 50 years. Byock argues that serious, chronic illness is an invention of the late 20th century, the fruit of scientific advancement.

But Byock argues, compellingly, that our epochal success in forestalling death impacts individual and family life in ways we have yet to understand. Byock writes that our society must take into account the new normal – serious illness, physical dependence, senescence, and senility.

It is a paradox that while so many treatments now work and many people survive longer it is not easy to die well. Clinicians have coined the term “illness burden” for the legion aches, pains, and disabilities that come with diseases and the side effects of treatment. Byock observes that people are more ill before they die today than ever before.

Byock observes that significant medical advances in prolonging or replacing organ functions have not been matched by proficiency in preserving comfort and quality of life for the sick or their families. Byock notes that even in excellent medical care facilities clinicians do not posses the skills needed for comprehensive caring. Physicians are over burdened by treating pain or nausea, ward visits, coordinating appointments for tests and transmitting information among various specialists.

The incessant focus on treatments for sustaining life can leave someone who is living with an advanced disease physically uncomfortable, feeling lost and confused, not knowing how to get through each day or how to prepare for the end. It is no wonder that a consistent finding of public surveys is that nearly everyone wants to spend their final days at home, surrounded by those they know and love.

According to Byock, 50 percent of deaths in the US happen hospitals and nearly 40 percent of those who die in hospitals spend their last days in ICU where they are sedated and restrained so they do not pull down breathing tubes, intravenous lines or catheters. Dying is tough!

Evidently, a transformation is needed in the way our society and culture -- not merely our health care system -- cares for the terminally ill and supports family as caregivers. In the short-term and urgently, effective advocacy by patients and families is needed to avoid common but deadly goofs, avert suffering, and prevent regrets.

Knowing what to expect, what to demand, and what limitations to accept can lessen the burdens of care giving, illness and certain death.

This book is crying out to be read!

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