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THE PRODUCTIVITY EQUATION -1-23-21
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THE PRODUCTIVITY EQUATION BENOIT TANO, M.D., Ph.D.
THE PRODUCTIVITY EQUATION ACHIEVE YOUR MAXIMUM POTENTIAL BY HACKING (MODELING) PRODUCTIVITY CASE STUDIES
REFERENCES SLIDES IN THIS PRESENTATION ARE ADAPTED FROM INTEGRATIVE IMMUNITY TRAINING PROGRAM RESOURCES. ALL REFERENCES ARE INCLUDED IN THE RESOURCES Copyrighted Material, all rights reserved Copyright © 2021 by Benoît Tano, M.D., Ph.D. No part of this presentation may be reproduced, stored in a retrieval system or transmitted, in any form or by any means—electronic, mechanical, photocopying, recording, or otherwise—without prior written permission For more information about this presentation and the Integrative Immunity Training Program, please visit the Integrative Immunity website: www.integrativeimmunityMD.com Providers go to: https://www.tayapro.com to create your website TEXT “I WANT TO BE A MEMBER” TO 952-737-8323, IF YOU WANT TO BE A MEMBER OF TAYAPROUNIVERSITY.ORG, OUR ONLINE UNIVERSITY THAT ALLOWS YOU TO DO TELEMEDICINE AND TEACH WORLDWIDE
ITP RESOURCES: 4 BOOKS # 1 BEST SELLER
THE MONEY EQUATION DISCOVER THE SECRET EQUATION MILLENNIALS ARE USING TO GET RICH BENOIT TANO, M.D., Ph.D.
COURSE OUTLINE • •
Productivity and Goals 21st Century Chronic Diseases Model
•
Back Story Observed Phenomena in Early 1980s The Behavioral Risk Factor Surveillance System ( BRFSS) - 1984 The First Obesity Map – 1985 The making of a Medical Detective (Field Epidemiologist) FIRST ESTATE: The Obesity Pandemic Environmental Toxins And Obesity - Evidence Government Covert Interventions The Government Intervention Timeline The USGS Pesticide Maps - 1992 The CDC Biomonitoring - 2001 The CDC Fourth Report -2009 Nature of the Chemical Groups in the CDC Fourth Report Relationship Between The Chemicals And Chronic Diseases - Organochlorines - Organophosphates and Carbamates - Other Chemical Groups Change of Government Policies - The Organic Food Production Act of 1990 SECOND ESTATE: The Estrogen Pandemic - Timeline - Silent Spring - Our Stolen Future - CDC Biomonitoring
• • • • • • • • • •
• •
• • • • • • • • • • • • • • • •
• • •
Mechanism of Action of Estrogens and other Chemicals in the CDC Fourth Report The Widespread Xenoestrogen Contamination and Identification of Xenoestrogens in your Foods Mechanism of action of Organophosphates/Carbamates and Organochlorine pesticides Mechanisms of action of Xenoestrogens and Phytoestrogens The Role of Estrogens in the Obesity and Allergy Epidemics THIRD ESTATE: The Allergy/Immune Complex Diseases Pandemic FOURTH ESTATE: The Anxiety/Depression Pandemic Most Common Medical Problems in 21st Century Clinics and hospitals Current Approach To Solving The Medical Problems Management of Environmentally Driven Chronic Diseases FIFTH ESTATE: The Bacteria/Viruses Pandemic INTEGRATIVE IMMUNITY Putting it all Together (Pathophysiology of Chronic Diseases) - Macromedicine Model - Atopic Diseases Model - Food Allergy and Autoimmune Diseases Model - Mast Cell Activation Syndrome Diagram - Basophil Activation Syndrome Diagram - Bacteria/Viruses Proliferation Diagram The Estrogen-Free Lifestyle Illustrative Case Study References © 2020 Benoît Tano, MD, Ph.D. Do not Duplicate without Written Permission
OBJECTIVES Upon Completion of this Module, you will be able to:
• • •
• •
• • • • • • • •
Identify and describe the interface between the endocrine system, the immune system Categorize the different environmental toxins and their effects as endocrine disruptors (especially the estrogen pandemic) and correlate with geographical distributions for the obesity pandemic, atopic and autoimmune diseases, anxiety/depression, and bacteria/virus pandemics. Evaluate connections between pesticides, common household chemicals and what I called hormone imbalance syndrome: high estrogen, thyroid dysfunction, gut dysfunction, low male hormones and their impact on well-being Discuss this hormone imbalance syndrome and its impact on obesity and its comorbidities, allergies, and anxiety/depression Illustrate why the south and Midwestern parts of the United States have more obesity, more morbidity, and mortality than other regions by evaluating pesticide maps, obesity maps, and morbidity and mortality maps for these regions Clarify connections between pesticides and growing estrogen pandemic Clarify connections between pesticides and growing obesity pandemic Clarify connections between pesticides and growing allergy, and Immune Complex Diseases pandemic Clarify connections between pesticides and growing anxiety/depression pandemic Clarify connections between pesticides and growing virus/bacteria pandemic Evaluate relationships between the endocrine and immune systems Design steps to effectively treat estrogen-induced diseases, obesity and its comorbidities, allergy, and anxiety/depression problems based on information presented Present a prototypical case study to illustrate this integrative immunity approach to 21st century patients © 2020 Benoît Tano, MD, Ph.D., All Rights Reserved Do not Duplicate without Written Permission
PRODUCTIVITY AND GOALS
WHAT IS PRODUCTIVITY? If you want to be productive, you must know what productivity is. Unfortunately, many people talk about productivity and goal setting as given facts that everybody should know. Many writers and influencers ask you to set goals and to find a system of visualization to accomplish these goals; however, if you do not know what a goal is, how can you set one?
© 2020 Benoît Tano, MD, Ph.D., All Rights Reserved Do not Duplicate without Written Permission
WHAT IS PRODUCTIVITY? • Productivity represents the realization or accomplishment of a preset goal that maximizes a given satisfaction • AS A PRODUCER, WHAT IS YOUR PRESET GOAL OR YOUR “DO OR DIE” THING THAT KEEPS YOU AWAKE AT NIGHT THAT YOU WANT TO ACCOMPLISH NOW? YOUR BURNING DESIRE? • HINT: WHY ARE YOU TAKING THIS COURSE?
© 2021 Benoît Tano, MD, Ph.D., All Rights Reserved Do not Duplicate without Written Permission
WHAT IS A GOAL? A goal starts with an intense desire or idea that often appears ex nihilo or nurtured through life experiences. Once the desire appears, you can ignore it (it is important to write all your good ideas down – you may lose great ideas if you don’t write them down), or you can pursue it with fervor. When you decide to pursue the idea, you decide to make the idea come to fruition (come to life), it becomes a preset goal. Productivity represents the realization or accomplishment of your preset goal that maximizes your given satisfaction
© 2020 Benoît Tano, MD, Ph.D., All Rights Reserved Do not Duplicate without Written Permission
The preset goal can be positive and generate positive externalities (help others)
The preset goal can be passive (dormant, no action accompanies the goal)
The preset goal can be negative and generate negative externalities (harm others)
WHAT IS YOUR PRESET GOAL OR YOUR “DO OR DIE” THING THAT KEEPS YOU AWAKE AT NIGHT THAT YOU WANT TO ACCOMPLISH NOW? YOUR BURNING DESIRE?
The preset goal can be active (acted on)
© Benoît Tano, MD, Ph.D., All Rights Reserved Do not Duplicate without Written Permission
PROVIDERS AND PATIENTS EQUILIBRIUM WELFARE
PROVIDERS WELFARE
WW
PATIENTS WELFARE
EQUILIBRIUM WELFARE
WHAT IS A MODEL?
• A MODEL IS A (MATHEMATICAL OR SMALL SCALE) REPRESENTATION OF A THEORY • WHAT IS A THEORY? • A THEORY IS AN EXPLANATION BEHIND OBSERVED PHENOMENA • TO CREATE A HEALTH MODEL WE NEED TO UNDERSTAND THE STATES OF HEALTH © 2020 Benoît Tano, MD, Ph.D., All Rights Reserved Do not Duplicate without Written Permission
WHAT ARE THE STATES OF HEALTH?
STATES OF HEALTH
WHY DO WE ASK THE QUESTION: HOW ARE YOU TODAY? • WELL (WELFARE) • TRANSIENTLY SICK • CHRONICALLY SICK
PROVIDERS AND PATIENTS EQUILIBRIUM WELFARE
PROVIDERS WELFARE
WW
PATIENTS WELFARE
EQUILIBRIUM WELFARE
PATIENT/PROVIDER VALUE LADDER
WHY DO WE ASK THE QUESTION: HOW’S BUSINESS TODAY?
STATES OF PRODUCTIVITY
• ALWAYS PRODUCTIVE (AP) • TRANSIENTLY PRODUCTIVE (TP) • NON-PRODUCTIVE (NP)
VOCABULARY 1.
Dream
2.
Ideas
3.
Choices
4.
Opportunity Costs
5.
Present-Oriented
6.
Future-Oriented
7.
Meaning
8.
Purpose
9.
Goals
10.
Target
11.
Plan
12.
Direction
13.
Future
14.
Destiny
15.
Visualization
16.
Commitment
17.
Unlimited
18.
Greatness
19.
Motivation
20.
Drive
21.
Action
22.
Effort
23.
Work
24.
Challenge
25.
Discipline
26.
Solution
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34.
Relationships Caring Encouragement Trust Compassion Clarity Service Empathy Listen Love Brain Programs Repetition Learn Thoughts Positive Perspective Focus Clarity Vision Self-Esteem Value Dignity Manners Virtue Good Honesty Humility Spirit Competence Maturity Wisdom Character Imagination
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33.
Attitude Energy Enthusiasm Confidence Determination Endurance Optimism Creativity Courage Patience Perseverance Integrity Heart Strength Will Resilience Change Belief Brave Can Freedom Responsibility Hope Balance Happiness Harmony Potential Opportunity Promise Prosperity Risk Reward Achievement
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.
Wealth Home Success Insight Intuition Possibility Excellence Quality Present Mindfulness Gratitude Peace
Clarity •
Ability to focus
•
Decisiveness
•
Having a vision
•
Focus on results, not activities
•
List your goals
• •
Review your goals often Speak with clarity
Competence •
Excellence yields opportunities
•
Hard work yields improvement
•
The market pays for excellence
Concentration
Creativity
•
Key to effectiveness
•
Tap creative potential
•
Best use of time
•
Look for better ways
•
Sense of urgency
•
Be flexible
Common Sense
•
Ask questions
•
Have one new idea
•
Train Your Mind
•
Think things through
Consideration
•
Listen to your intuition
•
Relationships determine success
•
Learn from your setbacks
•
People skills
•
Golden rules
•
Learn to listen
•
Most firings result from personality problems
Consistency
Courage
•
Dependable work is superior
•
Confront your fears
•
Consistency in relationships
•
Dare to go forward
•
Guard your integrity
•
Avoid ruts
•
Consistency in personal development
•
Be a little afraid
•
No security, just opportunity
•
Fear of failure begets failure
•
Persist despite adversity
Commitment •
To your company, boss, job
•
To your family, friends
•
To yourself, career, success
Confidence
•
To your goals
•
Self-doubt can paralyze
•
Self-confidence begets achievement
•
Behave confident
INTEGRATIVE IMMUNITY INTEGRATION AND AUTOMATION
ALLERGY BILLING
SCIT
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$$ SKIN TEST $$
FUNNEL SYSTEM SQUEEZE PAGE
PARTIALLY AUTOMATED
$$
ALLERGY EDUCATION SLIT
FOOD TEST $?
VIDEO LONG FORM SALES LETTER
COMPLETE AUTOMATION
SLIT
$$
HPI OPTIN
OFFICE VISIT
NUTRITIONAL SUPPORT
EDUCATION
ROS
PE
HORMONE EDUCATION s $$
ESTABLISH RAPPORT/TRUST
PASSIVE INCOME $$
$$
NUTRITIONAL SUPPORT
PASSIVE INCOME $$
$$
VA PRE-QUALIFICATION AND SCHEDULING RETARGETING
IVR QUESTIONNAIRE PAGE
PEHD
HORMONE KIT + F/U $$
LANDING PAGE Funnels-Clickfunnels and Websites-Tayapro Websites TARGET AUDIENCE
FACEBOOK ADS + GOOGLE ADS
3-6-12 MONTHS F/U
$$
THE PRODUCTIVITY EQUATION (TPE) REVISITED 𝑷𝑹𝑶𝑫𝑼𝑪𝑻𝑰𝑽𝑰𝑻𝒀 = 𝐸𝐹𝐹𝑂𝑅𝑇 𝑥 𝐶𝑅𝐸𝐴𝑇𝐼𝑉𝐼𝑇𝑌 𝑥 𝑇𝐼𝑀𝐸 𝑷𝑹𝑶𝑫𝑼𝑪𝑻𝑰𝑽𝑰𝑻𝒀 = 𝐸 𝑥 𝐶 𝑥 𝑇 𝑥 𝑒 ε 𝑬𝑭𝑭𝑶𝑹𝑻 = 𝐹(𝐸𝑁𝐸𝑅𝐺𝑌, 𝑀𝑂𝑇𝐼𝑉𝐴𝑇𝐼𝑂𝑁, 𝑃𝑅𝐸𝑆𝐸𝑇 𝑉𝐴𝐿𝑈𝐸𝑆, 𝑇𝐴𝑆𝑇𝐸, 𝐻𝑂𝑀𝐸, 𝐸𝑋𝑇𝐸𝑅𝑁𝐴𝐿 𝐹𝐴𝐶𝑇𝑂𝑅𝑆, ε) ENERGY = 𝐹(𝐼𝑁𝑇𝑅𝐼𝑁𝑆𝐼𝐶 𝐹𝐴𝐶𝑇𝑂𝑅𝑆 (𝐵𝐼𝑂𝐿𝑂𝐺𝐼𝐶𝑆), 𝐸𝑁𝑉𝐼𝑅𝑂𝑁𝑀𝐸𝑁𝑇𝐴𝐿 𝐹𝐴𝐶𝑇𝑂𝑅𝑆 (𝑇𝑂𝑋𝐼𝑁𝑆), ε)
𝑪𝑹𝑬𝑨𝑻𝑰𝑽𝑰𝑻𝒀 = 𝐹(𝐼𝐶, 𝐴𝐶, 𝐶𝐻𝑅𝑂𝑁𝑂𝑇𝑌𝑃𝐸, ε) 𝑪𝑹𝑬𝑨𝑻𝑰𝑽𝑰𝑻𝒀 = 𝐼𝐶 𝑥 𝐴𝐶 𝑥 𝐶𝐻𝑅𝑂𝑁𝑂𝑇𝑌𝑃𝐸 𝑥 𝑒 ε where IC is the intrinsic creativity or God given talents And AC is acquired creativity also known as intellectual baggage or skills set 𝑇𝐼𝑀𝐸 = 𝐶𝑂𝑁𝑆𝑇𝐴𝑁𝑇 24 𝐻𝑂𝑈𝑅𝑆 𝐴𝑁𝐷 𝐿𝐼𝑀𝐼𝑇𝐸𝐷
THE PRODUCTIVITY EQUATION (TPE) 𝑃𝑅𝑂𝐷𝑈𝐶𝑇𝐼𝑉𝐼𝑇𝑌 = 𝐸𝐹𝐹𝑂𝑅𝑇 𝑥 𝐶𝑅𝐸𝐴𝑇𝐼𝑉𝐼𝑇𝑌 𝑥 𝑇𝐼𝑀𝐸 𝑃𝑅𝑂𝐷𝑈𝐶𝑇𝐼𝑉𝐼𝑇𝑌 = 𝐸 𝑥 𝐶 𝑥 𝑇 𝑥 𝑒 ε
𝐸𝐹𝐹𝑂𝑅𝑇 = 𝐹(𝑇𝐴𝑆𝑇𝐸, 𝐻𝑂𝑀𝐸, 𝐵𝑂𝑆𝑆, 𝑂𝑇𝐻𝐸𝑅𝑆, ε)
𝐶𝑅𝐸𝐴𝑇𝐼𝑉𝐼𝑇𝑌 = 𝐹(𝐼𝐶, 𝐴𝐶, 𝐶𝐻𝑅𝑂𝑁𝑂𝑇𝑌𝑃𝐸, ε) 𝐶𝑅𝐸𝐴𝑇𝐼𝑉𝐼𝑇𝑌 = 𝐼𝐶 𝑥 𝐴𝐶 𝑥 𝐶𝐻𝑅𝑂𝑁𝑂𝑇𝑌𝑃𝐸 𝑥 𝑒 ε where IC is the intrinsic creativity or God given talents And AC is acquired creativity also known as intellectual baggage 𝑇𝐼𝑀𝐸 = 𝐶𝑂𝑁𝑆𝑇𝐴𝑁𝑇 24 𝐻𝑂𝑈𝑅𝑆 𝐴𝑁𝐷 𝐿𝐼𝑀𝐼𝑇𝐸𝐷
WHAT IS PRODUCTIVITY? • Productivity is the dependent variable and represents the realization or accomplishment of a preset goal that maximizes a given satisfaction • WHAT IS YOUR PRESET GOAL OR YOUR “DO OR DIE” THING THAT KEEPS YOU AWAKE AT NIGHT THAT YOU WANT TO ACCOMPLISH NOW? YOUR BURNING DESIRE? (SOME PEOPLE WILL SAY MAKE MONEY!) • THAT THING IS WHAT SOME PEOPLE CALL YOUR PASSION (WRONG NAME BECAUSE YOU DON’T HAVE IT YET)
Satisfaction and goal setting • Satisfaction comes first. For example, most millennials want to drive Lamborghinis or Tesla cars when they feel successful. This desire comes from what economists call the demonstration effect or keeping up with the Jones. Most successful millennials drive Lambos or Tesla, I am a Millennial and successful so I must drive a Lambo or Tesla. The satisfaction is the feeling of success. The good that is used for satisfaction is the car. Once the millennial has planted this idea of satisfaction in his/her mind, he will work toward that satisfaction. They will then find a way to arrive to their satisfaction such as creating an online course, sell goods on amazon, write kindle books and market them, or do affiliate marketing…
WHAT IS A GOAL? • A goal is an intense desire that appears ex nihilo (a dream) or nurtured through life experiences. Once the desire appears (write it down or you may forget it; design a system to capture your ideas), you can ignore it, or you can pursue it with fervor. When you decide to pursue the idea, you decide to make the idea come to fruition (come to life), it becomes a preset goal. Productivity represents the realization or accomplishment of your preset goal that maximizes your given satisfaction • The preset goal can be positive and generate positive externalities (help others = Meaningful Goals) • The preset goal can be negative and generate negative externalities (harm others) • The preset goal can be active (acted on = action is the main thing that drives the goal to the final product) • The preset goal can be passive (dormant, no action accompanies the goal) • Productivity can be piecemeal (You can create the MVP = Minimal Viable Product and you can perfect that ) • Productivity can be a whole
• WHAT IS YOUR PRESET GOAL OR YOUR “DO OR DIE” THING THAT KEEPS YOU AWAKE AT NIGHT THAT YOU WANT TO ACCOMPLISH NOW? YOUR BURNING DESIRE? (SOME PEOPLE WILL SAY MAKE MONEY!) • THAT THING IS WHAT SOME PEOPLE CALL YOUR PASSION (WRONG NAME BECAUSE YOU DON’T HAVE IT YET. THE GOAL COMES BEFORE PASSION)
WHAT ARE YOUR PRESET GOALS RIGHT NOW? • MAKE THE INVENTORY OF YOUR GOALS (research the goal-Youtube, Google, Amazon, library, online course platforms such as Udemy, Teachable, …) • DO YOU HAVE WHAT IT TAKES TO ACCOMPLISH THESE GOALS? • MAKE AN INVENTORY OF THE SKILLS NEEDED TO ACCOMPLISH YOUR GOAL • MAKE AN INVENTORY OF YOUR SKILLS • CALCULATE THE SKILL GAP • SKILL GAP = DESIRED GOAL SKILLS – YOUR CURRENT SKILLS • IF THE GAP IS POSITIVE (MEANING THE REQUIRED SKILLS ARE MORE THAN YOUR CURRENT SKILLS) THEN YOU SHOULD INVEST IN HUMAN CAPITAL • INVESTMENT IN HUMAN CAPITAL DEPENDS ON THE PRESENT VALUE OF THE INVESTMENT
PRESENT VALUE CALCULATION σ𝑛𝑖=1 𝑌𝑖 𝑃𝑉 = −𝐶 + 𝑅𝑖
If 𝑃𝑉 ≥ 0 then invest in human capital There are some hidden traps in this present value calculation that lead to serious miscalculations and a life of debt. Can you spot the potential errors of the PV calculation?
WHAT IS SATISFACTION? • Satisfaction is also known as utility. We all try to maximize our utility subject to a budget constraint. Our utility depends on our consumption needs. In general, the consumer’s problem is as follows: 𝑀𝑎𝑥𝑖𝑚𝑖𝑧𝑒 𝑈(𝑋) 𝑆𝑢𝑏𝑗𝑒𝑐𝑡 𝑡𝑜 𝐵𝑢𝑑𝑔𝑒𝑡 𝐶𝑜𝑛𝑠𝑡𝑟𝑎𝑖𝑛𝑡 − BC 𝐵𝐶 = 𝑃𝑋 ≤ σ𝑛𝑖=1 𝑌𝑖 σ𝑛𝑖=1 𝑌𝑖 is your cumulative income (lifetime income) σ𝑛𝑖=1 𝑌𝑖 = F(Land, Labor, Capital, Entrepreneurship, ε) Your income depends on your resources also known as factors of production The price of land is rent, the price of labor is wage, the price of capital is interest and the price of entrepreneurship is profit WHAT DO YOU HAVE?
WHAT DO YOU HAVE? WHAT ARE YOUR RESOURCES? • MAKE AN INVENTORY OF YOUR RESOURCES • MOST PEOPLE HAVE LABOR THAT IN REAL ESTATE TERMS IS KNOWN AS SWEAT EQUITY. YOU WILL EAT BY THE SWEAT OF YOUR BROW (LABOR) • THERE ARE FOUR TYPES OF LABOR: - Crude labor also known as unskilled labor - Semi-Refined Labor - Refined or Specialized labor also known as skilled labor (commends higher price because of the investment and time put in it) - Expert Level Labor This is the reason why many people go to school, and do on the job training We go to school to improve the quality of our labor so as to commend higher wages in the labor market • Education is a screening device: there is no true specialization • Where to acquire specialization in the 21st century? • IT IS NOT AS HARD AS YOU THINK!
WHERE TO ACQUIRE SPECIALIZATION IN THE 21ST CENTURY? • You can acquire specialization through free education on the internet: - Google (Use the GIN=GOOGLE IT NOW Method) - YouTube Videos - Facebook Group discussions - LinkedIn group discussions - Free Webinars and seminars - Amazon • You can acquire specialization through low-cost online course platforms: - Udemy - Teachable - Coursera - Online private schools and academies and all other online courses some courses are offered by the best universities - Cheap ebooks and books on Amazon
WHERE TO ACQUIRE SPECIALIZATION IN THE 21ST CENTURY? • You can acquire specialization through high ticket specialized training offered by: - Organizations - Accredited Live courses - Accredited online courses - Expert individuals through their mastermind classes or groups - Books written by Experts • You can acquire specialization through low cost online course platforms: - Udemy - Teachable - Coursera - Online private schools and academies and all other online courses some courses are offered by the best universities - Cheap ebooks and books
TOOLS AND SKILLS NEEDED TO ACCOMPLISH YOUR GOALS IN THE 21ST CENTURY
Know
Facebook, Instagram, YouTube, Google, Soloads, and Linkedin Ads
Know
Funnel Systems (Unbounce, Leadpages, Clikcfunnels, Tayapro)
Know
Camtasia for video creation and editing
Know
Cell Phone Video Creation and Editing, Tayapro Video Creation
Know
ActiveCampaign (Aweber, MailChimp, ConvertKit…)
Know
Google Analytics, Google Tag Manager, Connect with Funnels and FB Pixels, Perfect Audience
Know
eCommerce (Shopify, Etsy, and all others)
Know
eBook Publishing
TOOLS NEEDED TO ACCOMPLISH YOUR GOALS
Know
Amazon FBA
Know
Tayapro University
Know
Tayapro Academy
Know
Tayapro Website Builder
Know
Book writing and Publishing
Know
Product Creation and Launching
Know
Coaching
Know
Mastermind Groups
TOOLS NEEDED TO ACCOMPLISH YOUR GOALS
Know
Amazon FBA
Know
Tayapro University
Know
Tayapro Academy
Know
Tayapro Website Builder
Know
Book writing and Publishing
Know
Product Creation and Launching
Know
Coaching
Know
Mastermind Groups
MY JOURNEY • Sam Ovens’ Consulting Accelerator Course • Russell Brunson’s Clikckfunnels • Multiple free Youtube Videos about Facebook Ads (Miles Beckler’s, Kevin David… Free YouTube FB Ads Videos) • Facebook Courses (Dan Henry’s FAFE Course, Multiple Udemy Courses on Facebook Ads, Kevin David’s FB Ads Course, Sam Ovens’ FB Ads Module) • Multiple Courses in Udemy for Clickfunnels, Facebook Ads • Courses on ActiveCampaign • Courses and Webinars about Perfect Webinar creation and delivery • Courses in Online Course Creation (New Kajabi, Thinkific)
CASE STUDY #1: BURNING DESIRE TO GO TO MEDICAL SCHOOL • My back story • Research Findings (needed Biology, Chemistry-both General and Organic Chemistry, Physics, Physiology, Biochemistry…) • My Skills Set: High Level of Mathematics (Calculus, Linear Algebra, Differential and Difference Equations, Applied Calculus, Statistics, and high-level Statistics-Econometrics), Study Skills (boarding school pays), Writing (French Education Pays), reading, and presentation Skills, Essay Questions Skills, Calculation Questions Skills, and Computer Skills • Skills Needed: Multiple Choice Questions Skills (I can Learn that Easily) Plus many of the skills I already have • Skills Gap = MCQ Skills
WHY I FAILED MY FIRST YEAR OF MEDICAL SCHOOL • I had to repeat my first year of medical school • WHY? • What was missing in my Productivity Equation?
THE PRODUCTIVITY EQUATION (TPE) REVISITED 𝑷𝑹𝑶𝑫𝑼𝑪𝑻𝑰𝑽𝑰𝑻𝒀 = 𝐸𝐹𝐹𝑂𝑅𝑇 𝑥 𝐶𝑅𝐸𝐴𝑇𝐼𝑉𝐼𝑇𝑌 𝑥 𝑇𝐼𝑀𝐸 𝑷𝑹𝑶𝑫𝑼𝑪𝑻𝑰𝑽𝑰𝑻𝒀 = 𝐸 𝑥 𝐶 𝑥 𝑇 𝑥 𝑒 ε 𝑬𝑭𝑭𝑶𝑹𝑻 = 𝐹(𝐸𝑁𝐸𝑅𝐺𝑌, 𝑀𝑂𝑇𝐼𝑉𝐴𝑇𝐼𝑂𝑁, 𝑃𝑅𝐸𝑆𝐸𝑇 𝑉𝐴𝐿𝑈𝐸𝑆, 𝑇𝐴𝑆𝑇𝐸, 𝐻𝑂𝑀𝐸, 𝐸𝑋𝑇𝐸𝑅𝑁𝐴𝐿 𝐹𝐴𝐶𝑇𝑂𝑅𝑆, ε) ENERGY = 𝐹(𝐼𝑁𝑇𝑅𝐼𝑁𝑆𝐼𝐶 𝐹𝐴𝐶𝑇𝑂𝑅𝑆 (𝐵𝐼𝑂𝐿𝑂𝐺𝐼𝐶𝑆), 𝐸𝑁𝑉𝐼𝑅𝑂𝑁𝑀𝐸𝑁𝑇𝐴𝐿 𝐹𝐴𝐶𝑇𝑂𝑅𝑆 (𝑇𝑂𝑋𝐼𝑁𝑆), ε)
𝑪𝑹𝑬𝑨𝑻𝑰𝑽𝑰𝑻𝒀 = 𝐹(𝐼𝐶, 𝐴𝐶, 𝐶𝐻𝑅𝑂𝑁𝑂𝑇𝑌𝑃𝐸, ε) 𝑪𝑹𝑬𝑨𝑻𝑰𝑽𝑰𝑻𝒀 = 𝐼𝐶 𝑥 𝐴𝐶 𝑥 𝐶𝐻𝑅𝑂𝑁𝑂𝑇𝑌𝑃𝐸 𝑥 𝑒 ε where IC is the intrinsic creativity or God given talents And AC is acquired creativity also known as intellectual baggage or skills set 𝑇𝐼𝑀𝐸 = 𝐶𝑂𝑁𝑆𝑇𝐴𝑁𝑇 24 𝐻𝑂𝑈𝑅𝑆 𝐴𝑁𝐷 𝐿𝐼𝑀𝐼𝑇𝐸𝐷
ANALYZING MY PRODUCTIVITY EQUATION • Preset Goal, Check! • Effort Component: Home: Blessings and problems – My story (teaching full-time, new baby in the fall of first year, wife in Anesthesiology residency) Taste, Check! Boss (Professors? I did not have a boss, but I failed anatomy by 1/1000th of a point and that messed up my self-confidence and morale) that contributed to failing the whole year? Maybe! Others: My classmates were more positive and encouraging to quit my teaching job and focus on my studies, but it was already too late Time Component: I had a huge time constraint and my opportunity cost is not having enough time to study and tiredness
POST FELLOWSHIP STRATEGIES Armed with these skills set, I was able to complete a BS degree in Biology and I was three classes away from completing a BS in chemistry I was able to enter medical school, graduate and pass all my medical board exams (USMLE Step 1, USMLE Step 2, USMLE Step 3, Internal Medicine Board Exam, and Allergy and Immunology Board Exam).
PLAN AFTER MEDICAL SCHOOL AND RESIDENCY After medical school and residency and two fellowships, I wanted to be one of the best doctors in America and the world. I wrote two books to establish my expertise in a new field of study that I have created called Integrative Immunity. To promote the field to patients, I created the Integrative Immunity Health System clinic, and to promote the idea to doctors and other healthcare practitioners, I have created a CME course for healthcare practitioners.
MY JOURNEY To advertise the clinic, the books, and the training programs for the doctors and other healthcare practitioners, I needed some skills. I could outsource the advertising to an agency, but I have computer skills (My first job out of graduate school was due to my knowledge of computers) and I wanted to learn the new 21st century skills that can liberate anyone from a regular 9 to 5 job. My goal is to take more vacation and have other doctors run my clinics worldwide. Acquiring the new skills will allow me to outsource smart. This is my journey • Sam Ovens’ Consulting Accelerator Course • Russell Brunson’s Clikckfunnels • Multiple free Youtube Videos about Facebook Ads (Miles Beckler’s Free YouTube FB Ads Video) • Facebook Courses (Dan Henry’s FAFE Course, Kevin David’s Facebook AD Course, Kevin David’s Amazon FBA Course, Multiple Udemy Courses on Facebook Ads, and many other subjects) • Multiple Courses in Udemy for Clickfunnels, Facebook Ads • Courses in ActiveCampaign • Courses and Webinars about Perfect Webinar creation and delivery • Courses in Online Course Creation (New Kajabi, Thinkific)
CASE STUDY #1 • BURNING DESIRE TO ACQUIRE SPECIALIZED LABOR (GO TO SCHOOL)
Chapter one: WHO AM I I was born in Deimba (Do Gninma-the river which was the source of life in the village and still is, had clear waters that was likened to the eyes of a person dancing the fetich Do, so Do Gninma means the eyes of Do). My father was born in Kouadiokro which has now been renamed AKLOADEKIKRO (my full name). My paternal grandmother, nanan Yahmeah was born in Assuame, in the province of Agnibilekro; she was an Agni Djuablin woman. My grandfather nanan Akloa Deki was an Agni Bona Man (probably from Ghana because he had a typical Ghanean name-Akloa Deki is short for Akloafoe Di Aki, meaning the most powerful one is behind, or yet to come; this translates into you ain’t seen nothing yet). The alliance between my grandfather and grandmother, therefore, makes my father a half Djuablin and half Bona. My mother was from Deimba, a village located 10 km away from Agnibilekro, 15 km away from Assuame, and 25 km away from the Ghanaen border. My maternal grandmother nanan Affoua Nguettia was an Agni Bona women. My maternal great great grandfather was born in Ghana and was known as Kotoko Yao (Yao from Kotoko, a city in Ghana from which Ashanti Kotoko was coined;
he was, therefore, an Ashanti man). He moved to Cote d’Ivoire, and had a son called Tano Kouakou, who founded the village of Deimba. Tano Kouakou had a son that he named after his father, Kotoko Yao. Kotoko Yao the II took the surname Booboo Dagari, and when called by his surname, he responds that he does not deal with stupid people. He was known as Yao Dagari and that name has continued in the Family. There are currently, two people in my family called Yao Dagari, who are named after Kotoko Yao II (Yao Dagari). Yao Dagari married Affoua Nguettia and gave birth to Akoua Badou and Tien Akoua. Akoua Badou married Angoua Kouadio Ernest and gave birth to me (Akloa Deki, named after Angoua Kouadio’s Father), Tien Kofi (Kouassi) Dominique, Kouadio Nango Gaston, and Angoua Kofi. They also had a girl who died 7 days after her birth in KouadioKro. I was in Kouadiokro and witnessed that death. My mother subsequently remarried and gave birth to another daughter, my sister Akoua Niangoran Philomene. This is my lineage. My maternal great grandmother was stolen by Tano Kouakou and his people, from the North in a current Ghanaian city called Bole. She must have come from the Fulbe or Fulani tribe. My current DNA test shows that I am 17% North African, 56% Niger area, 23% Sierra Leonian, and 6% Kenyan. This DNA mixture pattern seems to trace the great melting pot Africa represents.
All the Agni people migrated from Ghana, at the height of the slave trade to avoid being sold into slavery. They, therefore, settled in eastern Cote d’Ivoire, close to
their origin in Ghana. The Djuablin especially the ones from Assuame, were led by two family heads, Nanan Eponon and Nanan Bossoma. The two families initially settled in Dokanou close to Tankesse, but the river, source of life could not sustain the yearly droughts and, therefore, several of the new settlers perished forcing the two families to seek a better refuge. They migrated 3 km closer to Agnibilekro and thus reunited with all the other Djuablin in the region. To date, there are 27 Djuablin villages in the province of Agnibilekro. The Assuamois settled around a small river
and awaited the first drought which passed without any drying up of the stream. The following year the drought passed by and the river stood. The new settlers therefore
named their village Assue Ayiam, which in Ashanti means the river has invited me.
The Agni people in general migrated from Egypt-Libya area and therefore preserved some of the Egyptian customs such as mummification and royalty. Here, only the kings are mummified. The Agni come from the bigger group known as the Akan group which includes most people from Western Ghana, Eastern Cote d’Ivoire, and Western Togo. All members of the Akan group have the same culture and traditions and have Kings, Queens and worship dead ancestors. On a smaller scale, this worship occurs everyday; on a greater scale these ceremonies occur once a year during the yam
festival which is the Akan Thanksgiving. For the Akan group, God is a duality: Mother Earth and God almighty (Gnamien Pli). Every libation recognizes Mother Earth first
and God almighty second, in reverse order of importance. The group also recognizes other deity and most people are both animist and Christian. People go to church on Sunday morning and make offerings to dead ancestors in the afternoon. However, God almighty (Gnamien Pli) supersedes all other deity.
The Akan believe in reincarnation, and metempsycosis (transmigration of souls from the dead to the living to deliver a message). For the Akan, most deaths are unnatural. Most people, especially young people die by the hands of sorcerers who through black magic give their people away either as a repayment of a debt or as a right to participate in sorcery. Napoleon Hill will say that these people have not mastered their first envelope. According to Hill, we are all born with two sealed envelopes. The first envelope contains all the good things “The contents of the first envelope, labelled “riches” includes the following list of blessings: Sound health Peace of mind Labor of love of your own choice Freedom from fear and worry A positive mental attitude Material riches of your own choice and quantity”
you will get if you take control of your mind and use it fully. If you do not take control of your mind and use it fully, then you pay the penalties contained in the second envelope: “The contents of the second envelope, labelled “penalties” includes the following list of prices one must pay for neglecting to take possession of one’s own mind: Ill health Fear and worry Indecision and doubt Frustration and discouragement throughout life Poverty and want A whole flock of evil consisting of: envy, greed, jealousy, anger, hatred and superstition” The Akan and many Africans have a lot of the contents of the second envelope. The Akan also have been aware of infidelity and usurpation of power for centuries and designed an inheritance system that purports to correct these problems. The system is matrilinearity, which means that the children belong to the mother and as such one inherits from the mother’s side. This means that Nephews inherit their maternal uncle. It is clear that
a sister shares the same blood as her brother and her children share the same blood as their
It is in this background that I was born one Saturday in June in the 1950’s. My father
had a first wife and had several children who died in early childhood. He then married my mother and I was the first born of that marriage and his first son and live
child. My father and mother then made a decision, which I still do not understand today, but in retrospect was the best decision they ever made. My paternal grandfather, Akloa Deki, died probably young and at that time my grandmother, Yahmeah, had four children left (She had many more children who died in early childhood). My father was the oldest child. In the matrilinear society, the person who inherits could keep the widow and her children or let them go. In this particular instance, my grandmother returned to Assuame with her three younger children
(Kouakou, Abokon, and Ehia) and my father remained behind in Kouadiokro (Akloadekikro).
When I was about three years old, my parents decided to send me to Assuame to live with my paternal uncle Tano Kouame Joseph, who initially was a common transportation driver and had decided to return to become a farmer. My father who only had his first-born boy in an agrarian society where first-borns and boys represent wealth, selfishly decided to let go this first-born male child. I still can remember my first day in Assuame with my uncle who was married to my soon to be mother Affoua Mouroufie. Initially, I was to stay with Nanan Yahmeah, but by a twist of good fortune, I liked my uncle’s wife very much and decided to live with her instead.
My early childhood was uneventful, except that I remember not willing to eat much. I was very skinny and the people in Assuame who gave nicknames to everybody called me Deki Bole Gnaa, which translates Deki without intestines. To this date, people who are still alive since that time still remember and are amazed
that I gained weight. I also remember that my adoptive mother was an Abron woman and spoke the Abron language which is close to the Ashanti language Qui (Twi), and she also spoke Agni. Early on, being exposed to several languages in the village (agni Djuablin, the Agni Bona that I spoke when I arrived, Abron, Dioula, More, Lobi), I learned to discriminate very quickly between the languages and made a song out of the different sounds of Bona and Djuablin which people still remember today.
I was very obedient and soft-spoken child. I do not recall any instance when I ran into trouble with any elders of the village, because in the village, it truly takes the whole village to raise a child. If a child were disrespectful to an elderly person, that child will be corrected twice: once by the offended himself and second by the child’s parents.
My parents were converted to Roman Catholicism and by age 6, I started to attend catechism in
Agni. The catechist, nanan Kouadio Niangoran was amazed by my retention and recall abilities and when the day of reckoning arrived, a disappointment stroke. The then Pere Luigi Finotti, the Italian Priest in Agnibilekro, who visits villages every year to baptize the children and allow them
to go for their first communion, decided that he was not going to ask me any catechistical questions because I was too young (those of you who are catholics know what I am talking about). I cried my head off and my father was forced to intervene and begged the priest to ask me the questions. His argument was to the priest that if I could not answer his questions then forget it, I should not be allowed to go for the first communion. Pere Finotti agreed and proceeded to the interrogation. After several questions were well answered, he started to applaud and all the attendees applauded with him; we covered almost every question in the Agni catechism booklet. Afterwards, the priest became my father’s friend and he gave my father one
of the nicest and largest Chapelet (rosary) that I have ever seen, it glows in the night.
By age seven or so, in 1963, most of my friends in the village were going to school but my father had not made the decision to send me to school. Adjoumani Marcel was my best
friend, he was in school and spoke French to me. I also was very much interested in reading so much that within a year, I could recite the whole book of Mamadou et Bineta by heart. I loved school, but since it was an unattainable goal for me, I made my decision to stay in our farm camp with my uncle Ndjore Kouakou (Mako, his surname meaning pepper), and start my own cocoa and coffee farm out of desperation for not being in school. Then, all happened. My father sent my uncle Yao Brou to Koffikro to bring me back to Assuame. My first response was that I did not want to go back and wanted to send him a
message that I wanted my machete that I had forgotten in Assuame when I left for Koffikro sent to me. My uncle Brou then revealed to me that he overheard my father uttering that he
wanted to send me to school.
I jumped of joy and returned to the village the same evening. The next day my father and two other parents accompanied us to Agnibilekro to see the Principal of the major primary school in the region EPP Plateau (Ecole Primaire Publique Plateau), Yao Ananze. Mr Ananze sent us back to the school where a teacher registered us for school. First grade started in September 1963. In November, President Kennedy was assassinated and I can remember that the teacher made an announcement that we were free to go because the president of the United States had been killed. For most children, this was good news because of the day off. However, I can still remember feeling really sad and wondered why someone will kill the president.
Initially, in my first grade class, there were pupils such as Ousmane cissoko, Adama Konate who were from the city and, therefore, knew a little more French. Ousmane frequently substituted for our teacher Mr. Aka and helped students who were struggling with their reading. The teacher writes the lessons on the board and students took turns to read. After one week, everyone in the class should be able to read everything on the board. The ones who could not were sent to kneel in front of the class and were punished. We also learned to write daily with our ardoises (slates). After few months we graduated to pencils and cahier (notebook) and by the end of the year we were able to write with ink. Looking back, this was a great accomplishment for first graders. The first composition came three months after school started and Ousmane ranked first, I do not recall who ranked second, but I ranked third. The final composition, in June, known as composition de passage (passing exam), I ranked first. From there forward, I established my leadership in every class and the whole school. I always ranked first except in second grade when on the first composition I ranked second after Lassina Toure and in fourth grade when I made a stupid” mistake in arithmetics and ranked second once again after Kanga Kouame during the first trimester exam.
In all these cases, I always ranked first in the final composition (exam) which mattered for advancing to the next level. Third grade was taught by Mr. Andre and he was a mean man who whipped the kids who could not recite their lessons. Our fourth grade teacher, Mr. Marcel, was a gentle man who did not beat the pupils. He was very knowledgeable and encouraging teacher who helped us develop sound arithmetic skills. Every day, before the noon recess, we had an arithmetic quiz which was a speed quiz and whoever finishes first was free to leave for Lunch. It
was during one of these quizzes that I made a mistake that led to my second ranking and that was not even the final passing exam and I was very unhappy and Mr. Marcel jokingly told me to let others get into first place ranking. I am telling you all of this to make you aware of how driven
I was. I had the farmer’s strength and converted all the energy to intellectual strength. I now live in the Midwest of the United States and can sometimes see that same strength and drive in children who grew up on the farm.
My apprenticeship took a dramatic turn for better when in fifth grade we waited about two months for our teacher who was assigned but was not coming. The two fifth grade classes were therefore combined and were taught by Mr. Tanoh. Rumors had it that our teacher to be was very wicked and he will inflict corporeal punishment on us. Finally, Mr. Bernard Nianhoulou arrived and we moved to his class (here again the universe has delivered, thank you God!). From the start, he demonstrated that he had far more superb pedagogy than most of the teachers in the school. He, actually, was a pedagogical counselor who was returned to teaching because rumors said he did not get along with his Inspecteur (superintendent) and slapped him. He made us have fun, and had all kinds of mnemonic means for us to remember French grammar and there was no instance of corporeal punishment. I remember learning tons of songs from him as well as “chocobi” which is Parisien French.
Mr. Bernard taught us note-taking skills and made sure that we practiced that in class by writing down most of the important things he said in class. Since that time, I found out that school is not that difficult if you take notes because most teachers and professors actually tell students what will be on exams and if you take notes and put stars or made special signs in your notes indicating that the teacher or professors says this will be on the exam and studied intelligently by focusing on these important points, then there is no reason to do poorly. I have continued to practice the habit of note-taking even now. A year ago, I found out that he even taught us tapping. Can you image learning tapping in the 1960’s in Africa? I used that technique often and I continue to use it today, but I did not know why I was doing it until I took a course in (2016) with Pamela Bruner and she emphasized tapping. You now know why I dedicated my fourth medical book, The Layman’s Guide To Integrative Immunity, to Mr. Bernard Nianhoulou.
When I completed my Bachelor’s degree in 1979, I visited with him in Adzope, a city in south eastern Cote d’Ivoire, where he was working as the Surveillant General of the boarding school of the College
Moderne of Adzope, to thank him for all his help and that was the last time I saw him. He died in the 1990s in bizarre circumstances. My major regret is that he never wrote anything and all his marvelous teaching techniques and all his knowledge are silenced forever. It is quite true that in Africa when an old
person dies, it is a whole library that has burnt. In sixth grade, initially, I was in Mr. Antonin’s class and I was completely lost because I had become so
accustomed to Mr. Bernard’s teaching that I could not organize. Mr. Antonin himself noticed and asked me what was wrong and obviously I could not answer that he had a different style that does not much my learning style. Eventually something happened and Mr. Antonin was transferred to a school in
Abengourou and by good fortune Mr. Bernard was designated to teach our sixth grade class. When I heard that Mr. Bernard was to teach us again I screamed of joy and indicated that I will pass my junior high school entrance exam.
Effectively, Mr. Bernard led most of the class to Junior High school. In sixth grade, I also had a case of bad malaria and could have potentially died if it were not for a God sent Ghanaen medicine man. I spent two weeks sick at home and was visited by my favorite teacher Mr. Bernard. When I passed
the Junior high school entrance exam he bought me my first suitcase and I went on to the College Moderne d’Abengourou which was our regional Junior High school and high school. I remember all my elementary school teachers: Mr. Aka, Mme Ahissia (Ananze)-second grade, Mr. Andre-third grade, Mr. Marcel-Excellent fourth grade teacher and finally Mr. Bernard. One of the most vivid events that I remember in 1966 was when Kouame Nkrumah was deposed by
Kotoka. The aftermath of the coup d’etat could be heard in Cote d’Ivoire. I can still remember the chants on the Ghanaen radio (Kwame Nkrumah nanwo koooh, Kotoka pamnon ooh - which translates, Kwame Nkrumah is gone, Kotoka has chased him out). Agnibilekro being 35 km away from the Ghanaen border, there were a lot of Ivorian military activities in Agnibilekro and at the border. Not knowing really what was going on, we feared a potential war between Cote d’Ivoire and Ghana.
In Cote d’Ivoire in 1969, there were 36 provinces (known in French as Departement) and each province had its own Junior High School/high school with boarding capacity. Most of the teachers in Junior High and High school were French citizens. I can remember teachers such as Mr. and Mrs. Martinez from Saint Jean De Luz, Mr. Charles Bietz who created an art school in Abengourou, Mr. Onezime my math teacher in several classes, Mr. Adam Andre George (Haitian) excellent history and geography teacher who made us draw all the maps of the world and taught us good history of the world, Mr. Tah Victor (Ivorian English teacher) who encouraged us by giving us passports to England, US, or Ghana depending on our answers to his questions, Mr. William Ntem (Ghanaen English Teacher) who actually encouraged us by giving us money for answering challenging questions in 7th grade English class, Mme Chaluleau, one of the best French teachers that I ever had, Mr. Merle French teacher, Mr. Robert Walbridge (American Peace Corps Volunteer, English) who stayed in Cote d’Ivoire, married an Ivorian woman and created a school in Cote d’Ivoire, Miss Treadgold (American Peace Corps Volunteer, English), Miss Haig (British English teacher), Mr. Gousse Ricard (Haitian, Spanish Teacher). I pay tribute to these teachers and those I did not name here today for giving us their time and giving us one of the best education in west Africa.
I definitely enjoyed my Junior high school where I learned comraderie, friendship and became more disciplined and developed methods of learning which have paid dividends. I remember friends such as Adou Tana Henriette, Michele Perrotey (Doni) (French citizen) who now lives in Madagascar and connected recently with me thanks to Facebook, Ebbah Kadio Roger (now in Philadelphia), Ndraman Amoikon, Tadiasse Adaman, Kouassi Kouassi Kan, Comoe Kouassi, Koumoe Kouassi, Korangui Kouadio Alain-Noel, Assie Leandre, Amoikon Kouao Kumassi (Friend and Rival), Tanoh Koffi, Kangah Apenan Pascal (who was injustly and cowardly murdered as he became the financial Director of SODECI and no culprit was ever found).
CASE STUDY #2 • BURNING DESIRE TO STUDY ABROAD
When I graduated Junior High School, I was oriented into Economics and social sciences at Lycee Technique d’Abidjan, one of only two (Lycee Municipal de Bouake was the other) that had that program. From Seconde AB, I continued onto Premiere B and Terminale B and passed the Baccaleaureat exam with honors and entered the faculte des sciences economiques of the Universite Nationale d’Abidjan. My first year in college was good and I passed my end of the year exam on the first trial. Every student is given two chances to pass the exam. If the first trial in June usually does not go well, the student is given another chance in September called the second session. If the student fails to pass the final exam, then, he has to repeat the whole year. There was no credit system like in the US where students earn credits in classes they do well in, and only repeat classes that they fail. Here, regardless of your performance in individual classes, if you do not achieve an overall passing grade of 10/20, then you have to repeat the whole year. This system still prevails in the French education. My sophomore year in college was more traumatic.
During the time of the final exam, one of my best friends committed suicide for no apparent reason and my first girlfriend, in the middle of exams sent me a separation letter. These two events were devastating to me and I could not focus on my work. I therefore failed my first session exam but had the summer to catch up and I was able to pass the exam in the second session. I went on to pass the junior year and senior year exams with flying colors. My senior year was the most significant year of achievement and I graduated with honors (Mention Bien – Magna Cum, no one ever graduated Suma Cum, when I was in college) from the Universite Nationale de cote d’Ivoire in June 1980. In those days, students who performed well, were sent abroad for graduate school. Although most students went to France, few students were chosen to go to the US and I was among the few.
There were three of us (N’din Dian, now in Montreal Canada, Seka Pierre Roche, former chairman of the economics department of the Universite Nationale de Cote d’Ivoire, who unfortunately passed away in December 2015, and myself) on our scholarship decree. We matriculated as civil servants and were sent to the US to earn Ph.D’s in various fields of economics and return to Cote d’Ivoire to serve the country. October of our second year in 1982, a national decision was made by Cote d’Ivoire to cut off the scholarships. There was no warning, I was in the middle of mid-terms at SUNY-Albany and in good academic standing, when I received news from N’din Dian who was at the American University in Washington, DC, that the scholarship has been cut off and that we needed to go to the Cote d’Ivoire Embassy in Washington, DC to get plane tickets for our return home. I was doing well in school, I was on target for graduation, but alas, I must forgo my dreams and return to Cote d’Ivoire.
To make matters worse, I had brought my girlfriend that summer to the US and we were married in August. Without money or any other means of support, I saw Dr. Paul Ward, the then foreign graduate student advisor, who was kind to us during our journey of changing my wife’s visitor’s visa to an F-2 visa. That process took a long time and drained all our funds. In the face of adversity, Dr. Ward, once again came through, and gave me a note to send to someone in the Solar house at SUNY-Albany (those of you who attended school at SUNY- Albany may still remember the solar house). When I arrived, the lady who read the note asked me if I were a special student, because Dr. Ward had asked for a six hundred dollars emergency fund for me and that, in 1982, was a lot of money. I saw the chairman of the economics department, Dr. Pong Lee, who told me that there were no more assistantships left. I then went to Dr. Thad Mirer, the then economics graduate students advisor and argued my case.
I remember telling him that my first semester at SUNY-Albany, I took four classes when everybody else took two or three maximum. Most African students matriculated for the master’s degree first and then went onto the Ph.D after the Master’s. I wanted to do things faster. I was therefore forced to take one master’s level class and the three Ph.D. classes (Microeconomics, Macroeconomics and Econometrics) sequences to be able to take the advanced levels of these classes in the Spring. I was able to achieve a B grade in all 4 classes. My argument to Dr. Mirer was that I was advancing faster than any other student in the program and will finish the Ph.D. faster. What also helped was that I had officially matriculated in the Ph.D. program in August 1982. After my discussion with Dr. Mirer, he urged me to write a letter to the graduate committee to explain why my country cut off the scholarship.
The graduate committee convened a meeting and they decided to provide me with a fellowship starting the Spring of 1983. I, therefore, had to find ways to sustain myself until January 1983. These moments were some of the hardest times of my life. Here I am, newly-wed, without money, and stranded in a foreign country such as the US. I called home and one of my uncles (Jean-Jacques Bouadou) was able to send some money, but it was not enough to sustain my wife and me. Honestly, the reason I married my young bride was to help her go to school in the US. The archaic French system had made her a victim. She was among the best students (ranked 5th) in her Terminale D class, at Lycee des Jeunes Filles de Bingerville. She took the Baccalaureat exam and was sent for the oral session, then a wicked professor failed her. I was so angry about the system that I decided for her to join me in the US. My plan was for her to quickly get her GED and then enroll in college. She actually did extremely well.
Her placement test was excellent and was able to quickly get to the last level of the GED preparation class. She was to take her exam early November, when in October, we received news that the scholarship was cut off. I really wanted her to succeed because she was a very good student. I then asked her if she would be willing to return to Cote d’Ivoire and repeat her Terminale D class. Since she was a brilliant student, she was to repeat her class with full scholarship and her spot in the boarding school was reserved. She therefore made the decision to return. She was already late for classes but the administration had pity on her and let her in. She went on and did well that year, 1982-1983 and passed her exam. She was oriented to the Medical School in Cote d’Ivoire. Her second year in Medical School in the summer of 1984, I was able to purchase a plane ticket for her to visit. When she arrived, she warned that it was time to have a baby or else it might be very difficult later because the medical school workload gets heavier and heavier.
We tried and the second month was successful and on May 18, 1985, we were blessed with a baby boy that we named Jean-Yves Kouame Tano. I name my son after my father Tano Kouame. I was able for the first time to visit Cote d’Ivoire after the birth of my son. During my visit, I was given some stipend by Dr. Atsain Achi, the architect of our civil servant scholarship in 1980, to evaluate the demand for commodities in the major markets of Abidjan (Adjame, Cocody, Treichville). This work was to be data gathering and econometric modeling. To my dismay, the only center for economics and social sciences of Cote d’Ivoire, headed by a director who earned his Ph.D. in economics in the US, had only French minicomputers called Goupil that were not compatible with any other micro-computers of the world.
The center therefore had hired a young amateur software designer to design
econometric software that could be used with goupil computers. After few sessions with the software designer, it became clear that the guy did not know
what he was doing. In the end, no data were collected and no statistical analyses were performed. I spent three months at CIRES doing nothing and did
not see any of the researchers accomplish much either. When I returned to the US, few weeks later, Mr. Claude Perrot, a Canadian citizen who was working at
the CIRES as a consultant wrote to me, demanding a report of my work during the summer 1985. Instead of writing to Mr. Perrot, I wrote to the Director, Dr.
Atsain Achi, and complained about the center’s inadequacy in computing and that the center will not achieve any results if things do not change.
I offered to Dr. Atsain to help him purchase few IBM compatible personal computers that will use econometric software such as TSP, RATS, SPSS, Gauss and other well-known econometric software used in the US that time. Dr. Achi did not respond to my request. When he subsequently visited us in Albany, I asked him about my letter to him and he replied in political terms that I did not know the constraints he had to work with. I understood that the funding of CIRES coming from the French there was a demand on the center to buy French mini-computers instead of American IBM compatibles that will be more efficient for the researchers. This was my first experience with some of the sources of economic tragedy in developing countries. Usually, these countries are given aid money, but the money must be used to buy products from the country that gives. This is known as aides liees
CASE STUDY #3 • BURNING DESIRE TO COMPLETE A PhD IN ECONOMICS
Candidate’s background: After obtaining my BS degree in economics with honors Côte d’Ivoire (Ivory Coast). I received a national scholarship for graduate studies in the US. I obtained my Ph.D. in economics with specialization in econometrics and labor economics at the State University of New York at Albany and taught economics at the University of Toledo for seven years. I have always had an interest in medicine and while teaching, I obtained a BS degree in Biology and eventually entered medical school at the Medical College of Ohio in Toledo. When I graduated, I found a residency position in internal medicine at the Ohio State University Medical Center in Columbus, Ohio. After my internal medicine residency, I thought it would be good to combine my economics and medicine. I found a two-year pharmacoeconomics and outcomes research fellowship sponsored by the Ohio State University Medical Center and GlaxoSmithKline that helped bridge my economics and medicine backgrounds. During my research fellowship, I spent a year at the GlaxoSmithKline headquarters in Research Triangle Park and worked with the Respiratory Global Health Outcomes group. My work led to five abstracts that were presented at national and international meetings and one publication. However, I wanted to pursue a clinical fellowship, and given my interest in asthma and respiratory diseases, and having worked with allergy and immunology patients for about a year, I decided to do my clinical fellowship in allergy and clinical immunology. In July 2004, I started my clinical fellowship training at the Johns Hopkins Asthma and Allergy Center in Baltimore. During my fellowship, I continued to do research in the area of acute treatment of asthma, looking at the cost-effectiveness of Heliox in the treatment of acute asthma. While looking at who gets Heliox, it was found that the epidemiology of Heliox therapy is not even characterized. I presented an abstract of an initial epidemiologic evaluation using Hopkins data, at the American Academy of Allergy, Asthma and Immunology (AAAAI) annual meeting in 2006. I have also presented a cost-effectiveness of Heliox study using Ohio State University Medical Center data at the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) European Congress in Barcelona, Spain in 2003. To my knowledge, there is no other cost-effectiveness study of Heliox. I was invited for a presentation of my findings at the AARC International annual meeting in San Antonio, Texas in December 2005 and at BOC Medical Heliox Conference at Imperial College in London, UK, in July 2006. Since completing my Clinical fellowship in June 2006, I have taken an associate professor position at the University of Texas Health Center at Tyler, which is the only major rural hospital in east Texas
As a physician who grew up in an African rural area and now participates in the care of the underserved and poor populations and as an economist who understands the value of investment in human capital and the effect of poverty on health promotions, I think that preventive medicine in America needs a boost. However, if research and money continue to be spent on mostly addressing current chronic disease burden, without digging at the roots and curing it, money thrown at these diseases will not be cost-effective. Lack of decent education and its ensuing consequences on employment remain the greatest threat to resolving the issue of health disparities in America. Growing up in Côte d’Ivoire, I saw how children of farmers with poor backgrounds obtained great education through government sponsored boarding elementary and high schools. Public boarding schools still exist in African, European and other countries and help children of poor backgrounds attain educational levels they would not have otherwise. In the US, most boarding schools are private and expensive. The educational landscape of inner city and rural America very much resembles that of third world countries and can benefit from an innovative public boarding school system. The rationale for education as a solution for eradication of health disparities stems from the observation that education leads to employment by greater proportions than non-education. Employment leads to income and health insurance that have immediate effect on healthcare utilization, adherence and health status, with feedback to more education in form of on the job-training, more investment in human capital secondary to tuition reimbursement programs and more access to employment, higher paying jobs and improved health status. In addition, education has an intrinsic effect on health status. This simple analysis demonstrates that one of the solutions to addressing socioeconomic problems in the inner city and rural settings that will have lasting effects on health disparities will be for society to be bold to embrace adequate schooling for inner city and rural future generations. I am therefore working on a socioeconomic model that will help alleviate health disparities in America.
My plan for the next two years is to: 1. Focus on data gathering and a cost-effectiveness analysis of European and African public boarding school systems. The outcomes of interest will be educational level attained by boarding school children (for example success on the Baccalaureate exam), their health behaviors and current health status compared to the day school children. This public boarding school system will be compared to the private boarding school systems in Europe, Africa and the US to assess the yearly average total cost. Cost-effectiveness will be measured as an incremental cost to outcome ratio (or cost-effectiveness elasticity) that will help in policy decision making process. 2. The interrelationships between education and health outcomes (health status and healthcare utilization) will be explored by looking at early intervention programs in the US. Indeed, programs exist in the US today that focus on early childhood education such as Head Start. During this data gathering period, the employment, income, health insurance and health outcomes of Head Start participants will be evaluated to assess whether early intervention has any lasting effect on health behaviors of adults. Head Start participants will be identified and a questionnaire such as the SF-36 will be administered to evaluate the health status of these participants. 3. The model of the interrelationships between education, employment, income, health insurance and health outcomes will also be tested by accessing large databases such as Medical Expenditure Panel Survey (MEPS) and establish the correlation between these variables. Year 3 and beyond: Once it is demonstrated that boarding schools are cost-effective and promote good health and that early intervention programs in the US also promote good health, then a pilot program of a public boarding school for children with poor backgrounds will be established in East Texas (Tyler). This will foster the relationship of the university health center with the rural community. This pilot project eventually, will lead to a multi-center prospective cohort study that could shed light on the impact of good, basic education on health promotions in inner city and rural areas. My economics/pharmacoeconomics and outcomes research and medical backgrounds represent a unique set of attributes that will assist me in the conduct of this project. My years of teaching and research coupled with my strong academic background represent assets that will assist me. My training in econometrics and labor economics will help in the economic modeling, statistical design and analysis of the data and my training in pharmacoeconomics and health outcomes research will help in the design and conduct of psychometric analyses, quality of life measures, cost-effectiveness, cost-benefit, and costutility analyses.
My short term research goal is therefore to get initial funding for the pilot project and I am applying for a K-23 award that will eventually lead to an application for an RO1 for the prospective cohort study. A multi-disciplinary team approach will be utilized and partnership with several federal government institutions (such as NIH, NSF) and state and local government institutions will be sought. I chose to be in the academic setting because of my prior experience and my love for research and I intend to contribute to the permanent solution of healthcare disparities in America and on a larger scale, provide a model for the rest of the world. As an Allergy/Immunology physician I also intend to contribute to this field. I will therefore continue to pursue my research in the treatment of acute asthma exacerbations as well as prevention of asthma, allergic rhinitis and sinusitis in children through immunotherapy. I want to thank you in advance for your consideration and support. Career Goals and Objectives: Since completing my Clinical fellowship in June 2006, I have taken an associate professorship position in Allergy and Clinical Immunology at the University of Texas Health Center at Tyler (East Texas). My career goal is to become an independent investigator with specific expertise in prevention of atopic diseases (asthma, rhinitis, and sinusitis) and other chronic diseases in children and adults and help resolve the issue of health disparities in America through good basic education for all American children. My short term research goal is to get initial funding for the health disparities project. I am applying for a K-23 award that will eventually lead to an application for an RO1 for a prospective cohort study. A multi-disciplinary team approach will be utilized and partnership with several federal government institutions (such as NIH, NSF) and state and local government institutions will be sought. Through this project, I will learn to access and analyze large databases. I have already started by attending a MEPS/HCUP Data Users’ Hands-On Workshop in Rockville, MD in august 2006. I intend to participate in other workshops and to learn SAS so as to be highly proficient in large database access and analyses. I will also learn invaluable lessons in this first multi-disciplinary approach to a community based project.I have Mentorship through Dr. David Coultas, our chief of Medicine at UTHCT and Dr. Steven Idell, Vice President of Research. We have weekly meetings on the disparities project and I am smoothly planning all the steps for the K-23 award application and subsequent RO1 application.As an Allergy/Immunology physician I also intend to contribute to this field. I will continue to pursue my research in the treatment of acute asthma exacerbations as well as prevention of asthma, allergic rhinitis and sinusitis in children through immunotherapy. This will enable me to learn the conduct of clinical trials. I have already taken classes at the Ohio State University Medical Center about clinical trials but I have not had a chance to practice the theory. I will learn this trade through the design of our immunotherapy project and my Heliox clinical trial project. In the long run I will have expertise in prospective cohort studies, large databases access and analyses, and design
Importance of the Mentored Patient-Oriented Research Career Development Award: Support from this award is critical for me for two principal reasons. First, the award will allow me to train in laboratory techniques for a better translational future studies in allergy vaccines and cellular response. This period of mentored patient-oriented research with Dr. Barnes will provide me the opportunity to develop highly specialized skills for measuring cellular response of allergy vaccines specifically and for all other vaccines in general. The newly developed QuantiFeron test for Latent TB offers a platform for measurement of the cellular response to allergy vaccines. My current environment is ideal for achieving these aims as the UT Health Center at Tyler has a long term commitment toward developing immunological based research in cellular response to TB and Chlamydia infections. Dr. Peter Barnes is an expert in cellular immunology and his expertise will guide to a productive innovation of the techniques used in his laboratory towards the measurement of cellular response in allergy vaccination. The end result for me will be an expertise in measurement of cellular response in allergy vaccines and all other vaccines and translational studies involving allergic diseases (asthma, Rhinitis and sinusitis). The studies outlined in this proposal will provide the foundation to broaden and deepen my clinical research skills. The proposal will provide me with the opportunity to addressing three important research questions that will add contributions to the health disparities questions. My economics/pharmacoeconomics and outcomes research and medical backgrounds represent a unique set of attributes that will add another dimension to study design and statistical analyses of the results. My training in econometrics will help in the economic modeling, statistical design and analysis of the data and my training in pharmacoeconomics and health outcomes research will help in the design and conduct of psychometric, quality of life measures, cost-effectiveness, cost-benefit, and cost-utility analyses. RESEARCH PLAN 1. SPECIFIC AIMS: In recent years American healthcare professionals and government officials have discovered a new problem: Healthcare disparities between inner city and suburb America and countless hours have been dedicated to addressing this problem. However, though the disparity question has gained national attention and studies have been conducted to address the problem, most of these studies have focused on documentation and observation of facts. No studies have ventured into the roots of the American inner city genesis and how to empower inner city dwellers to escape from poverty, which is recognized as enemy of good health. This study purports to briefly recall the genesis of Inner City America, with emphasis on the sub-education trap and its consequences on inner city economy and health and proposes a way to escape from the inner city environment.
I.
THE GENESIS OF INNER CITY AMERICA
Most cities in America today have their inner city, a nice way of describing the ghetto. In the 1950’s and 60’s, when American black slaves run from oppression in the south and migrated to cities in the North, they arrived with minimal initial endowment. In facts, these blacks and their ancestors had worked since 1518 without compensation. Arriving up North without the economic resources meant that they could only afford to live in places that their money can buy. These places in every city were where housing was not in good condition, usually, the oldest part of the city (the inner city). Most blacks therefore aggregated in the ``Inner City”. We all recall segregation laws and their educational and economic impacts on inner city dwellers and blacks. To recall briefly, these laws stated that blacks and whites could not live or work together in the same environment. This meant that blacks could not go to the same schools as whites or obtain high paying jobs as whites. Black children and even adults who undertake schooling have to remain in their inner city environment that has less to offer. Subsequently, the laws of school financing added that property taxes would be the basis for school financing. This meant that inner city schools would have the lowest quality. The black children starting with the lowest initial endowment end up with poor education, poor job prospects and high unemployment rate. Basic economics principles teach as that high unemployment rate has health and social consequences. Unemployment in genera leads to depression, substance abuse, divorce, suicide, and crime. These major facts have continued to dominate inner city life, despite the abolition of segregation, the implementation of affirmative action and states’ monetary contribution to inner city education. Blacks continue to attend predominantly inner-city schools. The economic base has not changed in decades because of the lack of education. Labor economics theory of investment in human capital stipulates that earnings are function of years of schooling and demonstrate that high school graduates earn more than elementary school graduates and that college graduates earn more that high school graduates. These theories also demonstrate that education is a screening device and a filter. Poor education in the inner city has therefore translated into high unemployment, depression, family separation, crime, incarceration, substance abuse and higher disease rates in inner city America. Against this background, health economics and health disparities studies have found that inner city dwellers are non-adherent/non-compliant (citation) and use the emergency rooms as their main medical care point (citation). Most of the inner city dwellers are uninsured, have Medicaid do not have equal access to healthcare and incur differential treatment by healthcare professionals. These observations have not translated into policy and current efforts of studying non-compliance, non-adherence in inner city dwellers do not address the major reason why these things happen. To understand the intricacies of inner city life, we will contemplate a hypothetical case of an inner city consumer, titled ``Conflicting Responsibilities and demand for health care in Inner City America.
II. CONFLICTING RESPONSIBILITIES AND DEMAND FOR HEALTH CARE IN THE AMERICAN INNER CITY Meet a typical inner city consumer: This is a 35 year-old woman, tenth grade dropout who has held several minimum wage jobs for the past 15 years. She has four children: a 15 year old, 12 year old, 9 year old and a 5 year old. All the children have different fathers who are not around because they do not have stable jobs and they all have been incarcerated one point in their lives and therefore cannot find any stable employment due to their criminal records which will haunt them for the rest of their lives. The children are left alone at one frequently when our consumer is at work. The lack of parental supervision and assistance with the children’s homework and overall education, has led to consistently poor school performance and behavioral problems in the older children. The burden of single parenthood has led to increased stress, depression, and obesity with its consequences of diabetes and high blood pressure in our consumer. She also has seasonal allergies and uses both prescribed and Over-The-Counter (OTC) medications daily. She lives in inner America, in a 100 year–old apartment that has tile flooring, radiator heat, gas stove, and window fans. The whole section of the city has cockroaches, mice and rats. This household has no pets. This consumer’s five year-old son has eczema, and has been treated several times in the emergency department for reactive airway disease that recently has been diagnosed as mild intermittent asthma. This consumer is the only provider for this 5-member- household. The initial endowment of the household is in form of subsidized housing. This consumer works for MT (Major Trouble)-incorporated as an administrative assistant. MT as all minimum wage facilities has productivity pressures and therefore makes heavy demands on the employees. MT does not provide any health insurance to her employees. This consumer has been warned about two absent days that she attributes to her child’s recurrent asthma flares. This consumer also notes that she has been let go from four previous jobs secondary to absenteeism related to her child’s care. One time, she was out of work for three months and almost lost her subsidized apartment for nonpayment of the rent. This consumer’s major concern today is to provide basic necessities for her children. The children attend the neighborhood daycare, elementary and high schools. The grandparents and other family members occasionally help in the babysitting business.
This morning, the 5 year-old child with asthma is coughing. He has had URI symptoms for the past three days. The cough is intermittent, dry and started last night. This morning, the cough has mildly increased in intensity but the child is still running around the house and stops only for coughing. This consumer’s problem is to maximize the utility (total satisfaction) of her household, subject to her budget constraint. She will need to choose the level of composite goods that includes leisure (X) and the level of household health (H) that maximizes the household utility. The Consumer’s problem is to Max U (X, H) Subject to Budget constraint = (Ph + wh) H + (Px + ws) X ≤ Y where H = Hp + Hc t = own-time input per unit of medical services Ph = Pp + Pc s = own-time input per unit of X Y= Yi + WNL Ph = out of pocket money price per unit of medical Hp = Parent’s health Px = money price per unit of X Hc = Children’s health Yi = initial endowment W = wage rate per efficiency unit N = Index of skills N transfers one unit of labor, L, into NL efficiency units, which are assumed to be perfect substitutes in the production of X. L = number of hours worked (see Tresch, p. 365) This utility maximization yields X*, the level of composite goods and H*, the level of health care that satisfy this consumer’s budget constraint. X* and H* are dependent on Y, (Ph + wh), and (Px + ws), the income, price of health care and price of the composite good. A brief comparative static analysis demonstrates that this consumer cannot increase her initial endowment Yi on her own. She can increase N, the index of her skills by undertaking more investment in human capital. However, investment in human capital comes at the expense of hours worked and therefore a reduction in the household’s total budget.
increase her initial endowment Yi on her own. She can increase N, the index of her skills by undertaking more investment in human capital. However, investment in human capital comes at the expense of hours worked and therefore a reduction in the household’s total budget. These difficulties suggest that positive economic solutions have failed for this household. A normative solution is therefore needed to keep this family afloat. Society should therefore intervene to rescue this family. In the past, government interventions in this type of setting, took the form of subsidies (housing, food stamps-welfare) that led to governmental waste because of pervasive abuse of the system. The system is therefore outlawed in several states and various work and educational solutions have been in place, but the inner city problems continue. To address the roots of America’s health care disparities, all the interconnections between education, employment, income, insurance, health status, adherence and healthcare utilization should be explored. The following diagram maps the interdependence of these major socioeconomic factors and health care outcomes.
Diagram of SES and Health Outcomes Interactions EMP ADH EDU
HU
HS
INS INC
Where EDU = Education EMP= Employment INC = Income INS = Insurance HS = Health Status ADH = Adherence HU = Healthcare Utilization Health disparity studies have focused on individual components of these intricate relationships. For example, several studies have tackled the question of access and looked at the impact of lack of insurance on adherence, health utilization, and health status, and have yielded conflicting conclusions. Models that attempt to grasp the interrelations among major SES variables and health outcomes variables are limited. In order to solve the inner city problems, society should focus on the whole diagram. Analysis of the relationship between SES factors and health outcomes, clearly points to education (schooling) as the driving force. Education has an intrinsic value in affecting an individual’s health status, adherence and health care utilization. Labor economics theory teaches us that education is a filter and a screening device. In a labor market where there is a predilection to discrimination, a lack of education is a double whammy that leads to huge unemployment. This explains why when the national unemployment rate is 5 percent, the inner city unemployment rate is around 40 percent. Education therefore leads to employment by greater proportions than noneducation. Employment leads to income and insurance that have immediate effect on health status, adherence and health care utilization, with feedbacks to both more education in form of on the job-training, more investment in human capital thanks to tuition reimbursement programs and more access to employment and higher paying jobs. This simple analysis demonstrates that in order to address socioeconomic problems in the inner city and put an end to health disparities, society should be bold to embrace adequate schooling for inner city future generations. Several school models have been proposed and currently under operation and some such as Head Start have yielded partial success. Studies that quantify the
impact of Head Start are now emerging and they show that Head Start participants enjoy educational benefits beyond high school (citation). The magnet schools, Head Start and other schooling models, however, have not solved the inner educational woes. The federal government has left the schooling business to state governments and with their limited resources, huge opportunity costs arise when a state tries to focus on inner city schooling. It is therefore imperative that the federal government intervenes in the inner city schooling business. The federal government and therefore the American society’s problem is to maximize a social welfare function that encompasses all individual utility functions such as that of our typical consumer’s and that will emphasize the probability of escape from the Inner City (Prob_ICE). Prob_ICE = Prob_ ED x Prob_EMP x Prob_HEALTH Prob_ ED = F (parents education, parents income, parents inner city status, parents initial endowment, ) Parents initial endowment (E) = , in other words, the inner city initial endowment is the sum of the cumulative endowments from 1518 (date of first slave arrival in the Americas) to present. If inner city parents have negative, no, or little endowment, then the children’s escape from the inner city without society’s help is nil.
Prob_EMP = F (ED, U_ic, Vs, V_us, N0. of Imm, Trans, e) where ED = Education; U_ic = Unemployment in the inner city; Vs = Vacancy for skilled jobs, V_us= vacancy for unskilled jobs (minimum wage jobs), No.IMM = number of immigrants in the inner city environment; Transp = transportation, e = error term that captures omitted variables. Society’s welfare function is a flexible generalized welfare function that incorporates the utilitarian and Rawlsian Hypotheses (citation). The utilitarian hypothesis is that, society will be better off if we can maximize a social welfare function that encompasses all individual utility functions. Rawls counters that society is better off if the utility of the least fortunate member is maximized. In essence we should maximize Min (Uh).
The flexible social welfare function is as follows: (1) Where v is a constant reflecting society’s aversion to inequality. If v =1, implies that W is the straight sum of the individuals’ utilities (utilitarianism). At the other extreme, v = -∞, implies maximizing the utility of the worse-off individuals, the Rawlsian maximin criterion. Given the background of slavery in America for centuries, and current unequal distribution of resources among races over these centuries and the ensuing job creation by each American racial/ethnicity group and the predilection of employment discrimination, the utilitarian approach will not fit our society’s goal of increasing the aversion to inequality. The Rawlsian approach, even though not perfect (see Arrow’s impossibility theorem), seems to fit better. To achieve health care equality or at least to reduce health care disparity, Society should be willing to maximize the welfare of the least fortunate members, all the poor people currently living in the inner city and rural areas regardless of race. For African-Americans, some voices have hinted to reparations for slavery as a way to bring equality in our society. Should we therefore maximize our society’s welfare by providing reparations for slavery? And who will redistribute equitably these reparations’ proceeds among the victims? How will society quantify the victims to compensate? The logistics of reparations therefore seem cumbersome and therefore unappealing. In order to solve America’s inner city problems so as to properly address the health disparity issues, society should focus on the probability of inner city escape for future inner city generations.
If society’s problem is a maximization of the welfare of future generations, we need to conceive a future generation welfare model with a future generation budget constraint. The future generation budget constraint can be conceived as the present value of all the investments in that future generation against the returns. PV = - C + i
n
R (1+ r ) n i
(2)
i
where I = 1 and n is the number of the productive years of a child C = Total cost of the investment in all the children in the inner city Ri = stream of income that will be derived from the investment during the child’s adult working years. The discounted stream of income is function of the probability of inner city escape (Prob_ICE). C = F (H, ED, CO), where H = health care, ED = education, CO = other child care expenses
(3)
R (1+ r ) n
= F (Prob_ICE)
R (1+ r ) n
= F (Prob_
n
i
i
(4)
i
n
i
i
ED
x Prob_
EMP
x Prob_
Health,
e)(5)
i
The investment is worth undertaking if the present value is greater or equal to zero.
If PV 0, then invest. Assuming that society’s minimal investment strategy will be to at least breakeven, then the present value (PV) has to be equal to zero. PV = 0 - C +
R (1+ r ) n i
n
i
=0
(6)
i
Therefore C =
R (1+ r ) n i
n
(7)
i
i
Society’s problem is therefore to maximize
W = (Uh V )1 / V Subject to
C=
R (1+ r ) n n
i
i
i
where
C = F (H, ED, CO)
R (1+ r ) n
= F (Prob_ICE)
R (1+ r ) n
= F (Prob_
n
i
i
i
n
i
i
i
ED
x Prob_
EMP
x Prob_
Health,
e)
The solution of this welfare maximization depends on the probability of escape from the inner city and therefore on the probabilities of education, employment and health. The probability of education in turn depends on school quality, school environment, parent’s education, parent’s income, parents’ inner city status, parents’ initial endowment. Since parents have low income, most have lived in the inner city all their life, and represent generations of no initial endowment, parents cannot help their children escape from the inner city. We can therefore make the argument that future generations should be trained in a different school environment than the current environment that is not conducive to learning. Some policy makers have thought of this situation and recommended school vouchers but the implementation of vouchers requires addressing other issues such as transportation cost and the return to the inner city environment after school. Since it is not optimal to take children away from their families and place them with families in suburbs, society should come up with viable alternatives. We propose boarding school education (Aim1), modeled on French and British education and their post-colonial education in Africa. At time of independence, former French and British colonies in Africa had about ninety eight percent (98%) of their populations in farming communities. The children of these farmers needed to be educated. The colonial powers, having achieved success with boarding school education in their own countries, transferred this schooling system to their “liberated colonies” so as to help them achieve their educational goals. In Côte d’Ivoire for example, the government created 36 secondary and high schools with boarding capacity. The educational experience of the children who attended boarding schools was highly positive. Most of the current educated work force in all African countries went through this educational system. There was also a built-in monetary incentive: All children who passed the 7th grade entrance examination were offered twelve thousand CFA Francs (12000) per year until graduation from high school, provided they keep a 12/20 grade point average. The students had the option of attending day school and keep the 12000 CFA francs or stay in the boarding school and forfeit the 12000 CFA francs.
•
TO DO
• Will talk about the cost-effectiveness of boarding school in Europe, Africa and the US. • Will talk about the actual structure of boarding schools in Europe, Africa and the US with focus on similarities and differences. • Will prepare a questionnaire for boarding school graduates in Europe, Africa and the US to assess boarding school experience. • Talk about the length of this prospective study (grade 3-12) • Talk about measurable outcomes of the project. • Talk about positive and (negative) externalities of the project • Talk about implementation phase • Talk about sources of funding • Talk about collaboration between the educational systems, the rural community in East Texas, the health care community and policy-makers D.3. Specific Aim 3: To determine the cost-effectiveness of the HBPR program. Introduction: High and rising health care costs are major national concerns and all health care interventions should be subject to economic evaluation. Structured, center-based pulmonary rehabilitation programs have been shown to be cost-saving {Griffiths TL, 2001 7 /id} and the physical activity intervention proposed for this trial of HBPR has been found to be more cost-effective than a structured exercise program in improving physical activity and cardio-respiratory health among a variety of populations {Sevick MA, 2000 139 /id}. This previous experience will provide us with a strong foundation for conducting and evaluating the cost-effectiveness of this HBPR program. The process of cost-effectiveness analysis includes four main steps including measurement of health outcomes, measurement of costs, linking of costs and outcomes, and exploration of uncertainty.
D.3.a. Health outcome measures: Health Related Quality of Life (HRQL) instruments are often classified as disease-specific or generic. Preference based HRQL measures are typically classified as a separate group. Disease-specific measures focus on the symptoms of the specific disease, such as shortness of breath. Generic measures provide information about many aspects of patients’ lives. Compared with generic measures, diseasespecific measures may be more sensitive, because a much higher proportion of their content is directly relevant to a specific disease (eg, emphysema). In addition, disease-specific measures are likely to be more responsive (eg, able to detect small but clinically important changes in health status) because they focus on the symptoms of the specific disease. Unlike generic measures, disease-specific measures are limited by their noncomprehensive approach and their inability to compare status across diseases. Examples of instruments specific to lungdisease include the St. George’s Respiratory Questionnaire, the Chronic Respiratory Questionnaire, the Oxygen Cost Diagram, the Baseline and Transitional Dyspnea Indexes, the Modified Med-and the UCSD Shortness of Breath Questionnaire. Generic HRQL instruments include the SF- 36, the Quality of Well Being Questionnaire, and the Sickness Impact Profile. Preferencebased HRQL measures, which can simultaneously capture degree of impairment, degree of bother, and willingness to undergo risk to reduce bother, offer important means for measuring the health benefits of interventions (eg, lung volume reduction surgery). Unlike disease-specific and generic HRQL measures, preference measures typically include in their analyses and interpretation patients who have died. Preference data may be used to estimate utilities and to allow for the estimation of quality adjusted life years (QALYs), which take into consideration quantity as well as quality of life consequences of illnesses and their treatments. By determining QALYs, utilities help determine the cost-effectiveness or cost-utility of a procedure. Typical disease-specific or generic HRQL tools cannot measure cost-effectiveness. Examples of four standardized utility assessment instruments include the Quality of Well Being Questionnaire, the Health Utility Index, the EuroQol, and the SF-6D derived from the SF-36. Studies (citation) have compared these instruments and have found that the SF-6D performs better. In this study, we therefore will use the SF-36 as a quality of life instrument and the SF-6D will be used to assess the related utilities. A secondary outcome for the cost-effectiveness analysis will be the number of exacerbations.
An incremental cost/utility analysis will be undertaken to assess the cost effectiveness of the program. The costs incurred and utility gained in the rehabilitated group over and above those for the control group will be determined. Thus, the net cost in dollars and net utility in terms of quality adjusted life years (QALYs) gained by adding pulmonary rehabilitation to standard care will be calculated and expressed as a ratio. While the main costs analyzed will be those directly borne by primary and secondary health services, costs to the patients themselves will also be taken into account. Analysis will be by intention to treat.
OUTCOMES Health status will be measured using the medical outcomes survey Short Form 36 item questionnaire (SF-36) before randomization, at the end of the 12 months intervention period, and 18 months after entering the study. The SF-36 is a selfcompleted instrument which has been validated for use in patients with COPD.18 19 In order to use this information in a cost/utility analysis, the SF-36 scores which measure health status on eight different scales will be converted to a single “preference based” utility score indicating the value that would be given to their health state by the general population. This will be done by extracting the appropriate SF-36 responses and using them to complete a six item health state classification, the SF-6D.20 The health states described by the SF-6D have a known value placed on them by a reference population and can be used as a measure of utility.20 In this way, the value placed on the different health states implied by subjects’ responses to the SF-36 questions can be expressed on a single utility scale. On this utility scale, scores of 0 and 1 represent the worst and best possible health states, respectively. A notional overall SF-6D utility score pertaining for the year will be derived for each patient, taking into account the unequally spaced timings of the observations. This SF-6D utility score will be combined with survival data to produce QALYs, which combine the quantity and quality of life following healthcare interventions. QALYs are the arithmetic product of the life duration and the utility score. Thus, 1 year of life with a utility score of 0.75 would result in 0.75 QALYs being produced. In our study follow up will be limited to 18 months. The product of the SF-6D score and the duration of life up to 18 months will give the QALYs produced for each subject.
D.3.b. Costs: The societal perspective will be used and all significant costs, regardless of whether financed by government, private insurer, or patient, will be considered {Russell LB, 1996 141 /id; Weinstein MC, 1996 142 /id}. Economic data for the cost-effectiveness analysis will focus on costs associated with delivering the intervention including personnel, materials, and equipment. A resource-based approach will be employed that identifies resources utilized and values their input at market values. This will be done for both SMC and HBPR groups. At baseline we will assess patients’ occupational status, insurance coverage and patients will be instructed on how to use diaries, as described above for exacerbations, to record healthcare - related costs including utilization for lung-related problems and non-lung-related conditions (i.e., physician visits, emergency room use, and hospitalizations), prescriptions filled, medical equipment costs, and any expenses associated with transportation. The diary data on costs will be collected monthly from patients in both groups using the CAT system. We anticipate that the majority of patients will be retired and/or disabled because of advanced age and associated disability {Coultas D, 2005 42 /id}, but the opportunity cost of their time will be measured using social security compensation rates. D.3.c. Discounting: Economic analyses should account for the inter-temporal costs of money and reflect the social rate of time preference for the present over the future. This is accomplished with discounting and both costs and benefits occurring beyond one year from intervention will be discounted into present value. The base case rate of discount will be 3 percent consistent with recommendations of a consensus panel convened by the US Public Health Service {Russell LB, 1996 141 /id}. Previous work has been done in this area. For example, Goldstein et al. {Goldstein RS, 1997 140 /id} explored the costeffectiveness of respiratory rehabilitation consisting of 2 months of inpatient care followed by 4 months of outpatient care. They found improvement in a substantial proportion of patients across different outcome measures. But these improvements came at substantial cost. A comparison of incremental costs and benefits is of great value to payers and policy makers in making coverage and payment decisions.
D.3.d. Cost-utility analysis: Once the utility value has been estimated, QALYs will be calculated by multiplying the utility value by the time for which it applies. For example, if the utility score from the SF-6D is 0.4, and we are looking at 18 months of pulmonary rehabilitation, then 0.4 equates to 0.72 QALYs. QALY gains can be less controversially used to assess the effectiveness of newly introduced therapies. For assessing the cost utility of a therapy, the QALY changes can be plotted against costs and an envelope of certainty can be drawn around the point estimate. The ideal new therapy would be significantly more effective (i.e., result in more QALYs) and cost less. This is called a “dominant” effect. Cost-utility analysis comes into its own when the treatment is significantly more effective but also costs more. The benefit can be assessed as the cost per QALY. This is the incremental cost-utility ratio. Payers are often thought to apply cost per QALY thresholds when assessing whether a new therapy should be used or not. In the United States, a threshold of $50,000 has been suggested. Grifith et al. indicated that in the United Kingdom, NICE denies having a threshold because it states that there is no empirical basis for deciding at what value a threshold should be set (64). The Institute also states that there may be circumstances when it would want to ignore a threshold. NICE believes that to set a threshold would imply that efficiency has absolute priority over other objectives and, also, as many of the technology supply industries are monopolies, a threshold would discourage price competition. NICE does, however, accept that there is a sigmoid relationship between the cost per QALY with a lower inflection between £5,000 and £15,000 below which rejection is unlikely and an upper inflection between £25,000 and £35,000 above which acceptance is unlikely, but not impossible (64). There are a growing number of cost-utility analyses of COPD therapies in the literature. Pulmonary rehabilitation has been estimated to cost between £2,000 and £6,000 per QALY (67) and thus in England and Wales would fall in the unlikely-to be-rejected zone of the NICE evaluation
The cost-effectiveness of the HBPR program will be described by the cost per unit change in each of the four domains of the CRQ {Goldstein RS, 1997 140 /id}. This cost per unit change will be calculated from the ratio of the average incremental costs (i.e., HBPR costs - SMC costs), and the average incremental effects (i.e., HBPR CRQ domain scores – SMC CRQ domain scores). In addition, the cost-effectiveness for different levels of effect (i.e., CRQ domain difference between groups: 0.5=minimal, 1.0=moderate, 1.5=large) will be estimated as described by Goldstein et al. {Goldstein RS, 1997 140 /id}. D.3.e. Hypothesis testing: For Specific Aim 3 the hypothesis is the HBPR program is more cost-effective compared to the SMC. Comparability between the treatment groups will be assessed on baseline demographic and clinical characteristics. General linear models will be used to assess cost-effective differences between two treatment groups controlling for the demographic, clinical and other confounding variables. D.3.f. Exploration of uncertainty: Uncertainty will be explored with sensitivity analysis to identify which variables have the greatest impact on cost-effectiveness and to assess the robustness of conclusions. COST/UTILITY ANALYSIS Investigation of the distribution of possible incremental cost/utility ratios generated by adding rehabilitation to standard care will be performed using the bootstrapping technique. The result of carrying out 1000 bootstrap replications of the incremental costs and utility will be shown on a cost effectiveness plane. Inspection of the resulting plots will confirmed that most of the modeled incremental costs and effects indicate that rehabilitation will generate QALYs while at the same time reduce the overall cost of patient care. A further proportion of the modeled costs and effects indicate QALY gain at increased cost. In very few of these simulations was loss of QALYs found. These data were used to construct a cost effectiveness acceptability curve showing the proportion of cost/utility simulations with a ratio less than any given ceiling ratio that might be regarded by a decision maker as cost effective. Grifith and colleagues showed that the probability of the true incremental cost/utility ratio of an outpatient rehabilitation program for the UK being below £0 per QALY is 0.64. The probability that the true cost per QALY is below £3000 is 0.74, the probability that the cost per QALY is below £10 000 is 0.90, and the probability that the cost per QALY is below £17 000 is 0.95.
ENVIRONMENT AND INSTITUTIONAL COMMITMENT TO CANDIDATE Description of Institutional Environment The University of Texas Health Center at Tyler has both biomedical and clinical research centers. The mission of the Center for Clinical Research is to provide high-quality, cost-effective clinical research services to clients so that tomorrow's medicine can reach patients as soon as possible. To fulfill the research commitment, both basic and bedside research that addresses clinically important problems are pursued. The clinical research effort spans more than half a decade of quality and timely investigations. This effort includes cooperative projects with numerous pharmaceutical and biotechnological companies and government agencies, including the National Cancer Institute (NCI) and the National Institutes of Health (NIH). The research centers have extensive experience working with contract research organizations (CRO's) as intermediaries in clinical research. All clinical studies conducted at The University of Texas Health Center at Tyler are performed within the guidelines of the U.S. Food and Drug Administration (FDA). The staff of the Center for Clinical Research works closely with the various divisions of The UT Health Center to complete Phase I through Phase IV trials. The research center employs individuals who are certified clinical research coordinators (CCRC's) to ensure that research activities are conducted utilizing GOOD CLINICAL PRACTICE standards. The clinical staff is well trained and represents all disciplines of medical delivery. Physician investigators are experienced and dedicated to performing high-quality studies. These studies are carefully selected and are subject to ongoing quality review. Many projects have resulted in national or international recognition, publication of peer-reviewed papers, and presentation at prestigious national and international meetings. Clinical research efforts have been very productive in regard to contracted recruitment goals and valuable patients with timely data completion and minimum data queries.
UTHCT Capabilities The Center for Clinical Research is a full-service research entity that performs all aspects of clinical trials which may be conducted on a local, regional, state, national, or international scale. The Clinical Research capabilities include the following areas of expertise: • Clinical Program Development • Study Design • Clinical Trials Management • Program Management • Data Management • Biostatistics • Epidemiology • Quality Assurance • Medical Communications • Regulatory Affairs • Institutional Review Board/Ethics • Broad Therapeutic Experience • Modern Facilities and Infrastructure • Global Communications • Cost Containment Special Services The University of Texas Health Center at Tyler is a regional and state referral center with both a large outpatient clinic facility and a physically adjacent hospital available for clinical research. The clinical laboratories offer a wide range of services to support clinical research. The laboratory staff is well trained and service oriented.
In addition to the clinical services offered by The University of Texas Health Center at Tyler, the Department of Biostatistics and Epidemiology provides experienced faculty to assist in the design and conduct of clinical research studies. This department maintains large databases, performs statistical analyses, and assists clinical researchers in designing well-planned studies. The Health Center supports an active telecommunications office. This technology can be used to access remote patient care areas and provide video conferences, as well as rapid transmission of clinical data for expert review. Collaboration: Collaboration with the other five University of Texas hospitals is available for research. Collaboration is also available on a larger scale with the university of Texas faculty at large. We have located social epidemiologists who are willing to partner with us on the health disparities project.
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CONCLUSIONS • SUMMARY OF TPE
Clarity •
Ability to focus
•
Decisiveness
•
Having a vision
•
Focus on results, not activities
•
List your goals
• •
Review your goals often Speak with clarity
Competence •
Excellence yields opportunities
•
Hard work yields improvement
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The market pays for excellence
Concentration
Creativity
•
Key to effectiveness
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Tap creative potential
•
Best use of time
•
Look for better ways
•
Sense of urgency
•
Be flexible
Common Sense
•
Ask questions
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Have one new idea
•
Train Your Mind
•
Think things through
Consideration
•
Listen to your intuition
•
Relationships determines success
•
Learn from your setbacks
•
People skills
•
Golden rule
•
Learn to listen
•
Most firings result from personality problems
ly
Consistency
Courage
•
Dependable work is superior
•
Confront your fears
•
Consistency in relationships
•
Dare to go forward
•
Guard your integrity
•
Avoid ruts
•
Consistency in personal development
•
Be a little afraid
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No security, just opportunity
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Fear of failure begets failure
•
Persist despite adversity
Commitment •
To your company, boss, job
•
To your family, friends
•
To yourself, career, success
Confidence
•
To your goals
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Self-doubt can paralyze
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Self-confidence begets achievement
•
Behave confident
INTEGRATIVE IMMUNITY INTEGRATION AND AUTOMATION
ALLERGY BILLING
SCIT
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$$ SKIN TEST $$
FUNNEL SYSTEM SQUEEZE PAGE
PARTIALLY AUTOMATED
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ALLERGY EDUCATION SLIT
FOOD TEST $?
VIDEO LONG FORM SALES LETTER
COMPLETE AUTOMATION
SLIT
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HPI OPTIN
OFFICE VISIT
NUTRITIONAL SUPPORT
EDUCATION
ROS
PE
ESTABLISH RAPPORT/TRUST
PASSIVE INCOME $$
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HORMONE EDUCATION s $$
NUTRITIONAL SUPPORT
PASSIVE INCOME $$
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VA PRE-QUALIFICATION AND SCHEDULING RETARGETING
IVR QUESTIONNAIRE PAGE LANDING PAGE
TARGET AUDIENCE
FACEBOOK AD
HORMONE KIT + F/U $$
3-6-12 MONTHS F/U
$$
INTEGRATIVE IMMUNITY INTEGRATION AND AUTOMATION
ALLERGY BILLING
SCIT
$$
$$ SKIN TEST $$
FUNNEL SYSTEM SQUEEZE PAGE
PARTIALLY AUTOMATED
$$
ALLERGY EDUCATION SLIT
FOOD TEST $?
VIDEO LONG FORM SALES LETTER
COMPLETE AUTOMATION
SLIT
$$
HPI OPTIN
OFFICE VISIT
NUTRITIONAL SUPPORT
EDUCATION
ROS
PE
ESTABLISH RAPPORT/TRUST
PASSIVE INCOME $$
$$
HORMONE EDUCATION s $$
NUTRITIONAL SUPPORT
PASSIVE INCOME $$
$$
VA PRE-QUALIFICATION AND SCHEDULING RETARGETING TARGET AUDIENCE
IVR
QUESTIONNAIRE FACEBOOK AD
HORMONE KIT + F/U $$
3-6-12 MONTHS F/U
$$