2 Why do People Want Alternatives?
3 But Does it work?
4 What's Wrong With Using the Placebo Effect?
5 How Can People Believe This Stuff?
6 What are Alternative Treatments?
7 But Conventional Medicine Harms People Too!
9 Are All Alternative Treatments Alternative?
11 What Can Alternative Medicine Practitioners Learn from Skeptical Doctors?
12 What Can Skeptical Doctors Learn from Alternative Medicine?
This page is admittedly biased in favor of health care that is science based. It is biased in favor of doctors giving advice and treatments that are plausible and are warranted by scientific evidence. The writings on this page are also biased in favor of promoting honesty and compassion in patient care. Being a skeptical doctor does not excuse one from being a compassionate doctor.
The term 'Alternative Medicine' is very confusing. It is fair to ask the question: "alternative to what?"
The National Science Foundation states, "alternative medicine refers to all treatments that have not been proven effective using scientific methods."
The National Center for Complimentary and Alternative Medicine (NCCAM) prefers the term 'Complimentary and Alternative Medicine' (CAM) and uses this definition: "(it is) a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine."
NCCAM then defines 'conventional medicine' as, "...medicine as practiced by holders of M.D. (medical doctor) and D.O. (doctor of osteopathic medicine) degrees and by allied health professionals, such as physical therapists, psychologists, and registered nurses."
So, per NCCAM, it is alternative to the usual practices of M.D.'s, D.O.'s, physical therapists, psychologists and registered nurses. NCCAM's definition leaves out the part about CAM treatments not being proven effective using scientific methods.
It seems odd that an applied science, such as medicine, would have an alternative. We currently do not have alternatives to other applied sciences such as engineering or aviation. Methods of engineering and aviation either work or they do not. Some methods work, but are not as efficient as others. In engineering, designs that work are simply considered 'engineering'. In aviation, designs that work are called "airplanes" (or "helicopters", etc.). Designs that are not proven to work - or have been proven to not work - are only part of the historical footnotes. They are not 'alternatives'.
It is important to try things and fail. These applied sciences would not be where they are today without learning from mistakes. Without these failures, we would still be on the ground. The endpoints in these fields are objective and obvious. The plane flies or it doesn't. The building stands or it doesn't.
Medicine is different. Success and failure are not always obvious. When the endpoints are subjective (like pain, fatigue), our biases can blind us to what is really going on. When the endpoints may occur even without the intervention, anything may appear to work. This is why we have basic science and clinical trials to guide us.
The term 'alternative' reveals the perceived need for a different way of doing things. In medicine, it may stem from the belief that "Western Medicine" only cares about drugs and surgery. This may be fueled by the observation that many doctors seem to lack compassion. Some doctors really do prescribe drugs that are not warranted. Some doctors really do perform surgeries that are not warranted. There is no doubt that many doctors are motivated by profit. There is also no doubt that pharmaceutical companies have often placed sales figures and share prices ahead of humanitarian goals. The perceived need for an alternative system really should be a wake-up call for the medical profession.
The need for an alternative way of doing things in healthcare should not mean a need for 'alternative science'. The fact that mainstream medicine is far from perfect does not justify the use of treatments with no evidence.
Most would agree that we do not have an ideal system. Medicine's problems today are multifactorial. We have a frustrating bureaucracy, a disconnect between our abilities to treat objective vs. subjective problems, a lack of time and sometimes compassion on the part of doctors, frighteningly poor science / health education, unhealthy lifestyles and soaring health care costs. It may be fairly argued that we need alternatives to many things in modern medicine. We need alternatives to a system that rewards the performance of wasteful tests and treatments. We need an alternative to impersonal 10 minute office visits, inequality of resources, and a society that promotes unhealthy lifestyles.
We do not need alternative science.
Why do People Want Alternatives?
People want alternatives. The government sponsored 2007 National Health Interview Survey revealed that Americans spend $33.9 billion on alternative medical services and products. $33.9 billion. That is only one year in the United States alone. Clearly there is a big market for it.
The literature examining why people choose CAM is scarce. The few articles on PubMed are mainly in CAM journals. BMC Complimentary and Alternative Medicine published surveys of CAM users in 1988 and in 2005. The article divides the reasons into "push" reasons (people are 'pushed' away from mainstream medicine) and "pull" reasons (people are 'pulled' toward CAM). People in the samples could report more than one reason for seeking CAM. In 1988, only 7% of the cohort were 'pushed' to CAM due to bad experiences with doctors (mainly due to poor communication and treatment). In the 2005 cohort, the number rose to 40%. In 1988, 9% sought CAM due to side effects of treatments. In 2005, 55% left due to side effects. In 1988, 42% went to CAM because they felt mainstream medicine was ineffective for their problems. In 2005, that number rose to 67%.
The above study reports that large percentages of the 1988 and 2005 groups sought CAM due to "pull" reasons. By 2005, over 90% of CAM users stated that they felt that CAM empowered them to have a more active role in their own health. They claimed to choose CAM because it emphasized treating the "whole person".
There are likely many reasons for turning away from scientific medicine. Perhaps an underlying reason is that most people do not understand the difference between science and pseudoscience. Our institutions also promote CAM along with scientific medicine, giving it credibility on par with scientific medicine. Others will seek such practices that agree with their ideological belief systems and world views. This latter group will likely never be swayed by empiric data. It is the former groups that we should focus on.
So why is CAM presented to the public as a legitimate alternative to conventional medicine? World views aside, why is it so popular? As with most things, it is complicated. As skeptical doctors, perhaps we should first be skeptical of ourselves.
Patients are people. People want to be treated like people. We hate the impersonal nature of large bureaucracies. We put our trust in people, not systems. We do not give our trust easily. Trust is nurtured. We trust people who acknowledge us, engage us and validate us as people. We trust people who seem to care about us.
Doctors are the people we entrust with our healthcare. But our healthcare system is impersonal. A typical appointment with the doctor involves waiting on hold on the phone, being told that there are no convenient appointments, filling out paperwork, insurance co-pays, long waits in a waiting room for a 10 minute visit, and a hurried doctor who uses unfamiliar and intimidating terminology. The visit typically will end with a prescription that must be taken to a pharmacy where more insurance cards, co-pays and wait times are required. Finally, the treatment - the pill - is obtained that comes in a sterile looking bottle with an incomprehensible name. The bottle is in a bag with a list of horrible side-effects stapled to it. It is not hard to see where the element of human caring and trust can get lost in the shuffle.
This dehumanizing system may be part of the motivation that drives some to look for 'alternatives'. There are plenty of practitioners out there who offer a large array of 'alternative options'. Many of these treatment options seem simple and understandable. The practitioners focus on simpler concepts, like 'balance' and 'energy'. They use words like 'natural' and 'holistic', implying that they practice in harmony with nature and care for the 'whole person'. Many alternative practitioners spend a great deal of time with their patients. They delve into people's personal lives and fears. They emphasize the patient's natural abilities to heal. In some cases, they tap into people's sense of spirituality. They often tell people what they want to hear. At the end, there are usually no insurance cards. But there is a price.
Alternative medicine practitioners know something that many 'traditional doctors' do not. They understand that people trust people, not impersonal systems. The people who seek out alternative systems trust a kind word, not science.
Science is, pretty much by definition, uncertain. We can never be 100% certain of any bit of scientific knowledge (see What is Science?). Scientifically trained doctors do not (and should not) offer certainty because the art of medicine is informed by science. People do not like uncertainty. Uncertainty removes a sense of control and drives anxiety. Yet, doctors offer uncertainty and then wonder why some of their patients don't like it.
In contrast, practitioners of alternative medicine frequently do offer a sense of certainty. They offer a sense of control. Their explanations tend to be simple and easy to understand (albeit often contradictory to science). Perhaps it is through a desire for certainty, understanding and control of one's life that so many seek alternatives to science-driven medicine.
However, this sense of control may be illusory.
We shall see that science-based healthcare can be delivered with compassion. If the seekers of alternative health care think otherwise, then that is our fault.
But do alternative treatments work? That depends on what one means by 'work'. Do people feel good about the care they received? In many cases they do. Are their medical conditions actually treated beyond subjective feelings and beyond the natural history of disease? The evidence says, "No".
In the NCCAM's first 10 years, over $2.5 billion tax dollars have been spent on controlled trials to study alternative treatments. To NCCAM's credit, they adhere to the scientific methodology of evidence based medicine, much to the chagrin of NCCAM's political support.
Remember, the scientific studies are not meant to confirm pet theories. One of the main reasons to do proper scientific studies is to eliminate biases such as the 'confirmation bias'. Statements such as Sen. Harkin's reveal deep and fundamental misunderstandings of how science works.
** To date, no significant findings have been made in favor of CAM.
In the EBM vs. SBM section, we discussed the dangers of doing science only from the standpoint of clinical trials without considering a claims plausibility from basic science. Many of the claims tested at NCCAM would not meet the plausibility requirement. Now, volumes of implausible claims are being tested (albeit with good methodology) and all of the claims are being listed as 'inconclusive'. Calls for further studies are then typically made by systematic reviewers like Cochrane.
"There's been a deliberate policy of never saying something doesn't work", says Stephen Barrett, M.D. in the Associated Press article.
"Many pseudo- and fringe-scientists often react to the failure of science to confirm their prized beliefs, not by gracefully accepting the possibility that they were wrong, but by arguing that science is defective." Ray Hyman, Ph.D.
The term "alternative medicine" adheres to the National Science Foundation's definition in that it has "not been proven effective using scientific methods."
What's Wrong With Using the Placebo Effect?
The difference between a 'placebo', as it is used in clinical trials, and the 'placebo effect' has been discussed extensively in The Placebo Effect section. Briefly, a placebo in a clinical trial essentially refers to a physical place-holder for the null hypothesis. The placebo effect refers to the subjective positive effects experienced by patients during a treatment that are due to all of the things involved in the treatment except for the treatment itself. All treatments have placebo effects. Real treatments result in effects above and beyond the placebo effect.
In research, if a treatment is a drug, and the studies show no benefit over the placebo pills, then the practical conclusion is that the drug does not work. The drug manufacturer cannot market a drug that is proven not to work. In fact, if the manufacturer did try to promote it, there would be loud accusations of fraud.
Now, let's substitute any favored CAM treatment for the word 'drug' in the above scenario. When CAM treatments are found to be no better than placebo, they are still practiced. When acupuncture is shown not to be beneficial over sham acupuncture, we hear no loud calls for the end of the practice. Instead, we see rationalization.
We found in the earlier section that harnessing the placebo effect involves deception (lying). We also considered three major philosophic schools of thought on Ethics (Deontology, Consequentialism and Virtue Ethics). We found that lying cannot be morally justified from all 3 perspectives.
So, is promoting placebo-equivalent treatments ethical? You decide.
How Can People Believe This Stuff?
Why believe things that have not been proven? Why believe things that have been disproved? The psychology and reasoning is complex. We have dealt with much of this in earlier sections.
In the Philosophy and Science section, we found that we naturally seek patterns and form beliefs. We then seek evidence to confirm our beliefs. Beliefs come before evidence.
In the Cognitive Dissonance section, we found that when faced with evidence that threatens our beliefs, we react with a very unpleasant feeling called 'cognitive dissonance'. We attempt to resolve this feeling by attacking or discounting the disconfirming evidence.
We mistake the so-called "placebo effects" for actual effects of our believed-in treatment.
In the Cognitive Bias section, we found that we are biased to value any evidence that confirms our beliefs and ignore evidence that contradicts them.
We tend to favor anecdotes and personal testimonies over cold numbers and data.
Logical fallacies can be used to construct reasonable sounding arguments to support our unreasonable beliefs.
We can use denialism to ignore disconfirming science. We can become pseudoskeptics by claiming to be skeptical of established science. We can discount established evidence by concocting conspiracy theories that involve powerful forces who are trying to deceive us, and that only we 'in-the-know' can see through.
And finally, we can try to have it both ways by claiming to value science, but then claim that science is not equipped to test our belief.
There seems to be no end to the list of alternative treatments and products. NCCAM divides CAM into groups: natural products, mind and body medicine, manipulative and body-based practices, and the broad category of "other". Many of these treatments will be discussed in detail in the Pseudoscience in Healthcare section.
These are under the heading of nutrition "supplements". These include herbal medicines (also known as botanicals), vitamins, minerals, and other "natural products."
The word supplement ,as it is used here, is a bit ambiguous. In the U.S., products that are meant to be ingested are either considered foods or drugs. The Food and Drug Administration has strict rules regarding the marketing of drugs. The F.D.A. defines "drug" as any article (except devices) "intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease" and "articles (other than food) intended to affect the structure or function of the body." Thus, products with actual health claims are considered 'drugs' and fall under the regulation of the F.D.A.
If this phrase is found on a product, then it is under the protection of DHESA. Any inferred claim on the product label must be worded vaguely and is usually meaningless. Statements such as "boosts the immune system" and "supports brain function" imply claims without actually being claims. What does it mean to "boost the immune system" or to "support brain function"?
Botanical products contain actual substances that can and do act as drugs. Many of our current pharmaceuticals were derived from naturally occurring plant-derived chemicals. Botanicals are sold over-the-counter and are not regulated. Many of them are promoted as having benefits that go way beyond what is known scientifically.
Homeopathic products are usually sold as if they are herbal / botanical supplements, but they are not. The rub here is that homeopathic products do not even contain the reported 'active' ingredient. We will cover homeopathy more extensively in the Medical Practices Unsupported by Science section.
Many people are under the impression that 'they' wouldn't be allowed to sell it if it wasn't safe / effective (meaning passed scientific tests). This impression is incorrect. DHESA made it possible. These products require no testing or regulation for safety. Consumers are on their own.
Mind and body medicine practices "focus on the interactions among the brain, mind, body, and behavior, with the intent to use the mind to affect physical functioning and promote health."
Neuroscience is a relatively young science and the relationships between the brain and the consciousness are being worked out. Much is known, and more is being learned. The brain is an organ of the body, yet many regard 'mind' as separate from 'brain'. While few would deny the effects of these practices on relaxation and subjective feelings of peace, actual claims relating the interactions between 'mind' and body should be considered premature. The implied claim (that the brain interacts with 'mind') raises the philosophic question of 'mind-body dualism'. What is 'mind'? Is there another entity within, yet separate, from the brain? This does not pass our first skeptical tool of Hume's Fork & Falsifiability. It is likely that the claim of dualism between brain and mind is not something that can be addressed by science. It is perfectly fine to hold such an opinion, but it cannot be defended rationally. Scientific sounding claims about mind and body can only be sophistry.
These practices "focus primarily on the structures and systems of the body, including the bones and joints, soft tissues, and circulatory and lymphatic systems."
Here, NCCAM includes chiropractic and massage therapy, although chiropractic can also be listed under 'energy medicine' below because the idea for chiropractic (at least in its pure form) involves the manipulation 'subluxations' of the spine to unblock the flow of 'innate intelligence', an unmeasurable vitalistic energy, through the nervous system to promote healing. We will discuss chiropractic in more detail in its own section.
Massage therapy has many different types, some that involve ideas from eastern mysticism, such as the manipulation of chakras, energy flows, acupressure points, and humors. Again, our criteria of Hume's Fork / Falsification prevent us from considering appeals to unmeasurable energy fields as science.
Energy medicine is a broad category listed under "other" by NCCAM. This group of 'treatments' claim to manipulate various forms of energy fields in a patient to promote health. "Such fields may be characterized as veritable (measurable) or putative (yet to be measured)."
Treatments involving "veritable" energy fields include magnet therapy. Here, magnets (typically the strength of kitchen magnets) are placed within jewelry, shoes or clothing with the intent to use magnetic fields to alter the flow of blood and whatever else the sellers of magnets claim. The fact that the iron in blood is non-magnetic doesn't seem to matter. And, if even if it was, the magnetic field from a kitchen magnet is very weak and its effects dilute to virtually nothing outside of a few millimeters away. Thus, magnet therapy is an extremely extraordinary claim that would require alternate physics to work.
Energy medicine involving "putative" energy fields include reiki, and therapeutic touch. Acupuncture can also be included here as well as in mind & body medicine. NCCAM states plainly that these energy fields have "yet to be measured". Yet to be measured. These treatments are claimed to work via an energy field that has never been observed. This raises an important question. How does one decide that there is an energy field to manipulate if it has never been measured or observed? As discussed in the EBM vs SBM section, we are skipping the stasis point of conjecture. Dr. Hall would call this Tooth Fairy Science. Unmeasurable entities cannot be considered science and therefore should not be treated as such by academic centers.
These systems are listed in the "other" category of CAM. These are "complete systems of theory and practice that have evolved over time in different cultures and apart from conventional or Western medicine". These include very old systems such as Ayurvedic Medicine and traditional Chinese Medicine. They also include systems developed relatively recently like homeopathy. Homeopathy will be discussed in detail on its own page. Naturopathy is a collection of systems that include many of the above 'treatments' with the idea that the body will heal itself with the aid of CAM therapies.
This practice is another broad category of CAM but not dealt with per se on the NCCAM website. The word "detoxification" is used in traditional medicine to describe the process of helping people through the withdrawal of alcohol or other drugs of abuse. "Detoxification" in the world of CAM is used to describe a host of practices by which 'toxins' are removed from the body to promote health.
It is true that we consume toxic substances and produce them as waste. Our liver and kidneys are the main organs that eliminate them. The effects of real toxins become obvious when these organs fail. However, proponents of detoxification CAM procedures and products would have us believe that most of us are suffering from the effects of toxins due to overload of our defenses. Today, many detoxification products and schemes are available for sale to rid our bodies of these toxins. Some of these products are harmless but deceiving, while others can be quite dangerous. They range from foot pads that turn dark after several hours, enemas (including coffee enemas!), to dangerous and unwarranted procedures like chelation.
There is no scientific evidence that these claims are true.There are certainly no scientific reasons to proceed with such schemes. As with the supplement industry, buyer beware.
But Conventional Medicine Harms People Too!
At this point, it would be helpful to review the Ad Hominem Tu Quoque logical fallacy.
It is true that the treatments of conventional medicine come with well documented side-effects and medical errors. These side-effects can be devastating, costly and deadly. In fact, the dangers of conventional medicine may be greater than with CAM treatments. These facts are loudly proclaimed by many advocates of alternative medicine, implying that skeptical doctors have no right to point to the dangers of alternative medicine. This argument is emotionally compelling on the surface, but falls apart under scrutiny.
The key is to consider risks and benefits over large populations. Science is particularly good at calculating these risks and benefits. Medical practices should be employed only when the greater good will be served. Chemotherapy can cause tremendous side-effects and, in some cases, hasten death. But if it is found that more people will benefit (prolonged life or a decrease in overall suffering), then the treatment should morally be offered and instituted.
The NNT (number needed to treat) and the NNH (number needed to harm) are concepts that make this point measurable. For instance, NNT and NNH have been well studied in statin therapy for the prevention of cardiovascular events (heart attack, stroke). They can cause serious side-effects (rhabdomyolysis). The NNT for statin therapy in a moderate risk population was found to be 27. This means that a doctor would only have to treat 27 patients over 5 years with a statin to prevent one serious event. The NNH was high (3400). In other words, a doctor would have to treat 3400 patients with statins for 5 years to seriously harm one (and most of these injuries would not result in death). Obviously, this study shows that for a large group of patients over a relatively long period of time, it is far more beneficial to treat them with statins than to abstain.
"From June 1978 through December 1980, at least 36 cases of amebiasis occurred in persons who had had colonic-irrigation therapy at a chiropractic clinic in western Colorado. Of 10 persons who required colectomy, six died."
Since we can infer that the NNT for colonic irrigation approaches infinity, and that the NNH is a small but whole number, the risk / benefit ratio approaches infinity.
With CAM treatments, no overall benefits beyond placebo have been found. Therefore, the risk / benefit ratio approaches infinity. No harm that comes from CAM, no matter how small the risks, should be morally tolerated.
Today, if we combine medical pseudoscience, denialism, and conspiracy theory into one person, we get a profile of the typical alternative medicine 'guru'.
These are people that deserve a great deal of up-front skepticism, but instead are rewarded with popularity and unwarranted authority. Gurus are often self-proclaimed. They frequently have questionable credentials or no relevant credentials at all. The guru is usually selling products and ideas of which they claim unique and special knowledge. These products are usually exempt from government regulation, such as supplements, detoxification devices and books. Their claims are simplistic and dramatically certain. They may claim to know the one true cause or the one cure of all disease. Gurus tend to exhibit many of the traits found on the Pseudoscience page. When selling their claims, they appeal to uplifting beliefs, use vague language, rely on anecdotes for evidence, avoid scrutiny by avoiding peer review and reporting straight to the media, and they work in isolation. When criticized, they respond with hostility and demonize their enemies.
When confronted with disconfirming evidence, they are impervious with denialism and self-seal their story with conspiracy theory. They reverse the burden of proof: they claim that they are being suppressed by a hostile establishment. They are always selling something. Profit at the expense of the gullible is their motive. When confronted with their profiteering, they will point to the fact that pharmaceutical companies and science-based doctors make a lot of money too (this is the classic ad hominem tu quoque logical fallacy). Somehow, this is supposed to justify their unwarranted, and often dangerous, claims.
A perfect example of someone who appears to fit this profile is pseudoscience huckster and convicted credit card scammer, Kevin Trudeau. Boasting a net worth of over $200 million, he makes his money by selling books that aim to convince his readers that (among other dangerous claims) scientific medicine is a scam conspired by the FDA and the pharmaceutical industry. He actively encourages the public to shun proven medical treatments for serious diseases like cancer and AIDS, implying that it is really the chemotherapy and anti-retroviral treatments that are causing the disease. We should instead pursue "natural cures". He has been found guilty of fraud and fined massive amounts of money over the years, but even these facts get twisted into 'evidence' for his conspiracy theories of being persecuted by a puppet government for promoting cures that "they" don't want you to know about. He is just one of many dangerous examples.
In medicine, a guru should never be confused with an expert.
Wikipedia's definition of expert is, "someone widely recognized as a reliable source of technique or skill whose faculty for judging or deciding rightly, justly, or wisely is accorded authority and status by their peers or the public in a specific well-distinguished domain."
In science, expertise is relevant only within its own particular, relevant field. The title of expert implies recognition from peers in that particular field. In our society, an expert is generally recognized through both proper credentials (relevant professional degree plus ongoing maintenance of certification) and reputation within that field. Experts are never self-proclaimed. The medical expert should never exhibit the hallmarks of pseudoscience listed above. They use specific language and rely on scientific data. Experts present their claims to peer review and proper outlets such as scientific journals, rather than reporting directly to the lay media. Their research is transparent and collaborative. Things are not considered to be true because experts say them, but rather experts are known for saying verifiably true things. And most of all, an expert should (ideally) assume the burden of proof and accept being wrong.
Scientific knowledge is obtained through proper scientific methodology and properly scrutinized by experts in that particular field. The information is challenged over and over through repeat studies and analysis of combined studies. If the information survives such treatment, then it generally gains acceptance withing the community of relevant experts. Thus, a consensus is reached about a particular piece of knowledge. To argue against such a consensus is to assume a massive burden of proof.
Consensus among scientists / experts IS science.
The world of alternative medicine is populated with gurus. Their claims rarely cohere with the consensus of recognized experts within the particular, relevant field. Although it is likely that most proponents of alternative medicine believe in their claims, and truly mean well, it seems unlikely that most 'gurus' share these positive qualities.
Of course, the claims of a guru are not necessarily wrong, but they do warrant skepticism.
Are All Alternative Treatments Alternative?
Remember, the National Science Foundation states, "alternative medicine refers to all treatments that have not been proven effective using scientific methods." With this in mind, many so-called "alternative" treatments could come off of the list and join the world of medicine without the need to 'integrate' them. It is the unsubstantiated claims that keep many of these treatments on the alternative list.
Clearly, healthy diet and regular exercise are not alternative. Nutrition and exercise have been studied extensively. Although the research is incomplete and the recomendations are changing, we have volumes of conclusive evidence that proper diet and exercise are good for us. They lower the risk of diabetes, heart disease, stroke, osteoarthritis, osteoporosis, some forms of cancer and perhaps even Alzheimer's disease. It would seem that defenders of CAM may wish to keep diet and exercise under the heading of CAM because these practices are supported by real science. An argument against CAM would be an argument against diet and exercise. This is a strawman argument. Diet and exercise are not alternative. They should be considered foundational recommendations of medicine.
The 'alternative' aspect of diet and exercise comes in when unsubstantiated claims are made. Fad diets, "superfoods", and unsubstantiated food fears are what keep diet as a category in the CAM canon.
Massage generally feels good. Massage usually accomplishes what one would expect and also does not belong on the list of 'alternative' treatments. However, if the massage therapist makes unwarranted claims regarding "energy" or other unmeasurable effects, then we drift back into the alternative realm.
There can be an alternative slant to exercise as well. Yoga can be part of an excellent exercise program. It can help back pain as much as regular stretching. However, Yoga is credited with many health benefits beyond measurable effects such as increased immunity, "rejuvenation" of the pituitary and thyroid glands, and even less wrinkles!
Meditation and deep breathing are what they are. There should be no conflict here unless the advocate is making unsubstantiated claims about them. Meditation can be very relaxing and refreshing. Deep breathing can also calm anxieties. Many feel more relaxed and in-control with the help of 'guided imagery', a practice to help "guide your imagination toward a relaxed, focused state."
If the endpoint is to feel relaxed with a 'clear head', then practices such as these can be effective in people who practice them. Progressive relaxation, massage, and hypnotherapy are effective if the recipients of these therapies say they are. In this regard, practices such as these could easily be classified as 'aesthetics' for they are pleasing to the senses just as people can be calmed, relaxed and refreshed from different types of music or art. Other practices that can bring about the subjective endpoints of peace and calmness may include conversation with a friend, sitting by the ocean, a hug from a loved one, playing with an infant, or petting a cat. However, if one claims that the health benefits to any of these practices extend beyond the known benefits of being calm and less anxious, then we we have to properly put those practices back on the shelf of pseudoscience.
** It is the unsubstantiated claims of alternative medicine that make it "alternative".
Medical education and practice in the United States was divided and chaotic in the early twentieth century. Medicine was not governed by science. Dogmatic beliefs were taught simultaneously with the sciences of anatomy, physiology, pathology and microbiology. A scientific revolution then took place that lifted our system out of its dogmatic slumber.
However, the lessons learned are being ignored in our academic centers, possibly due to economic pressures. Pseudoscience is being "integrated" (or rather reintegrated) back into medical education, thus blurring the lines between reality and illusion.
What Can Alternative Medicine Practitioners Learn from Skeptical Doctors?
It would seem that CAM practitioners may be of the opinion that science-based doctors would like to rid the world of the things that CAM has to offer. This does not have to be the case. As we just read in the paragraphs above, there are undisputed benefits that result from healthy lifestyles, and techniques for relaxation and stress reduction. Many of the so-called "alternative" treatments need not be alternative.
What skeptical doctors wish to convey to CAM practitioners is that science matters. Basic science matters and clinical science matters. If a belief is implausible (contrary to basic science), or if a belief is consistent with the null hypothesis (contrary to clinical science), then it is honorable for us to change our minds.
It is said that CAM does not make advancements like science does. If this is true, then it is true for the very reason that CAM believers do not change their minds in light of new evidence. This is a lesson that many traditional doctors have not learned either. Changing one's mind is not a weakness, it is a strength.
Why is it that we cannot offer many of the treatments above without making unsubstantiated claims? Why must we appeal to pseudoscience to back up these practices?
If we could drop the pseudoscience, there would be no need to 'integrate' CAM with traditional medicine. Hypnotherapists can simply do what they do. Massage therapists could state that they will simply make people feel good by giving them a massage. Chiropractors could state that they may help people with their acute back pain, but refrain from claiming blocked innate intelligence and unseen subluxations. So-called supplement experts could properly study what is known about nutrition and promote those few supplements that are scientifically known to help, like vitamin D (remember, claims should pass both basic science plausibility and clinical trials). Of course, that would require a great deal of hard work and proper credentials (dietitian is the legally protected term, nutritionist is not). Personal trainers and fitness experts could simply promote exercise, as most already do.
However, it may be o.k. to 'imagine'.
What if we embraced the concept of "imagine"? John Lennon asked us to "imagine" there's no countries or religions (i.e. things that divide us). He knew full well that such countries and religions exist. He asked us to imagine, to suspend belief, and explore what might happen if things were different.
Imagine your scene, and try to add some detail. For example, is there a breeze? What does the sky look like? Is it clear, or are there clouds?
"...imagine that you are breathing in through your toes, then out through your toes. Continue to breath in and out through your toes, drawing the breath further up your body each time. Imagine the breath retracing its path down your body and out the toes on each exhale. If you can't draw the breath up throughout the whole body, switch to imagining the breath drawing in through your fingertips, belly button or eyes, in order to relax the whole body."
Notice that no claims are being made. The authors simply ask the reader to imagine.
Magicians ask people to suspend belief. They ask people to imagine. They do not claim to have powers (like so-called 'psychics'). Practitioners of 'energy medicine' (such as Reiki) may harness relaxation and peace by asking patients to "imagine there is an energy field..." Massage therapists can instruct patients to "imagine" that their energy is balancing. Homeopaths can say, there is nothing actually in this, but "imagine" that it will give you strength. It is unlikely to happen, but we can imagine such a world.
This, of course, would not justify practices with potentially dangerous effects like acupuncture or chelation.
And for Pete's sake, don't deny science.
Vaccines are good. 'Natural' does not mean 'better'. Water does not have memory. Gurus do not know better than a scientific consensus. There is no one cause of all disease. Enemas do not eliminate 'toxins'. Coffee is for drinking.
What Can Skeptical Doctors Learn from Alternative Medicine?
CAM practitioners often claim that they are 'holistic' in that they care about the 'whole' patient. The implication is that science-based doctors do not care about the patient as a 'whole' person, at least not to the extent of the CAM provider. Although many doctors specialize, most who commit their professional lives to medicine do so to help 'whole' people. To primary care doctors, the implication that they somehow do not care about 'the whole patient' seems absurd. However, that is the image that some have of us. We can do better.
We should first consider why people tend to be drawn toward alternative medicine in the first place.
There are those who are drawn due to ideological predispositions toward magical thinking and the belief systems involved. For such people, we must be sensitive to their beliefs. Simply pointing out facts will not be effective and, in fact, will cause immediate conflict. Such people are not swayed by data, they are swayed by personal and emotional stories. Skeptical doctors must proceed with caution, planting small seeds along the way. We must be respectful, avoid being condescending, yet maintain our integrity.
CAM may seem to better validate people's feelings, fears and anxieties. CAM practitioners are apt to spend more time with patients. They are more apt to offer treatments that are high in aesthetic value. CAM is presented with certainty and simplicity, thereby lowering anxiety about conditions and treatments.
"...therapeutic benefits do arise from processes within the homeopathic consultation involving communication skills, empathy, hopefulness, enablement and narrative competence."
So, patients can achieve significant benefits from consultations in which the practitioner is effective at communicating empathy, hope, clarity and, essentially, decreasing uncertainty.
It is true that science-based doctors (skeptical doctors) cannot offer certainty about diagnoses or treatment outcomes. But, doctors can offer certainty about their intentions; certainty about their understanding of the patient's feelings; certainty that the patient is a person, not a number.
We can offer certainty that we care.
Let's make sure that we do.
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Fellow Focus – Dave Jones
Self portrait with rats. Credit: Dave Jones.
In a dark corridor directly beneath the Art Centre's Playhouse Theatre littered with staging detritus Dave Jones shows me a luminous rat running along the edge of a wall. Suddenly it disappears to be replaced by rats with glowing yellow eyes multiplying in a plague-like swarm across the wall.
They're actually projected interactive animations that he can control using an iPad and remote-controlled projector. Jones has been workshopping them as part of a collaboration with Chamber Made Opera for Captives of the City, a new contemporary opera incorporating puppetry, animation and multimedia.
We then head upstairs out onto the silent empty stage to find somewhere to chat. Without hesitation he swings off the edge down to the seating level, making it look easy. Not surprising, as he says rock climbing used to be the main thing he did; sponsored to trek to the world's most challenging climbs. Jones is built of strong stuff, stocky with trunk-like arms and broad shoulders though his voice is gentle and quiet.
He's down in Melbourne for the week from his home base in Natimuk, a small town in the Wimmera wheat belt near Horsham. Once it was an agricultural town notable for little other than its proximity to Mount Arapiles, Victoria's best rock climbing area. Since he moved there over 15 years ago however, it's also become something of a regional arts 'hot spot' with a thriving arts community.
When I ask Jones how he describes himself he says, 'If someone wants a one-word answer, I say animation.' Certainly animation is the start of the story as he has made a number of award-winning short animated films. His practice however, extends into multimedia design, illustration, sculpture, community arts projects, interactive installations, puppetry and projections, such as his work with aerial performer Jillian Peace projecting 30m images onto the Natimuk wheat silos.
'I get quite bored if I do something for too long,' Jones explains. 'It makes it hard to build a name for doing something in particular I 's'pose. But I kind of like that.'
Assisted by an Australia Council for the Arts Creative Australia Fellowship, Jones has recently been concentrating on two major projects in which he has been creating real-time interactive animations. The Captives in the City project with Chamber Made Opera has been one of these projects; the other has been Feed; a collaboration with Thieves Theatre.
Based on the novel of the same name by American writer M.T. Anderson, Feed is set in a dystopic future world where people have the 'feed', or internet, wired into their heads. Jones's animations try to visualize this for an audience, creating cloud-like animated text and images, which surround the actors and respond to their gestures in real-time. Jones likens it to animated puppetry.
Much of the new technology Jones uses has been designed for computer gaming so it's fast and responsive when it comes to generating immersive visuals. Just as importantly, it's also relatively cheap and easy to buy off the shelf. It means he must compromise his preferred aesthetic but he sees exploring the technologies potential as worth it. As he explains, when he used stop motion or pen and ink to create his animations it might take a week to create 10 seconds of footage. It's making all sorts of new things possible.
The best thing about the Fellowship, Jones says is the opportunity it has provided to develop and explore ideas, both those that have been on the backburner and new discoveries. New technology and ways of doing things are literally becoming possible every month, he says. To just have the time to see how that can fit into your repertoire and whether it enhances what you do or not has been invaluable. Then there're what Jones calls 'happy accidents'; insights that happen while working on something else that usually have to be put aside when you're on a deadline.
While working on these latest two projects Jones says he's created a framework and come upon a number of exciting things that he will be able to develop into new projects in the next few years. 'I just have this really solid basis to create amazing new work going forward,' he says. 'Stuff that I hadn't even thought of a year ago when I proposed the Fellowship.'
'A lot of the good discoveries that have been possible this year have been because of that luxury to just sort of…' Jones pauses, then sighs happily. '…wander.'
More of Dave Jones work can be seen at the Art Is Festival in Horsham, 30 May – 9 June, 2014

redpajama_set_name: RedPajamaCommonCrawl


Have you heard about those three words that can tell exactly where you are without using any address or coordinates? Hard to believe that navigation can be that easy? The start-up what3words promises that in the near future, every navigation system in the world will function with only three words.
Before learning more about this innovative business idea, let us have a closer look at the successful female entrepreneur behind it: Clare Jones. Since 2015, she is the Chief Commercial Officer of what3words. As she will be speaking at the Global Female Leaders Summit 2019, we have been curious about what brought her to this leading position.
What we found is inspiring. To be honest, it is not only her current project that makes her so special, but her whole career path. Why did she decide to revolutionize the whole navigation industry? How did she come to that leading position? If you are curious about the answers, you should definitely read this article.
Surprisingly, the British woman did not study economics. Instead, she graduated in English Literature and Geography at the University of Cambridge. After graduation, she was engaged in several social projects.
In 2012 for example, she ran marketing for a charity. The project was based in Ethiopia, where British medics flew out to perform complex surgical procedures. Even if this project took only a few months, it seems like the social work set the basis for her astonishing future career.
After that, she worked at the 2nd Chance project. This initiative builds second chance educations for young people, who are not in employment, education or training. Clare Jones worked there 1.5 years, showing that she cares about other people's living situation not only in poor countries like Ethiopia but also in her own.
The project was running in London, one of the biggest cities in the world. As we know, in those cities the gap between rich and poor becomes bigger and bigger. Clare Jones' work helped to compensate this development a bit.
Besides that, she always volunteers for different projects. Since 2012, she is part of the Streetlink Project, which fights against poverty. Here, she also worked as a strategic advisor. Moreover, she tutored disadvantaged children in London to help them achieve graduation.
Due to the network she developed through her diverse projects, she came in touch with investors, who were specialized in social businesses. Thanks to her interest in the combination of business and social impact, the idea of what3words immediately got her.
But what has the revolution in navigation to do with social business? To answer this, let us have a closer look at the idea behind what3words.
The principle is quite simple: The company divides the whole world into billions of 3×3 meters squares. Each square gets one unique word combination of 3 simple words. So if you want to tell someone where to meet you, you can just give him the three words of your square and he will find you easily.
No more addresses that lead to a whole building and making you search for the parking space or entrance. No more meeting friends in a big city park and needing hours to find their camp. Next time you are going to meet someone, you will know exactly where.
Maybe you are asking yourself: Why are those three words better than simple coordinates? With the latter, one can communicate an exactly whereabouts too. Basically, this thought is right. But three words are just simpler to communicate. People can understand and memorize those 3 words better than a sequence of numbers – and communication is essential when it comes to navigation.
The previous examples are of course not the only situations, where what3words can help out. Here is where the social impact comes into place.
Clare Jones told in an interview, that her solution does also work in critical situations. During a large earthquake in Mexico City for example, rescuers have been able to help faster thanks to the three words. The communication of three words have given less space for misunderstandings and ensured a precise localization of victims.
Another example in South Africa, health services and doctors use what3words to fight against the death rate of young mothers. Doctors can simply use the app to find patients quickly. Many people in South Africa have no address because they are not living not in a house next to a street. With what3words, residents can just memorize the three words for the square where they live and communicate them if they need help. For doctors, it is much easier and faster to find them.
The problem of homeless people is not only a South African problem but a worldwide one. Clare Jones told during an interview, that what3words provides those people without a postal address with a solution.
Jones herself had the luck to live in a house with a postal address at the west coast of Great Britain. Nevertheless, the postman always has given all packages to her neighbours. Even the pizza boy often did not find the way to her front door just because it is around a corner.
Her team currently consists of 80 members, but they grow very fast. What3words is negotiating with companies and governmental institutes all around the globe. Their goal is as ambitious as Clare Jones herself: They want every single device and all cars in the world to use those three words for navigation.
The future looks great for the start-up. What we can definitely say is, that Clare Jones is an astonishing woman with best ambitions in social environments. We are happy to meet her congenial personality in May at the Global Female Leaders Summit. If you also want to meet her, book your seat soon!


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Bill Turnbull agrees to co-host 'Good Morning Britain' with Susanna Reid in emotional reunion
Albertina Lloyd
Entertainment reporter, Yahoo UK
Yahoo Celebrity UK 6 November 2019
Bill Turnbull was a guest on GMB (Credit: ITV)
Bill Turnbull has accepted an invitation to fill in for Piers Morgan as Susanna Reid's co-host on Good Morning Britain.
The former BBC Breakfast host was a guest on the ITV show this morning where he confessed he would love to return to presenting with his former colleague, asking "What are you doing tomorrow?"
Reid asked her Turnbull: "What would you think about, on a day where Piers Morgan perhaps has been incapacitated.
Read more: Naga Munchetty tells Bill Turnbull she misses him in
"Why don't you come and sit next to me and present the programme?"
Susanna Reid and Bill Turnbull were delighted to be reunited on 'Good Morning Britain' (Credit: ITV)
The 63-year-old presenter - who revealed last March he had been diagnosed with incurable prostate cancer in 2017 - replied: "I would love to, name the day. I wouldn't do it full time. It is a little bit stressful and stress is not good for cancer, but every once in a while would be great. What are you doing tomorrow?"
Reid, 48, and Turnbull worked together on BBC Breakfast between 2006 and 2014. Turnbull presented his last episode of the morning show with Louise Minchin in February 2016.
He appeared on GMB to discuss trying cannabis for his new Channel 4 documentary Bill Turnbull: Staying Alive .
Bill Turnbull and Susanna Reid worked together on 'BBC Breakfast' (Credit: BBC)
Turnbull confessed: "It was an embarrassing moment actually, I wasn't expecting that to happen. I was doing a piece to camera, or trying to, and I just couldn't form a sentence."
Read more: Bill Turnbull calls for 'proper conversation' on cannabis laws
Speaking about its medicinal purposes he said: "On cannabis, my view is that the jury is still very much out. Cannabis has been used as a medicine for thousands of years, we made it illegal about 100 years ago. And yet I think there are lots of benefits we just don't know about...
"It can have a very serious psychiatric effect on people's mental health if they take too much of the wrong kind. I've seen it first hand, the effects it can have. So I'm not at all saying lets smoke weed as much as we like. On the other hand, if you did legalise it, it would be regulated and the strength would be moderated."
Concluding the interview Reid said of Turnbull: "I love him, absolutely love him."
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Long-Run Health Matters
A Research Portal on the Origins of Global Health Inequality and its Societal Impact
A Micro-Based Evaluation of Water Projects
The trend of emotional well-being in Nineteenth-century Britain
The drivers of institutionalization among the elderly in Europe
Beatriz Rodríguez Sánchez. Show Author details
Exercise class with the elderly
Nowadays, there are 900 million people aged 60 years old and above worlwide, from which 16% are older than 80 years old (UN, 2019). By 2050, 2,000 million people will be older than 60 (WHO, 2018), 21% of them being 80 years and above. In addition to ageing, increasing life expectancy poses a major challenge to current societies and to the sustainability of welfare systems as we know them so far due to (among others) the prevalence of chronic health conditions in the population and the vast increase in the age-dependency ratio, defined as the number of inactive older adults aged 65 years old and above over the total number of employed people (European Commission, 2021). One of those chronic conditions that have emerged as a top health priority is diabetes, since its prevalence and incidence have rapidly increased globally. Future projections indicate a near quadrupling of the prevalence figures at the turn of the century (2.8%) by the year 2030 up to 11.3% of the whole population (more than 640 million people) and 12.2% by 2045 (783 million people) (more about the burden of diabetes worlwide here). Older adults will lead this increase, representing around 50% of the people with diabetes and with a prevalence of diabetes around 25%, meaning that one in every four people older than 65 years old will have diabetes.
Furthermore, partly due to the aforementioned increasing age-dependency ratio, population ageing will come along an increase in the demand for long-term care, including residential care (OECD Health Statistics, 2018). These projections have made healthcare policymakers to define organizational changes in the models of care services provision (this topic has been covered in this blog here and here), placing the focus on quality of life and aiming to ensure the maximum autonomy as possible subject to specific functional status, ranging from completeley independent to severely dependent people, as older people in nursing homes might be.
Diabetes and nursing home admission
Traditionally, diabetes has been associated with a higher risk of being dependent and of being institutionalized. Some evidence from the US reported that diabetes is a determinant of nursing home placement among the frail elderly and, moreover, old people with diabetes are 1.8 times more likely to be institutionalized (Matsuzawa et al., 2010; Newton et al., 2013).
The effect of diabetes on nursing home admission is expected to be mediated by both clinical and functional complications, which might be at the same time caused by other diseases and other factors, as the figure below shows. Sociodemographic factors such as age, gender, marital status, education, and number of children are associated with the risk of institutionalization. Other factors such as employment status and income should be considered, as well as a list of chronic conditions, functional and cognitive impairment, since they might be associated with the risk of being transferred into a nursing home.
When designing public policies, it is essential to identify target populations, in addition to understand their characteristics and the drivers of healthcare use. Using data from the Survey of Health, Ageing and Retirement in Europe (SHARE) and information on total expenditure for nursing homes per country from the OECD data and statistics, I assess the factors leading to institutionalization and the associated costs among older Europeans with diabetes (Rodríguez-Sánchez et al., 2017). By merging both datasets, I was able to assess which factors are associated with higher odds of being admitted to a nursing home and the nursing home expenditures attributable to diabetes and its complications, including sociodemographic indicators (age, gender or education, among others), clinical conditions (a set of chronic conditions, in addition to diabetes) and functional status (four categories according to the number of limitations in the activities of daily living, such as bathing, dressing or toileting). Moreover, I analysed whether there were differences across European countries and other subgroups of analysis, distinguishing by age or gender and by length of stay. The analyses referred to the period 2004-2010 and covered twelve European countries: Austria, Belgium, Czech Republic, Denmark, France, Germany, Greece, Italy, The Netherlands, Spain, Sweden, and Switzerland.
The results obtained confirmed that diabetes increases the risk of institutionalization, although its effect decreases when diabetes-related clinical complications are included and especially when functional status is introduced. This points towards a mediation effect of functional complications that reduces the impact of diabetes on the probability of being admitted to a nursing home, since these complications are related to this disease. We can see this in the figure below. If we first focus on individuals without functional impairments (left bars), factors also related to diabetes – stroke, cognitive impairment and cancer – explain nursing home admission. Still, when functional impairment severity was considered, chronic diseases were no longer the main determinants (right bar), as various degrees of potentially diabetes-associated functional impairment account for the largest fraction of nursing home admissions, and the relative importance of cancer, stroke and cognitive impairment decline.
My analyses also show that the effect of functional impairment on the risk of institutionalization is age-dependent (right panel). As people become older, the risk of nursing home placement increases among individuals with various degrees of functional impairment, especially if they exhibit severe and moderate levels.
Total average nursing home costs reached $12.66 per capita over all countries, as the figure below shows. Importantly, 78% of these costs can be attributed to complications from several degrees of functional impairment. The most important among these degrees is mild functional impairment, which happens when the individual reported to have some problems in one or two activities of daily living. When assessing cross-country differences, this pattern is confirmed: the largest cost shares relate to functional status. In countries such as Spain, The Netherlands and Germany such costs actually represent the greatest proportion, usually followed by stroke.
Towards a fairer and more efficient health care sector
My research provides so far a deeper knowledge of the economic drain of diabetes regarding its associated healthcare (Rodríguez-Sánchez & Cantarero Prieto, 2019), drug treatment, medical visits (Mata-Cases et al., 2020) and non-healthcare (nursing home use) costs. This is an essential matter in the healthcare policy making process in order to achieve an efficient allocation of scarce resources. Diabetes prevalence, together with other chronic conditions, is increasing and, in addition to population ageing, their associated costs are highly likely to noticeably grow in the subsequent years, constituting a challenge, but also an opportunity for current societies. These trends should not be regarded as problematic: would it be fair to state that young people use too many places in schools or universities? Why do we talk about older adults 'overusing' healthcare? From a well-being and humanitarian perspective, people matter regardless of their age. Therefore, keeping the elderly as independent and healthy as possible should be in any policy agenda that aims at improving the lives of citizens.
This article is based on the following publication by the author: Rodríguez-Sánchez, B., Angelini, V., Feenstra, T., & Alessie, R. J. (2017). Diabetes-associated factors as predictors of nursing home admission and costs in the elderly across Europe. Journal of the American Medical Directors Association, 18(1), 74-82. (link)
The associated image of this post is taken from Flickr (link).
European Commission (2021). The 2021 ageing report. Economic and budgetary projections for the EU member states (2019-2070). Economic and Financial Affairs, Institutional Paper 148, Brussels.
Mata-Cases, M., Rodríguez-Sánchez, B., Mauricio, D., Real, J., Vlacho, B., Franch-Nadal, J., & Oliva, J. (2020). The association between poor glycemic control and health care costs in people with diabetes: a population-based study. Diabetes Care, 43(4), 751-758.
Matsuzawa, T., Sakurai, T., Kuranaga, M., Endo, H., & Yokono, K. (2010). Predictive factors for hospitalized and institutionalized care-giving of the aged patients with diabetes mellitus in Japan. Kobe J. Med. Sci, 56(4), E173-E183.
Newton, C. A., Adeel, S., Sadeghi-Yarandi, S., Powell, W., Migdal, A., Smiley, D., … & Umpierrez, G. E. (2013). Prevalence, quality of care, and complications in long term care residents with diabetes: a multicenter observational study. Journal of the American Medical Directors Association, 14(11), 842-846.
Organisation for Economic Co-operation and Development. OECD health statistics 2018. Paris, France.
Rodríguez-Sánchez, B., Angelini, V., Feenstra, T., & Alessie, R. J. (2017). Diabetes-associated factors as predictors of nursing home admission and costs in the elderly across Europe. Journal of the American Medical Directors Association, 18(1), 74-82.
Rodríguez-Sánchez, B., & Cantarero-Prieto, D. (2019). Socioeconomic differences in the associations between diabetes and hospital admission and mortality among older adults in Europe. Economics & Human Biology, 33, 89-100.
United Nations (2019). Department of economic and social affairs, population division. World population ageing (link). Accessed on the 14th of March 2022.
World Health Organization (WHO) (2018) – ageing and health (link). Accessed on the 14th of March 2022.
Dr. Beatriz Rodríguez Sánchez
Assistant professor (Complutense University of Madrid)
Visit personal website
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ITC Allowability to Landowner before Issuing Completion Certificate
As per the recommendations made by the GST Council in the 43rd Meeting which was held on 28th of May 2021 with respect to the allowability of credit of taxes paid by a developer to the landowner in case of Joint Development Agreement, there was a major change that helped in eliminating one of the issues faced by the construction industry in the country in case of such areas or arrangement of construction.
Joint Development Agreement
In an area sharing Joint Development Agreement (JDA):
– A Landowner will transfer the development rights of their piece of land to the Developer, and
– The Developer develops and constructs a structure i.e., superstructure for the Landowner on their piece of land.
– For this a Transferable Development Rights (TDR) or Floor Space Index (FSI), shall be obtained.
GST shall be charged on the services provided by the Developer to the Landowner in the form of construction.
Time of Supply Before 43rd Council Meeting
Until now GST Law provided that the Developer shall pay GST on the construction services provided by them to the Landowner on the basis of the Development Rights
– at the time of providing the certificate stating the completion, which is also known as the Completion Certificate (CC), or
– first occupation,
whichever is earlier.
And, in case the Landowner further sells these allotted areas or the flats build in such areas, to other buyers available in the market, before the issuance of CC, the Landowner is required to raise the invoice and also charge GST on the basis of the date on which payment is due from the buyer, and this resulted in accumulation of ITC.
Accumulation of ITC
As the Landowner has to pay tax on the basis of the same being due from his buyers, the tax shall be paid in cash, which might become due prior to the issuance of CC.
And the Developer will raise the invoice and charge GST at the time of issuance of CC or first occupation whichever is earlier, this will now lead to accumulation of ITC in the hands of the Landowner.
Let's take an example for the same,
Mr. A is the Developer here and Mr. B is the Landowner, and there is a JDA (Joint development Agreement) formed between these two parties. The date of issuance of the completion certificate for the same is 31.03.2022. But Mr. B transfers his portion of flats before 31.03.21, to Mr. C.
As the date of issuance of completion certificate is 31.03.2022, Developer, Mr. A will be paying GST on supply of Construction Services to Mr. B only during the tax period 2021-22 i.e., 31.03.2022. But Mr. B will have to pay the entire tax liability on the supply of flat to Mr. C before this date of issuance of CC, as the payment is due from Mr. C before 31.03.21. And the ITC for GST paid in this regard by Mr. A shall only be available for the tax period of 31.03.2022. Hence, this ITC shall now be accumulated in the credit ledger of Mr. B.
Time of Supply After 43rd Council Meeting
Now as per the amendment which was brought in by the 43rd Council Meeting of GST, vide Notification No. 3/2021 – Central Tax (Rate), it has been given that:
Time of sale or providing of construction services supplied against Transferable Development Rights (TDR) or Floor Space Index (FSI) shall arise "in a tax period not later than the tax period in which,
– the date of providing of the certification stating the completion, or
– the date of its first occupation,
So, we can understand that the Developer shall be allowed to pay GST on such supply of construction services to Landowner before issuance of CC or the first occupation whichever is earlier. The Landowner can ask the Developer to pay such GST, such that the landowner on receipt of payment on sale of such flats or space, utilize the same and ensure that there is no extra cash flow or accumulation of ITC taking place.
The same can be understood easily with the help of the example which was taken before with respect to Mr. A being the Developer and Mr. B being the Landowner.
Mr. A is the Developer here and Mr. B is the Landowner, and there is a JDA between these two parties. The date of issuance of the completion certificate for the same is 31.03.2022. But Mr. B transfers his portion of flats before 31.03.21, to Mr. C.
Contrary to what was stated before, Mr. A pay GST before tax period during which such CC was issued such that the Landowner which is Mr. B in this case can avail the ITC while making payment of GST, on his sale of flat to Mr. C and collection of payment with GST from Mr. C for the same, by virtue of the amendment which was made by the GST Council in the 43rd Meeting held by the Council.
The Landowners now by virtue of this Notification and Amendment eliminate the confusion and accumulation of funds which was actually increasing the cost for them as they had to pay GST to the developer as part of their invoice payment while not being able to avail the same due to the time disparity in remittance of the same to the GST Authority by both the parties, in case the Landowner sell their flats to a buyer in the market before such CC is issued and the payment from such buyer becomes due.
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text:
Q: Why is input rate so big in Spark Structured Streaming UI? Spark Structured Streaming UI

this is my app's Structured Streaming tab
I want to know that why is input rate bigger than I think.
Now I'm using Spark Structured Streaming API with Kafka input Source.
And I'm producing 90 records every 30 sec. into my Kafka topic which my spark app read.
So I expected Input Rate about ~90, but actual results is too big.
I really want to know why
** And If it is a reasonable result, how is the rest of input being handled?(because Process rate is too small than Input rate)

redpajama_set_name: RedPajamaStackExchange


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text:
Příjmení Rychlý nosí více významných osobností:

 Jana Rychlá (* 1970) – česká profesionální tenistka
 Ondřej Rychlý (* 1992) – český herec
 Pavla Rychlá (* 1964) – česká dabérka
 Petr Rychlý (* 1965) – český herec, moderátor a režisér

Externí odkazy

redpajama_set_name: RedPajamaWikipedia


text:
package o;

import com.quizup.lib.misc.dbcache.DBCacheManager;
import java.util.ArrayList;
import java.util.Collection;
import java.util.Collections;
import java.util.HashMap;
import java.util.Iterator;
import java.util.List;
import java.util.Map;
import java.util.Map.Entry;
import java.util.Set;

public final class ɫ
  implements Comparable<ɫ>
{
  public final String ˊ;
  public final int ˋ;

  private ɫ(String paramString, int paramInt)
  {
    this.ˊ = paramString;
    this.ˋ = paramInt;
  }

  public static List<ɫ> ˊ(List<ⅽ> paramList)
  {
    ArrayList localArrayList1 = ˎ(paramList);
    ArrayList localArrayList2 = new ArrayList(7);
    ɫ localɫ = null;
    if (localArrayList1.size() > 7)
    {
      List localList1 = localArrayList1.subList(0, 3);
      List localList2 = localArrayList1.subList(3, localArrayList1.size());
      HashMap localHashMap = new HashMap();
      Iterator localIterator1 = localList2.iterator();
      while (localIterator1.hasNext())
      {
        ⅽ localⅽ = (ⅽ)localIterator1.next();
        String str = ((Į)DBCacheManager.getInstance().appContext).ˎ().ˎ(localⅽ.ˊ).ﹳ;
        if (str != null)
        {
          Integer localInteger = (Integer)localHashMap.get(str);
          if (localInteger == null)
            localHashMap.put(str, Integer.valueOf(ډ.ˊ(localⅽ.ʽ)));
          else
            localHashMap.put(str, Integer.valueOf(ډ.ˊ(localⅽ.ʽ) + localInteger.intValue()));
        }
      }
      ArrayList localArrayList3 = new ArrayList(1 + localHashMap.size());
      Iterator localIterator2 = localHashMap.entrySet().iterator();
      while (localIterator2.hasNext())
      {
        Map.Entry localEntry = (Map.Entry)localIterator2.next();
        localArrayList3.add(new ɫ((String)localEntry.getKey(), ((Integer)localEntry.getValue()).intValue()));
      }
      Object localObject;
      if (localArrayList3.size() > 4)
      {
        Collections.sort(localArrayList3);
        localObject = localArrayList3.subList(0, 3);
        List localList3 = localArrayList3.subList(3, localArrayList3.size());
        int i = 0;
        Iterator localIterator3 = localList3.iterator();
        while (localIterator3.hasNext())
          i += ((ɫ)localIterator3.next()).ˋ;
        localɫ = new ɫ("Other", i);
      }
      else
      {
        localObject = localArrayList3;
      }
      localArrayList2.addAll(ˋ(localList1));
      localArrayList2.addAll((Collection)localObject);
    }
    else
    {
      localArrayList2.addAll(ˋ(localArrayList1));
    }
    Collections.sort(localArrayList2);
    if (localɫ != null)
      localArrayList2.add(localɫ);
    return localArrayList2;
  }

  private static List<ɫ> ˋ(List<ⅽ> paramList)
  {
    ArrayList localArrayList = new ArrayList(paramList.size());
    Iterator localIterator = paramList.iterator();
    while (localIterator.hasNext())
    {
      ⅽ localⅽ = (ⅽ)localIterator.next();
      localArrayList.add(new ɫ(localⅽ.ˊ, ډ.ˊ(localⅽ.ʽ)));
    }
    return localArrayList;
  }

  private static List<ⅽ> ˎ(List<ⅽ> paramList)
  {
    ArrayList localArrayList = new ArrayList();
    Iterator localIterator = paramList.iterator();
    while (localIterator.hasNext())
    {
      ⅽ localⅽ = (ⅽ)localIterator.next();
      if (((localⅽ.ʽ > 0) || (localⅽ.ˋ > 0)) && (!((Į)DBCacheManager.getInstance().appContext).ˎ().ˎ(localⅽ.ˊ).ˎ))
        localArrayList.add(localⅽ);
    }
    return localArrayList;
  }

  public final String toString()
  {
    return "TopicLevel{slug='" + this.ˊ + '\'' + ", level=" + this.ˋ + '}';
  }
}

/* Location:           /Users/vikas/Documents/Mhacks_Real_app/classes-dex2jar.jar
 * Qualified Name:     o.…´
 * JD-Core Version:    0.6.2
 */

redpajama_set_name: RedPajamaGithub


Jobs in Malviya Nagar 2019 Delhi. Apply for 609 freshers jobs in Malviya Nagar. Refreshed on 20 April 2019.
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Malviya Nagar Jobs opportunities in Delhi 2019. Freshersworld.com is the No.1 Jobportal for Jobs & placement papers in Malviya Nagar, Delhi. Recent 609 Jobs opportunities in Malviya Nagar, Delhi, Delhi for Freshers and experienced candidates. Refreshed on 20 April 2019. As of now Malviya Nagar have 609 jobs for job seekers, students & College dropouts. Sign up with freshersworld.com and get latest job notifications in Malviya Nagar. Find most recent job openings in Malviya Nagar, Delhi from a pool of upcoming career opportunities for Freshers and experienced candidates. Create your profile! One click to apply for jobs; Better matching jobs for you; Get noticed by Govt Companies like FCI, GAIL, HPCL, HSCC through Freshersworld. Above we listed a number of jobs, for freshers & experienced candidates with high salary packages. There are 4000+ fresher's jobs in Malviya Nagar which you can apply. It will definitely help the candidates to find their dream job according to their preference. For this year 2019, there is a huge number of job opportunities for those who wish to work in Malviya Nagar, Delhi, Delhi. One can simply submit their resume by registering with Freshersworld and start applying for jobs in Malviya Nagar. Find the lists of latest jobs in Malviya Nagar from Top MNCs & Private companies like Flipkart, Bosch, L&T, Airtel . In Freshersworld we aren't only updating Jobs, in addition to this we are also updating the recruitment details of the jobs with last date, location, job position, Salary, Experienced/ freezer, Skills preferred, Age, Eligibility criteria etc., Select the best Malviya Nagar jobs in Govt Jobs, IT/Software Jobs, Core Technical jobs, Sports Jobs, Finance Jobs sectors etc for freshers and more openings for experienced graduates in top MNCs. Apart from the government jobs in Malviya Nagar, Delhi few top companies in Malviya Nagar is also hiring freshers & experiences candidates for part time and full time. In this Malviya Nagar Jobs page, we are listing all 2019 jobs with qualifications like M.Ed, MHM, Mphil/PhD, MS etc. Register & Subscribe to our Job portal and get frequent job alerts. On this jobs page you can see all different categories of jobs in Malviya Nagar. And you can also apply for jobs in other near cities like Malviya Nagar, Saket, Shahpur Jat, Hauz Khas etc. This will increase the probability of getting the job. Be the first one to apply. Be the first one to get hired.


text:
Secret Service Funds Depleted by Trump's Large Family, Constant Travel
Secret Service director tells USA Today that it can't afford to protect the president
Brian Flood | August 21, 2017 @ 6:41 AM	Last Updated: August 21, 2017 @ 6:55 AM
The Secret Service is running out of cash because of President Trump's large family and frequent trips to his properties, according to USA Today.
The paper reported on Monday that the Secret Service "can no longer afford to pay hundreds of agents it needs to carry out an expanded protective mission." Shortly after the report was published, the term "Secret Service" became a top trend across social media.
Secret Service Director Randolph "Tex" Alles told the paper that over 1,000 agents have already hit federally mediated overtime caps because they must protect Trump and his adult children who are regularly on the move.
Also Read: CNN's Brian Stelter Asks If Trump is Racist, Mentally Unfit for Office (Video)
"The president has a large family, and our responsibility is required in law," Alles told the paper. "I can't change that. I have no flexibility."
Trump often travels to his homes in New Jersey and Florida, while his children have been all over the map for both business and pleasure, including trips to Uruguay and Aspen, Colorado. The secret service is responsible for protecting 42 people, including 18 members of the president's family. The Secret Service protected 31 people during the Obama administration, according to the paper.
The Secret Service has started negotiating larger salaries and more overtime for agents, but Alles told the paper it probably won't happen "in the near term."
"It is clear that the Secret Service's demands will continue to be higher than ever throughout the Trump administration," Maryland Rep. Elijah Cummings' spokeswoman said.
17 Times Fox News Hosts Criticized Donald Trump, From Charlottesville to Helsinki (Photos)
It's been known for a long time that Donald Trump is a fan of Fox News. And, in turn, the conservative network is a fan of his, often running positive stories about the administration that Trump then uses to fuel his Twitter feed. But Fox News isn't always on board the Trump Train. Here are 17 times Fox News gave Trump the business.
Megyn Kelly calls Trump out on women
Trump famously feuded former anchor Kelly after she asked him a tough question at a Republican primary debate about derogatory statements he's made about women. Trump took it personally, judging by his response on Twitter and in interviews. He later famously said Kelly must have had "blood coming out of her wherever" regarding the question. Watch the debate question here.
Kelly to Trump: "Facts matter"
Trump kept hammering at Kelly on Twitter and elsewhere. When he called her out for not using the IBT poll when he was leading the Republican primary field, Kelly rebuked him with a tweet showing she did use the poll. "Facts matter," she wrote.
Fox mocks Trump with statement on debate skipping poll
After polled his Twitter followers to see if he should drop out of a Fox-hosted Republican primary debate, Fox responded artfully with a sarcastic statement that it had learned from "secret" sources Trump might be treated unfairly as president by foreign leaders.
Bill O'Reilly calls out Trump's tweet with totally wrong stats
"The O'Reilly Factor" grilled Trump in a Nov. 2015 interview about his tweet that erroneously said black people killed whites at a rate of 81 percent, while whites kill blacks at a rate of 15 percent. O'Reilly told Trump, "You shouldn't tweet." Trump did not take that advice.
Shepard Smith backs CNN on Russia reporting
Anchor Shep Smith was on Team CNN after Trump's January press conference, in which he refused to take a question from CNN's Jim Acosta, saying, "You're fake news." Smith said, "neither they (CNN) nor any other journalists should be subjected to belittling or delegitimizing by the president-elect of the United States." Watch it here.
Chris Wallace bucks Trump calling media "enemy of the public"
After his press conference in January 2017, Trump continued his attack on media he doesn't like on Twitter. Anchor Chris Wallace wasn't having it on "Fox & Friends." Wallace said Trump's comments "crossed an important line" and said they were dangerous.
Smith calls Trump out on terrorism lie
Smith isn't a fan of Trump's false assertions. When Trump said the media "doesn't want to report" terrorist attacks, Smith took him to task. "The White House knows that it was false or could have learned that it was false with a quick Google check, but either did not do so or decided not to tell the truth." Watch it here.
Wallace says the media is too easy on Trump
In an interview with TheWrap, Wallace said he thinks Sunday political shows in particular should be tougher on Trump. "I think if anything, the media has treated him too well. By that I mean they've allowed him to play by different rules." Read the full interview.
O'Reilly tells Trump Putin is "a killer"
In a February interview, O'Reilly brought up Trump's apparent refusal to criticize Vladimir Putin, calling the Russian president "a killer." Trump famously responded by saying, "What, you think our country is so innocent?" Watch it here.
Smith wails on Trump's refusal to talk about Russia hacks
Nobody on Fox hits Trump harder than Shep Smith. "We have a right to know… You call us 'fake news' and put us down like children for asking questions on behalf of the American people." Watch it here.
Smith backs CNN and rebukes Trump's 'fake news' assertion
Trump's favorite insult against media he doesn't like is to call it "fake news." But Shep Smith again supported CNN against the president after Trump's anti-media speech to the Conservative Political Action Committee. Watch it here.
Neil Cavuto tells Trump he's the problem, not mainstream media
Responding to Trump's tweet claiming the mainstream media wants him off social media, Cavuto called out Trump for losing track of his own agenda. "Mr. President, it is not the fake news media that's your problem, it's you," Cavuto said. Watch it here.
Smith blasts Trump administration on Russia: "Lie after lie after lie"
Shep Smith was at it again following the news breaking about Donald Trump Jr.'s meeting with a Kremlin-linked lawyer. He took the Trump administration to task for its many lies about meetings with Russia, including Jared Kushner failing to report the meeting on his security clearance forms. "My grandmother used to say, 'What a tangled web we weave when first we try to deceive,'" Smith declared on air, leaving fellow anchor Chris Wallace speechless. Watch it here.
Eboni K. Williams slams Trump's remarks about Charlottesville
Following the Unite the Right rally in which a counter-protester was murdered, Trump blamed "both sides" for the violence. On "Fox News Specialists," host Eboni K. Williams took Trump to task for not standing up to white nationalists and white supremacists who support him, calling his initial remarks about the rally "cowardly and dangerous."
Watch the clip here.
Brian Kilmeade calls Trump tweet "ridiculous" blaming U.S. for Russia relations
In a rare sight in the lead up to the summit in Helsinki between Trump and Putin, Trump tweeted, "Our relationship with Russia has NEVER been worse thanks to many years of U.S. foolishness and stupidity and now, the Rigged Witch Hunt!" On "Fox and Friends," a show that has been extremely favorable to Trump (he even calls in), host Brian Kilmeade said of the tweet, "That's by far the most ridiculous tweet of late, and that is insulting to past administrations. He can't be saying that going into the Russian summit." Watch the clip here.
Cavuto blasts Trump's performance in Helsinki: "disgusting"
Neil Cavuto took Trump to task more than once after his Helsinki press conference with Putin. When former Deputy Assistant Attorney General Tom Dupree said Trump could have rebuked Putin for his Russia's attack on U.S. elections, Cavuto said, "But he didn't and that's what made it disgusting. That's what made his performance disgusting. I'm sorry, it's just the only way I feel. It's not a right or left thing for me, it's just wrong." Watch it here.
Trish Regan says Trump "should have defended us" against Putin
Fox Business host Trish Regan got mad about Trump's performance on her show "The Intelligence Report." "He should have defended us," she said.
"He should have defended his own intelligence community. Or just don't take the meeting! Don't go to Helsinki if you can't look the guy in the eye and tell him what's what!" Watch it here.
Donald Trump's favorite network, Fox News, isn't always rosy on what he says and does, especially when he backs Russia over the U.S. intelligence community
'Morning Joe' Guest Says 'Hollywood People' Want to Know When Trump Will Leave Office (Video)
By Brian Flood | August 21, 2017 @ 6:22 AM
CNN's Brian Stelter Asks If Trump is Racist, Mentally Unfit for Office (Video)
Jerry Falwell Jr Defends Trump: 'He Does Not Have a Racist Bone in His Body' (Video)
By Thom Geier | August 20, 2017 @ 7:32 AM


With the peak oil pot bubbling, it is time for another reminder that there is no time like the present to get ones financial house in order. Invest in commodities and buy real things, like bicycles, personal microhydropower, seeds, whatever you think might help.
Oh, and if you are in a position where you might need to declare bankruptcy, now would be a good time, as of right now.
Unless you happen to be a millionaire. Then you can safely wait.
The Rude Pundit has the details, unvarnished as always.


text:
Q: Recieving an "invalid login" when attempting to login using php and mysql I have viewed many sites compared various login scripts and can't find any solution. I put in the correct info and get an 'invalid login' also if i don't put anything in there i get an 'invalid login'. I could really use some help to troubleshoot. Here is the code
<?php
  include_once ('dbc.php');

  $user_email = mysql_real_escape_string(isset($_POST['email']));

  if (isset($_POST['Submit'])=='Login')
  {
    $md5pass = md5($_POST['pwd']);
    $sql = "SELECT id,user_email FROM users WHERE
              user_email = '$user_email' AND
              user_pwd = '$md5pass' AND user_activated='1'";

    $result = mysql_query($sql) or die (mysql_error());
    $num = mysql_num_rows($result);

    if ( $num = 0 )
    {
      // A matching row was found - the user is authenticated.
      session_start();
      list($user_id,$user_email) = mysql_fetch_row($result);
      // this sets variables in the session
      $_SESSION['user']= $user_email;

      if (isset($_GET['ret']) && !empty($_GET['ret']))
      {
        header("Location: $_GET[ret]");
      } else {
        header("Location: myaccount.php");
      }

      //echo "Logged in...";
      exit();
    }

    header("Location: login.php?msg=Invalid Login");
    //echo "Error:";
    exit;
  }
?>

Form Code----
<form name="form1" method="post" action="">

Your Email:
      <input name="email" type="text" id="email">

 Password:
      <input name="pwd" type="password" id="pwd">

      <input type="submit" name="Submit" value="Login">

Register | Forgot

  </form>

A: if (isset($_POST['Submit'])=='Login')

Will never run the code in that block.  isset returns true or false.
Try
if (isset($_POST['Submit']) && $_POST['Submit'] =='Login')

That's why you always get redirected to the invalid login URL.  Beyond that, I didn't really check to see if there were any logical errors in the code.
Also, $user_email = mysql_real_escape_string(isset($_POST['email'])); won't give you the desired result either.
See isset()
You also need to change if ( $num = 0 ) to if ( $num > 0 ).  In either case, you need to use a double-equal == to compare values.  That would assign 0 to $num and execute the code in the body of that if statement.

A: if ( $num = 0 )
should be
if ( $num == 1 )
http://php.net/manual/en/language.operators.comparison.php
Update:
You should check for multiple rows that match. Throw exception/log anytime $num > 1. Such a check would help detect any database consistency issue that creeps in before your db is a complete disaster.


text:
A satellite image of tropical storm Eta moving over the US Florida Keys on November 9, 2020. (AFP or licensors)
Storm Eta hits Florida
Tropical Storm Eta has landed in Florida, USA, leaving death and destruction behind in countries across Central America.
Tropical storm Eta hit the Florida Keys late on Sunday night, after wreaking devastation through parts of Central America over the weekend.
After having travelled and destroyed parts of Mexico, Cuba and Guatemala, authorities in Florida are asking that people "please take this very seriously", and urging them to follow rules and protocol.
The National Hurricane Centre has warned that Storm Eta is likely to bring with it "strong winds, heavy rains and dangerous storm surge" over parts of South Florida and the Florida Keys.
In preparation, the closure of schools, public transport, and beaches has been ordered, and shelters have been opened for people living in mobile homes, parks and campgrounds in low-lying areas as they will be evacuated.
Pope Francis on Sunday prayed for all the victims of the storm in Central America. Eta, he said, has caused "many victims and considerable damage", aggravating "the already difficult situation of the pandemic".
After the recitation of the Angelus, the Pope prayed that the Lord might "welcome the dead, comfort their families and support those who are most affected, as well as all those who are working hard to help them".
Pope prays for Central America as Hurricane Eta wreaks havoc
At least 20 people were killed in Mexico, around 17 in Panama and 10 in Honduras, where hundreds of people are reportedly waiting to be rescued from flooded areas.
In Guatemala, homes were buried by mudslides, leaving some 150 people either dead or missing. Luckily, ahead of the storm's arrival, Cuba had already evacuated tens of thousands of people. State media reported that there had been "no loss of life or significant damage to homes".