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改 善
Daniel
Jordan,
PhD, ABPP
PUBLIC HEALTH MYTHS AND REALITIES:
International University
for Graduate Studies
July 2012
www.iugrad.edu.kn
© Daniel Jordan, PhD, ABPP, [email protected]
改 善
Starfish
Downstreamers
TWO PARABLES
A New Parable of the Downstreamers
Daniel Jordan, PhD, ABPP, [email protected]
Adapted and Revised From: Ardell, D. (1986). The Parable of the Downstreamers. High Level Wellness: An Alternative to Doctors, Drugs & Disease. Ten Speed Press. Berkeley, CA.
People Were Drowning!
Downstream villagers saw the first
drowning person in the river many
years ago, but they could offer little
help.
No one knew how to swim, so they
organized swim training.
Some even got certificates and
advanced degrees.
People Kept Drowning!
But more drowning people kept
floating down the river.
Sometimes it took hours to pull
dozens from the river, and then
only a few would survive.
Some drowners even jumped back
into the water and were swept
away.
People Kept Drowning!
The Downstreamers wrote a grant
to get specialized life saving
equipment.
They raised private funds to build a
waterside rescue facility.
Volunteers staffed it 24/7.
They finally got funds for paid staff.
But Things Just Got Worse!
The number of victims kept
increasing, so . . .
They analyzed specific patterns of
how people were floating down the
river, looked for specific eddies and
currents, then modified those water
flow patterns to reduce local risks
and improve the ability to respond
Finally Things Improved!
Outcomes research showed that
Downstreamers’ rescues increased
from 27.8% to 62.3% in 20 minutes
or less, 16.7% are saved in 7
minutes or less!
Downstreamers were very proud!
They wrote articles, attended
conferences, got awards
Downstreamers were Proud of Services and Supports . . .
New hospital at the edge of the river,
A flotilla of rescue boats ready,
Comprehensive plans for staffing
Highly trained and dedicated swimmers ready to risk their lives
Mental health counselors deal with trauma
Downstreamers are Proud of Services and Supports . . .
This has been good for the economy
A lot of “good people” have good paying jobs, they also feel productive and useful, fulfilled
Downstreamers hold an awards banquet every year
They get government honors and grants, newspaper articles
. . . But Some Downstreamers Disagree
They believe that people need to take care of themselves
They’re upset with having to help people “who won’t help themselves” by learning to swim
They say other needs go unmet, and they are being taxed to death for people who aren't Downstreamers anyway, send them back where they came from
No new taxes!!!!!!
Both Groups Overlook Some Key Questions.
Someone finally asks . . .
What’s Going on Upstream??!!
Who Keeps Throwing People in the River??!!
Are systemic causes getting people in trouble?
And then in the most Radical Act of All . . .
. . . a couple of Downstreamers Shift
their focus: They ask why drowning people are in the river at
all
Even Worse: They decide to go
upstream to find out who is throwing people in the river, and even
worse than that: They decide to do
something about it.
Many Downstreamers Get Upset with the Questioners
Some complain that the people going upstream are too radical. If people are drowning, it’s their own fault.
Others worry that trying to change things will mean people drowning right now won’t get helped. Their work is important.
But: What if drowning people stopped floating down the river?
Many Downstreamers Say These People are too
Radical The couple are told they should keep
working “inside the system,” that's how change really happens. Don’t make waves, even more people will drown.
They're told not to make too much of a fuss, it isn't polite, and funders might decide to stop giving grants.
The couple say they're going anyway and start to pack.
The Downstreamers Act!
Downstreamers hold a meeting and decide to ostracize the couple.
The couple load their car to go upstream.
Downstreamers rush the couple, grab them, and throw them into the river.
They float away.
Problem solved!
And Everyone Upstream and Downstream Lived
Happily Ever After
Except for the drowning people of course, and those who wanted
to reduce the need.
改 善
A shift in focus: The community,
society
Serve individuals for community
welfare
Community is the client
Social model not medical model
Physical, mental, and emotional
Context Matters
What is the responsibility of the
primary care provider?
PUBLIC HEALTH IS . . .
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If we just keep helping people at
the individual level, the needs
will be the same or worse 10, 20,
100 years from now.
HYPOTHESIS I
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The degree, extent or rate of
inequality and discrimnination
are the two most consistent
predictors of social problems
HYPOTHESIS II
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Elitism is efficient (and efficiency is good)
Exclusion is necessary
Prejudice is natural
Greed is good
Despair is inevitable, and is the goal to assure conformity
[These conditions are sustainable]
SIX TENETS THAT
MAINTAIN INEQUALITY
Derived from Danny Dorling, Injustice: why social inequality persists
http://sasi.group.shef.ac.uk/presentations/injustice/
改 善
Pursue social change, with and for vulnerable and oppressed individuals and groups: Confront poverty, unemployment, discrimination, and other forms of injustice
Not practice, condone, facilitate, or collaborate with any form of discrimination based on race, ethnicity, national origin, color, sex, sexual orientation, age, marital status, political belief, religion, or mental or physical disability
NASW ETHICAL RESPONSIBILITY: SOCIAL JUSTICE & DISCRIMINATION
改 善
Promote general welfare of society, local to global levels, development of people, communities, and environments
Advocate living conditions that fulfill human needs
Promote social, economic, political, and cultural values and institutions to realize social justice
NASW ETHICAL RESPONSIBILITY:
TO BROADER SOCIETY
改 善
Engage in social and political action to ensure that all people have equal access to resources, employment, services, and opportunities to meet basic human needs and develop fully
Be aware of impact of politics on practice
Advocate for changes in policy and laws to improve conditions to meet basic human needs and promote social justice
NASW ETHICAL RESPONSIBILITY:
SOCIAL & POLITICAL ACTION
改 善
Act to expand choice and opportunity for all, especially vulnerable, disadvantaged, oppressed, and exploited people and groups
Promote respect for cultural and social diversity nationally and globally
Promote policies and practices that show respect for difference, support expansion of cultural knowledge and resources
NASW ETHICAL RESPONSIBILITY:
SOCIAL & POLITICAL ACTION
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Advocate cultural competence, and policies
that safeguard rights of and confirm equity
and social justice for all people
NASW ETHICAL RESPONSIBILITY:
SOCIAL & POLITICAL ACTION
改 善
Act to prevent and eliminate domination of, exploitation of, and discrimination against any person, group, or class based on race, ethnicity, national origin, color, sex, sexual orientation, age, marital status, political belief, religion, or mental or physical disability
NASW ETHICAL RESPONSIBILITY:
GLOBAL SOCIAL JUSTICE
改 善
Public health is about helping people
find ways to lead healthier lives, in every
sense.
Public health’s roots tap into social work
activism about the betterment of society.
Public health standards are divided into
three core functions further broken down
into ten essential services
FUNDAMENTAL CONCEPT
改 善
THREE CORE
FUNCTIONS
TEN
ESSENTIAL
PUBLIC
HEALTH
SERVICES
SYSTEM
MANAGEMENT
改 善
More
Citizen Control
Empowerment
Delegated Power
Partnership
Education
Placation
Consultation
Informing
Therapy
Manipulation
Less TE
N L
EV
EL
S O
F
CH
AN
GE
Modified from, Arnstein, Sherry R. Eight
Rungs on the Ladder of Citizen
Participation. In Cahn, Edgar S. and
Passet, Barry A, eds. Citizen
Participation: Effecting Community
Change. New York, Praeger, 1971., p. 70.
Lower steps can
be used to
influence higher
steps, e.g., therapy
can be a tool to
raise awareness to
educate and
empower people.
改 善 © Daniel Jordan, PhD, ABPP, [email protected]
Role of the
change agent
PRAXIS &
CRITICAL
COMMUNITY
EDUCATION:
EMANCIPATION FOR
EMPOWERMENT
Se
cti
on
II
改 善 改 善
From: Tones. K.
(2002) Reveil le
for Radicals!
The paramount
purpose of
health
education.
Oxford J.
PRAXIS &
CRITICAL
COMMUNITY
EDUCATION:
EMANCIPA-
TION FOR
EMPOWER-
MENT
Community worker seeks: • To gain acceptance
by community • Listens and
empathises • Encourages
expression of ideas
Identify root causes of social problems, e.g.,environmental, social, economic, political
Success breeds success. New needs identified by community members. They develop skills and gain confidence to undertake new tasks.
Praxis: Stage of
Reflection and Action:
Solutions identified,
discussed, and acted on
Community Action
Community Self-
Advocacy
Identify
Community
Leaders
Provide
Supports
Develop
Skills
Establish
Community
Coalitions
Identify
Felt
Needs
Community worker raises awareness of health and social issues, e.g., help community members develop video voice maps of environ-mental conditions, public speaking exercises
改 善
PUBLIC HEALTH AND
COMMUNITY TRANSFORMATION
Show up, shut up, and
Listen In other words,
therapists have a lot to offer efforts to
change the contexts that cause social problems
改 善
WHAT WE HAVE TO OFFER THE
COMMUNITY
改 善
改 善
Exposure to toxins, pesticides, poisons
Air quality: diesel exhaust, carbon monoxide
Noise pollution (leads to decreased academic
performance)
Water pollution
Perverse incentives : Fast food
would not be cheaper without
tax incentives to produce
those types of products
SERIOUS INCREASES IN DISEASES AND
ILLNESSES
改 善
FAST FOOD NATION, FAST FOOD WORLD
改 善
Since 1991 US obesity rates increased
74%.
HERE’S WHERE WE GOT OFF COURSE
改 善
Average BMI = 35 (obesity = height to weight ratio >30)
NAURU: MOST OBESE NATION ON EARTH
95% OBESITY
改 善
CONSIDER THE MOST OBESE
NATION ON EARTH
改 善
Millions, perhaps billions have been spent
on obesity and diabetes reduction and
treatment.
Have the numerous campaigns to reduce
the rates of obesity and diabetes been
effective?
Time period: 1985-2010 (Note: the CDC
changed its reporting methods in 1995)
HEALTH DATA STATISTICS: PART ONE
改 善
Hypothesis: The greater the degree of
inequality in a society the higher the levels of
virtually every type of social problem,
including health problems.
Sources
Wilkinson and Pickett. The Spirit Level: Why Greater
Equality Makes Society Stronger http://www.equalitytrust.org.uk/
The State of Working America Economic Policy Institute: Working Group on Extreme Inequality
http://www.stateofworkingamerica.org/
http://extremeinequality.org/
20 Facts About US Inequality Everyone Should Know http://www.stanford.edu/group/scspi/cgi -bin/facts.php
HEALTH PATTERNS
改 善 © Daniel Jordan, PhD, ABPP, [email protected]
Level of income disparity [inequality] in the study was the difference between the upper 20% and the lowest 20%.
Inequality can be low one of two ways: Everyone is relatively rich or Everyone is relatively poor
Examples:
Arkansas: Low inequality, low overall income
New Hampshire: Low inequality, high overall income
Correlation is not causation, but . . . When a hypothesis can be formed, and literally dozens of measures
all point in the same direction, a case begins to emerge that two factors that correlate consistently are likely to have a causal relationship.
WORKING DEFINITIONS
© Daniel Jordan, PhD, ABPP, [email protected]
© Daniel Jordan, PhD, ABPP, [email protected]
© Daniel Jordan, PhD, ABPP, [email protected]
© Daniel Jordan, PhD, ABPP, [email protected]
© Daniel Jordan, PhD, ABPP, [email protected]
© Daniel Jordan, PhD, ABPP, [email protected]
© Daniel Jordan, PhD, ABPP, [email protected]
© Daniel Jordan, PhD, ABPP, [email protected]
© Daniel Jordan, PhD, ABPP, [email protected]
© Daniel Jordan, PhD, ABPP, [email protected]
© Daniel Jordan, PhD, ABPP, [email protected]
© Daniel Jordan, PhD, ABPP, [email protected]
© Daniel Jordan, PhD, ABPP, [email protected]
© Daniel Jordan, PhD, ABPP, [email protected]
改 善 © Daniel Jordan, PhD, ABPP, [email protected]
CDC DATA: OBESITY AND
DIABETES
Dri
ll D
ow
n E
xam
ple
Case Study:
Trends in Diagnosed Obesity
and Diabetes
CDC’s Division of Diabetes Translation.
November, 2011
National Diabetes Surveillance System:
http://www.cdc.gov/diabetes/statistics
Obesity Trends* Among U.S. Adults BRFSS, 1985
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% Note the Percentage Scale
Obesity Trends* Among U.S. Adults BRFSS, 1986
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% Note the Percentage Scale
Obesity Trends* Among U.S. Adults BRFSS, 1987
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% Note the Percentage Scale
Obesity Trends* Among U.S. Adults BRFSS, 1988
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% Note the Percentage Scale
Obesity Trends* Among U.S. Adults BRFSS, 1989
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% Note the Percentage Scale
Obesity Trends* Among U.S. Adults BRFSS, 1990
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% Note the Percentage Scale
Obesity Trends* Among U.S. Adults BRFSS, 1991
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% Note the Percentage Scale
Obesity Trends* Among U.S. Adults BRFSS, 1992
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% Note the Percentage Scale
Obesity Trends* Among U.S. Adults BRFSS, 1993
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% Note the Percentage Scale
Obesity Trends* Among U.S. Adults BRFSS, 1994
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% Note the Percentage Scale
Age -Adjusted Prevalence of Obesity and Diagnosed Diabetes Among U.S. Adults
Note the Percentage Scale: 14% was the original high
Age -Adjusted Prevalence of Obesity and Diagnosed Diabetes Among U.S. Adults
Age -Adjusted Prevalence of Obesity and Diagnosed Diabetes Among U.S. Adults
Age -Adjusted Prevalence of Obesity and Diagnosed Diabetes Among U.S. Adults
Age -Adjusted Prevalence of Obesity and Diagnosed Diabetes Among U.S. Adults
Age -Adjusted Prevalence of Obesity and Diagnosed Diabetes Among U.S. Adults
Age -Adjusted Prevalence of Obesity and Diagnosed Diabetes Among U.S. Adults
Age -Adjusted Prevalence of Obesity and Diagnosed Diabetes Among U.S. Adults
Age -Adjusted Prevalence of Obesity and Diagnosed Diabetes Among U.S. Adults
Age -Adjusted Prevalence of Obesity and Diagnosed Diabetes Among U.S. Adults
Age -Adjusted Prevalence of Obesity and Diagnosed Diabetes Among U.S. Adults
Age -Adjusted Prevalence of Obesity and Diagnosed Diabetes Among U.S. Adults
Age -Adjusted Prevalence of Obesity and Diagnosed Diabetes Among U.S. Adults
Age -Adjusted Prevalence of Obesity and Diagnosed Diabetes Among U.S. Adults
Age -Adjusted Prevalence of Obesity and Diagnosed Diabetes Among U.S. Adults
Age -Adjusted Prevalence of Obesity and Diagnosed Diabetes Among U.S. Adults
改 善 © Daniel Jordan, PhD, ABPP, [email protected]
Growing inequality will result in increasing
rates of disease and illness
Rich developed societies have reached a
turning point in sustainability
Politics needs to become about the quality of
social relations and how we can develop
harmonious and sustainable societies.
Inequality predicts disease and illness
Focusing on individual behavior offers little
opportunity for change.
CONCLUSIONS
改 善 © Daniel Jordan, PhD, ABPP, [email protected]
In brief: two main ways of reducing
income inequality
smaller differences in pay before tax
(e.g., Japan)
redistribution through taxes and benefits
(e.g., Sweden)
Economic and Political Democracy are
both necessary to improve health (US
and UK have neither right now)
CONCLUSIONS
改 善 © Daniel Jordan, PhD, ABPP, [email protected]
Trust among people, and quality of life,
would go up 75%
Mental Illness and Obesity would drop by
65%
Teen births would be cut in half
Prison populations could drop by half
People would live longer and could work
two weeks less a year as well. Etc. . . . .
WHAT IF WE REDUCED INEQUALITY?
改 善 © Daniel Jordan, PhD, ABPP, [email protected]
Increasing equality is good for everyone,
the rich included.
Life gets better for all: Remember,
quality of life is NOT related to income or
wealth within a society.
The rich may think they wind up better
off, but in the end they lose as well.
WHAT ABOUT THE RICH?
改 善
WHAT’S THE BIG DEAL?
• In 1974 The Lancet identified obesity as “the
most important nutritional disease in the
affluent countries of the world.” • Infant and adult obesity [editorial]. Lancet 1974; i:17-18.
• What happened since then? We got fatter.
• Worldwide, we’re dying at higher rates and
nations are becoming obese.
• It’s a syndemic: Obesity, diabetes, asthma,
other related diseases are tied together.
改 善
改 善
A NUMBER OF NEW YORKERS ARE UPSET BY MAYOR
BLOOMBERG’S SODA BAN, SAYING THAT IT IS A
CHANGE THAT WILL DRAMATICALLY EFFECT THEIR
LIFEST YLE.
改 善
ABOUT “IT’S JUST
ONE SODA
x 365 days/year =
15 pounds of body fat
So-called “juice drinks” and “power drinks” are just as bad.
They all rot your teeth.
Half of Americans’ calories come from soda. Half!
改 善
ABOUT RESTAURANTS
• A typical restaurant portion size is two to
three times more than servings should be.
• We’ve been conned into measuring quality of
food in terms of quantity.
• We get far more saturated
fat and far fewer nutrients
than we should. We’re
starving while becoming
obese.
改 善
ABOUT RESTAURANTS
• Kids get hit the hardest: They get twice as
many calories in restaurant meals than they
need.
• This simple fact yields a population of kids
that is amazingly obese, will have lifelong
health problems, and will die younger than
they should.
• Our marketing system is killing our kids, and
we’re letting it happen.
改 善
Traditional Focus Transformative Focus
Deficits-based
Reactive
Individual & Family
Professional-driven
Strengths-based
Primary Prevention
Empowerment
Community Conditions
“SPEC” MODEL:
ISAAC PRILILTENSKY
Http://people.Vanderbilt.edu/~isaac.prilleltensky
Role shift: From “expert helpers” to “critical change agents”
Focus shift: From individual to community (context)
Power shift: From “providers” to community members
Locus of control shift: From victim to empowered actor
改 善
No. If they did, we would see successes.
“A trap we must avoid, set by the food industry [is] the belief that education is the answer to nutrition problems.
The ostensible rationale is that people do not understand nutrition, that educating them will drive up demand for healthier foods, and that the industry will be happy to meet that demand.
The hidden rationale is that such programs will have little impact, allowing industry to do business as usual. I can see industry executives jump with glee each time government officials point to education as the answer .” Kelly D. Brownel l . http:/ /www.lat imes.com/news/opinion/ la -op-dustup19sep19,0,1026838.story
DO OUR CURRENT HEALTH SYSTEMS
WORK?
改 善
1. education has weak effects, if any;
2. it drains resources;
3. it makes industry seem on the side of consumers; and
4. it bolsters industry's hope that government will allow it to self-regulate while government agencies sit on the sidelines.
5. It is the “perfect” script for public health failure.
• Ke l l y D . B rowne l l . h t t p : / /www. la t imes . com/news/op in ion / l a -op-dus tup19sep19 ,0 ,1026838 .s to r y
RESULTS OF HEALTH EDUCATION
改 善
ABOUT INDIVIDUAL BEHAVIOR
This epidemic is about more than just individual behavior.
Analyzing only individual behavior, assigning blame just to each individual does not explain the stunning change in the pattern of behavior across individuals.
Something more than just “individual responsibility” is going on.
(But that doesn’t let individuals off the hook!)
改 善
So why does the US continue spend any money
at all on health information and education,
obesity prevention, healthy lifestyles, etc.,
when it clearly does not work?
If a similar pattern were experienced in any
domain – private business, government, non-
profit – what would you advise be done?
Follow the money: Who benefits from these
realities?
The Point: You have to dig deeper.
QUESTIONS
改 善
CONSIDER
“If people want to drink 24 ounces of soda, it’s their choice, and nobody else’s business.”
Does social, economic, political context have an impact on individual behavior?
Are we “free” in some abstract way or does the context in which we live impact our choices?
改 善
Brainstorming Context: Forget everything you
know about health, healthcare, mental health,
substance abuse, wellness, systems and
programs.
Using the core assumption: If you were free to
spend a health budget however you could,
what would you do?
“CLEAN SHEET” EXERCISE
改 善
If we were to create a health system from scratch
today, how would we organize ourselves and allocate
resources, and what would be our community
priorities?
Work in small groups and develop clean sheet
systems of care. Brainstorm wild ideas as well as
practical.
Choose a policy domain(s) of interest to your group.
You can focus on real agencies, your own
communities, local entities, state or national policy,
your choice.
“CLEAN SHEET” EXERCISE
改 善
Try to develop something that you could work toward
in your own community.
How would you design your approach to developing
your plan?
Who would you talk to?
What procedures would you use to implement your
plan?
How would you promote it?
What community -level indicators would you
measure?
CLEAN SHEET EXERCISE
改 善
If we keep doing things the way we do them
right now, 50 years from (assuming the world
hasn’t imploded) the next generation will be
doing exactly the same things we’re doing
now.
Only the need will be even greater.
The more an intervention engages power
equalization, the more transformative it will
be (Isaac Prilitensky)
CORE ASSUPTION:
CONTEXT MATTERS
改 善
Small group presentations.
What are the implications of using the NASW
standards and to reform the helping
professions, health care plans in this case?
15 minute small groups, design a broad
intervention strategy.
DISCUSSION
改 善
Bunker JP, Frazier HS, Mostel ler F. Improv ing health: measuring ef fects of medical care . Mi lbank Quar ter ly 1994;72:225 -58.
Bolen JR, Sleet DA , Chorba T, et a l . Overview of ef for ts to prevent motor vehicle - related in jury. In : Prevent ion of motor vehic le -related in jur ies: a compendium of ar t ic les from the Morbidi ty and Mortal i ty Weekly Repor t , 1985 -1996. At lanta, Georgia: US Depar tment of Heal th and Human Serv ices, Centers for Disease Control and Prevention, Nat ional Center for In jury Prevent ion and Control , 1997.
Hoyer t DL, Kochanek KD, Murphy SL. Deaths: f inal data for 1997. Hyattsvi l le , Maryland: US Depar tment of Heal th and Human Serv ices, CDC, Nat ional Center for Heal th Stat ist ics, 1999. (Nat ional v i ta l s tat ist ics repor t ; vol 47, no.20) .
CDC. Fatal occupat ional in jur ies - - Uni ted States , 1980-1994. MMWR 1998;47:297-302.
Anonymous. The s ixth repor t of the Joint Nat ional Committee on Prevent ion, Detect ion, Evaluat ion, and Treatment of High Blood Pressure . Arch Intern Med 1997;157:2413-46.
Burt BA , Eklund SA . Dent istr y, dental pract ice , and the community. Phi ladelphia , Pennsylvania: WB Saunders Company, 1999:204 -20.
Publ ic Heal th Serv ice. For a healthy nat ion: returns on investment in publ ic health . At lanta, Georgia : US Depar tment of Heal th and Human Serv ices, Publ ic Heal th Serv ice, Of f ice of Disease Prevent ion and Health Promotion and CDC, 1994.
ADDITIONAL REFERENCES
© Daniel Jordan, PhD, ABPP, [email protected]
改 善 © Daniel Jordan, PhD, ABPP, [email protected]
CONTACT FOR MORE INFORMATION
About this presentation:
Daniel Jordan, PhD, ABPP at
About the International University for
Graduate Studies graduate
programs:
www.iugrad.edu.kn