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In addition to differences in the use of surgery, there may also be racial disparities in surgical outcomes. For some procedures, it is well established that black patients are more likely than white patients to undergo surgery urgently or emergently,10,11 a well-known risk factor for operative mortality. In addition, it is possible that blacks receive their care in poorer quality hospitals. For example, blacks are up to twice as likely to undergo high-risk procedures in very low-volume hospitals.12,13 Several studies have suggested that black race is an independent marker for operative mortality.10,14,15 However, most studies to date have focused on individual procedures, based on data from different time periods and study populations.
Our study suggests potential reasons for apparent racial disparities in operative mortality. First, black patients have higher baseline risks than whites. Although they were younger and tended to have similar comorbidity scores for some procedures, black patients were considerably more likely to be admitted to the hospital emergently, an important risk factor for operative mortality.21 They also tended to reside in low-income areas, another independent risk factor.4,22 For cardiovascular procedures, but not cancer procedures, adjusting for these patient characteristics attenuated the observed associations between race and crude mortality, ie, reduced odds ratios of mortality by race. Although these attenuations were relatively modest in magnitude, they may have been larger had we access to more detailed information about illness severity and acuity (from clinical data) or patient-level data on socioeconomic status.
Second, black patients were more likely to undergo surgery in hospitals with higher mortality rates, independent of race. As suggested previously,12,23,24 black patients were considerably more likely to receive their care in very low volume hospitals: more than 20% more likely for all procedures. For most of these procedures, low hospital procedure volume is a well-established risk factor for increased operative mortality.25,26 Moreover, surgical volume is not the only contributor to worse mortality rates; for some procedures, hospitals that treated a large proportion of black patients had higher mortality rates independent of their procedure volume. Therefore, relationships between race and mortality may be confounded by other factors influencing hospital mortality rates.
Although the first focusing on surgical outcomes, our study is not the first to suggest to that racial disparities in health care may be partly attributable to suboptimal systems in which black patients receive their care. Bach et al recently reported that physicians treating black patients are less likely to be board certified and have worse access to specialists and other technologic resources.27 Barnato et al have shown that racial disparities in quality of care following acute myocardial infarction are partly attributable to hospital.27a And Bradley et al have shown that racial differences in time to reperfusion following acute myocardial infarction are partly attributable to the hospitals to which minority and white patients are typically admitted.28
Our findings, along with those of previous studies,10,35 reinforce the need to focus on why black patients are more likely to present urgently for surgical intervention. Racial differences in patient preferences about surgery may be partly responsible. For example, previous studies of patients with colorectal and prostate cancer have indicated that black patients are more likely to delay or refuse surgical care until disease has become relatively acute or advanced.36,37 However, black patients may also be getting different advice from their physicians than white patients.35 Several studies have suggested that providers are less likely to recommend or facilitate surgical care for black patients than for whites with comparable disease.38,39 In settings where earlier intervention clearly improves outcomes, efforts aimed at changing both patient and provider behavior should be sought and encouraged.
However, our study suggests that racial disparities may be as much about the system in which black patients get their care as about patient- or physician-level factors. Selective referral, moving high risk surgical patients at hospitals with high mortality rates to other centers with better outcomes, is one obvious but likely impractical approach to addressing potential problems at hospitals that disproportionately treat black patients. Large numbers of patients would be involved and their access to low mortality rate centers (even if they could be readily identified) is uncertain. Moreover, removing surgical caseloads from hospitals that disproportionately treat black patients might worsen care for other patients by further eroding resources at those centers.
This report documents the rates of incarceration for white, Black and Latinx Americans in each state, identifies three contributors to racial and ethnic disparities in imprisonment, and provides recommendations for reform.
This report details our observations of staggering disparities among Black and Latinx people imprisoned in the United States given their overall representation in the general population. The latest available data regarding people sentenced to state prison reveal that Black Americans are imprisoned at a rate that is roughly five times the rate of white Americans. During the present era of criminal justice reform, not enough emphasis has been focused on ending racial and ethnic disparities systemwide.
Going to prison is a major life-altering event that creates obstacles to building stable lives in the community, such as gaining employment and finding stable and safe housing after release. Imprisonment also reduces lifetime earnings and negatively affects life outcomes among children of incarcerated parents.1 These are individual-level consequences of imprisonment but there are societal level consequences as well: high levels of imprisonment in communities cause high crime rates and neighborhood deterioration, thus fueling greater disparities.2 This cycle both individually and societally is felt disproportionately by people who are Black. It is clear that the outcome of mass incarceration today has not occurred by happenstance but has been designed through policies created by a dominant white culture that insists on suppression of others.
This report documents the rates of incarceration for whites, African Americans, and Latinx individuals, providing racial and ethnic composition as well as rates of disparity for each state.7 The Sentencing Project has produced state-level estimates twice before8 and once again finds staggering disproportionalities.
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Coon songs were a genre of music that presented a stereotype of black people. They were popular in the United States and Australia from around 1880 to 1920, though the earliest such songs date from minstrel shows as far back as 1848, when they were not yet identified with "coon" epithet. The genre became extremely popular, with white and black men giving performances in blackface and making recordings. Women known as coon shouters also gained popularity in the genre.
Although the word "coon" is now regarded as racist, according to Stuart Flexner, "coon" was short for "raccoon", and it meant a frontier rustic (someone who may wear a coonskin cap) by 1832. By 1840 it also meant a Whig as the Whig Party was keen to be associated with rural white common people. At that time, "coon" was typically used to refer someone white, and a coon song referred to a Whig song. it was only in 1848 when the first clear case of using "coon" to refer to a black person in a derogative sense appeared. It is possible that the negative racial connotation of the word may have evolved from "Zip Coon", a song that first became popular in the 1830s, and the common use of the word "coon" in blackface minstrel shows.
The song "Zip Coon", a variant of "Turkey in the Straw", notably in performances by George Washington Dixon who performed in blackface, was published around 1834. The word "coon" meaning "black person", was in use by 1837. An alternative suggestion of the word's origin to mean a black person is that it was derived from barracoon, an enclosure for slaves, which became increasingly used in the years before the American Civil War as temporary enclosure for slaves escaping or traveling. It may also have been used earlier on the stage; a black man named Raccoon was one of the lead characters in a 1767 colonial comic opera "The Disappointment". Whatever the origin, by 1862, "coon" had come to mean a black person.
The first explicitly coon-themed song, published in 1880, may have been "The Dandy Coon's Parade" by J. P. Skelley. Other notable early coon songs included "The Coons Are on Parade", "New Coon in Town" (by J. S. Putnam, 1883), "Coon Salvation Army" (by Sam Lucas, 1884), "Coon Schottische" (by William Dressler, 1884). The most popular coon songs of this early period, however, were written by whites, and only one, "New Coon in Town", has enough syncopation "to foreshadow the true, shouting, ragtime school". Black Americans had also entered the music business by this time, and their syncopated music then came to be identified with real coon songs.
On August 13, 1920, Marcus Garvey's Universal Negro Improvement Association and African Communities League created the red, black and green flag as a response to the song "Every Race Has a Flag but the Coon" by Heelan and Helf. That song along with "Coon, Coon, Coon" and "All Coons Look Alike to Me" were identified by H. L. Mencken as being the three songs which firmly established the derogatory term "coon" in the American vocabulary. Originally in the 1830s, the term had been associated with the Whig Party. The Whigs used a raccoon as its emblem, but the party also developed a more tolerant attitude towards blacks than the other political factions. The latter opinion is likely what transformed the term "coon" from mere political slang into a racial slur. 2b1af7f3a8