Improving U.S. Housing Finance Through Reform of Fannie Mae and Freddie Mac: Assessing the Options

Presents criteria for evaluating proposals for reforming the two government-sponsored enterprises. Outlines the key arguments for their structural strengths and weaknesses, a framework and goals for reform, and features of specific proposals to date

Neighborhood Characteristics and Elevated Blood Pressure in Older Adults

IMPORTANCE: The local environment remains an understudied contributor to elevated blood pressure among older adults. Untargeted approaches can identify neighborhood conditions interrelated with racial segregation that drive hypertension disparities. OBJECTIVE: To evaluate independent associations of sociodemographic, economic, and housing neighborhood factors with elevated blood pressure. DESIGN, SETTING, AND PARTICIPANTS: In this cohort study, the sample included Health and Retirement Study participants who had between 1 and 3 sets of biennial sphygmomanometer readings from 2006 to 2014 or 2008 to 2016. Statistical analyses were conducted from February 5 to November 30, 2021. EXPOSURES: Fifty-one standardized American Community Survey census tract variables (2005-2009). MAIN OUTCOMES AND MEASURES: Elevated sphygmomanometer readings over the study period (6-year period prevalence): a value of at least 140 mm Hg for systolic blood pressure and/or at least 90 mm Hg for diastolic blood pressure. Participants were divided 50:50 into training and test data sets. Generalized estimating equations were used to summarize multivariable associations between each neighborhood variable and the period prevalence of elevated blood pressure, adjusting for individual-level covariates. Any neighborhood factor associated (Simes-adjusted for multiple comparisons P ≤ .05) with elevated blood pressure in the training data set was rerun in the test data set to gauge model performance. Lastly, in the full cohort, race- and ethnicity-stratified associations were evaluated for each identified neighborhood factor on the likelihood of elevated blood pressure. RESULTS: Of 12 946 participants, 4565 (35%) had elevated sphygmomanometer readings (median [IQR] age, 68 [63-73] years; 2283 [50%] male; 228 [5%] Hispanic or Latino, 502 [11%] non-Hispanic Black, and 3761 [82%] non-Hispanic White). Between 2006 and 2016, a lower likelihood of elevated blood pressure was observed (relative risk for highest vs lowest tertile, 0.91; 95% CI, 0.86-0.96) among participants residing in a neighborhood with recent (post-1999) in-migration of homeowners. This association was precise among participants with non-Hispanic White and other race and ethnicity (relative risk, 0.91; 95% CI, 0.85-0.97) but not non-Hispanic Black participants (relative risk, 0.97; 95% CI, 0.85-1.11; P = .48 for interaction) or Hispanic or Latino participants (relative risk, 0.84; 95% CI, 0.65-1.09; P = .78 for interaction). CONCLUSIONS AND RELEVANCE: In this cohort study of older adults, recent relocation of homeowners to a neighborhood was robustly associated with reduced likelihood of elevated blood pressure among White participants but not their racially and ethnically marginalized counterparts. Our findings indicate that gentrification may influence later-life blood pressure control

SDG5 “Gender Equality” and the COVID-19 pandemic: A rapid assessment of health system responses in selected upper-middle and high-income countries

Introduction: The COVID-19 pandemic disrupted healthcare and societies, exacerbating existing inequalities for women and girls across every sphere. Our study explores health system responses to gender equality goals during the COVID-19 pandemic and inclusion in future policies. Methods: We apply a qualitative comparative approach, drawing on secondary sources and expert information; the data was collected from March–July 2022. Australia, Brazil, Germany, the United Kingdom, and the USA were selected, reflecting upper-middle and high-income countries with established public health and gender policies but different types of healthcare systems and epidemiological and geo-political conditions. Three sub-goals of SDG5 were analyzed: maternity care/reproductive health, gender-based violence, and gender equality/women's leadership. Results: We found similar trends across countries. Pandemic policies strongly cut into women's health, constrained prevention and support services, and weakened reproductive rights, while essential maternity care services were kept open. Intersecting gender inequalities were reinforced, sexual violence increased and women's leadership was weak. All healthcare systems failed to protect women's health and essential public health targets. Yet there were relevant differences in the responses to increased violence and reproductive rights, ranging from some support measures in Australia to an abortion ban in the US. Conclusions: Our study highlights a need for revising pandemic policies through a feminist lens

Intractable Alcoholism in a Patient with a Levine Shunt

Ellen Shaw. M.D., Fellow in Hepatology: Mr. J is a forty-six-year-old white male who was initially seen on the medical service in July 1982. At that time he presented with hepatic encephalopathy, jaundice, and ascites. A liver biopsy was performed, confirming the clinical diagnosis of alcoholic hepatitis superimposed on cirrhosis. Following discharge it was difficult to maintain Mr. J as an outpatient. He did not follow dietary restrictions or take diuretics as prescribed. Additionally he was unable to control his drinking. Finally about a year ago a Levine shunt was implanted in an effort to control his ascites. Subsequently he did well for a period of several months. He was able to abstain from alcohol with a resulting decrease in his ascites and jaundice. Recently he has resumed drinking, with a return of his symptoms. He has missed his last several appointments in the clinic. Control of his medical problems remains problematic unless his alcohol abuse can be better controlled

Business Models for Energy Entrepreneurship in Emerging Markets

Access to electricity produces greater levels of economic value and increases the quality of life in emerging markets across the globe. Emerging economies have surpassed developed nations in clean energy investment and deployment1 , but based on our review of the literature, there is a lack of high-level study on the factors that most affect the success of these businesses. The goal of this project is to identify these success factors, and use them to inform entrepreneurs’ strategic decision-making as well as elucidate the environments in which these ventures have a higher probability of success. By better understanding what drives success in the renewable energy industry, both entrepreneurs and key stakeholders such as policy makers, investors, and interested non-governmental organizations (NGOs) can better prioritize their efforts and investments to drive increased levels of clean energy adoption. This project focuses on clean energy business models in two emerging economies: India and Uganda. These countries have significant differences in levels of access to energy and development of their entrepreneurial landscapes, and therefore, provide a broad scope for analysis. This report presents an overview of existing empirical research on factors that hinder or increase success of business models, identifies potential gaps in this research, and presents analysis based on qualitative, in-country interviews conducted by our team. Based on a comparative analysis between the literature review and interview findings, the team drew conclusions about factors that would benefit from better coordination and investment from industry players. The team also identified aspects of the entrepreneurial experience in developing countries that are strong candidates for further academic research. Throughout the project, entrepreneurs and industry experts (such as the stakeholders above) highlighted several of the key topics identified in existing research, including the challenge of attracting private investment, strategies for revenue collection given limited ability to pay among customers, the effect of domestic energy policy, and the industry’s lack of institutional support, whether it be nonexistent or ineffective small business associations, trade associations, lobbying groups, etc. While it was reassuring to see entrepreneur and stakeholder interviews validate what had been uncovered in the literature review, the key value created by this project was largely the nuance the interviews provided regarding the structural issues that were inhibiting growth for the renewable and clean energy industries, and provide context around how some of these issues were overcome in India and Uganda. Our research questions aimed to understand how entrepreneurs can directly improve their prospects for success and where their efforts require coordination with other partners in the renewable energy value chain or key policymakers. The interviews revealed a clear distinction between the factors that entrepreneurs and industry experts found to be most relevant and important to the success of clean energy entrepreneurs. Factors such as positioning/strategy, company structure, ability to collect revenue, and business model flexibility were by far more relevant for entrepreneurs than industry experts. This understanding of which factors are more directly in entrepreneurs’ control can allow them to prioritize which factors to focus their attention and resources on. In contrast, industry experts regularly mentioned factors that were not top of mind for entrepreneurs in interviews such as domestic energy policy, customer financial resources, and distribution and utility infrastructure. Despite the relative dichotomy between entrepreneurs and industry experts, there was some overlap among what factors the two groups found to be the most important. These factors include talent attraction and retention, accessibility of private investment, competitive landscape, consumer education and strategic partnerships. The overlapping factors indicate the significance of these challenges, and highlights the potential areas where strategic partnerships would be the most beneficial to foster a healthier entrepreneurial ecosystem. Overall, the interviews raised new issues that were not discussed as in-depth in the literature. For example, the conclusion that there is a lack of product awareness and trust among most consumers, and that regulatory uncertainty of even the most well-intentioned policies can be extremely detrimental. In India, there were difficulties retaining employees. In Uganda, there appears to be a weak pipeline of educated, local talent. These issues demand comprehensive solutions that can only be realized by greater cooperation and coordination between entrepreneurs, industry experts, and policy makers. In sum, the hope is that this research will inform market players of key factors of entrepreneurial success and act as a catalyst for future research. In particular, what factors do entrepreneurs and industry experts see affecting success, where do they see greater opportunities for coordination, and how are the Indian and Ugandan experiences representative of other emerging markets?Master of ScienceSchool for Environment and SustainabilityUniversity of Michiganhttps://deepblue.lib.umich.edu/bitstream/2027.42/148815/1/Business Models for Energy Entrepreneurship in Emerging Markets_P46.pd

Managing diabetes and hypertension in western Kenya: A qualitative study of experiences of patients supported by the primary health integrated care for chronic conditions (PIC4C) model of care

The Primary Health Integrated Care for Chronic Conditions (PIC4C) pilot project was launched in 2018 to strengthen prevention and control of four non-communicable conditions at primary health care level in western Kenya. We conducted a qualitative study to explore the extent to which PIC4C integrated services supported people with hypertension and/or diabetes towards timely diagnosis and referral, treatment, follow-up and adherence, from the perspective of those receiving care. Semi-structured interviews were conducted with a purposively sampled patient cohort at two time points, with the intention of capturing changes over time (total (n) = 43, completion of both interviews (n) = 37). We extracted existing survey data to describe socio-demographic characteristics and analyzed qualitative data thematically. We identified two cross-cutting contextual factors, individual's financial resources and their social situation, which shaped each stage of their interactions with PIC4C services. The PIC4C model successfully engaged people in accessing screening services to enable timely diagnosis and referred them to enter care. Free community level screening services and decentralization of care to lower level facilities reduced cost barriers for patients. However, retention in care and adherence to treatment were affected by the wider system context in which PIC4C was operating, including inconsistencies in medication availability and patients' limited financial capacity. Individually tailored advice from health care workers to work around some of these challenges supported self-management strategies. Further development of the service should focus on supporting health care workers to adopt flexible, contextually responsive approaches in order to support patients facing economic and other constraints to engage in (self) care

Climate vulnerability assessment for Pacific salmon and steelhead in the California Current Large Marine Ecosystem.

Major ecological realignments are already occurring in response to climate change. To be successful, conservation strategies now need to account for geographical patterns in traits sensitive to climate change, as well as climate threats to species-level diversity. As part of an effort to provide such information, we conducted a climate vulnerability assessment that included all anadromous Pacific salmon and steelhead (Oncorhynchus spp.) population units listed under the U.S. Endangered Species Act. Using an expert-based scoring system, we ranked 20 attributes for the 28 listed units and 5 additional units. Attributes captured biological sensitivity, or the strength of linkages between each listing unit and the present climate; climate exposure, or the magnitude of projected change in local environmental conditions; and adaptive capacity, or the ability to modify phenotypes to cope with new climatic conditions. Each listing unit was then assigned one of four vulnerability categories. Units ranked most vulnerable overall were Chinook (O. tshawytscha) in the California Central Valley, coho (O. kisutch) in California and southern Oregon, sockeye (O. nerka) in the Snake River Basin, and spring-run Chinook in the interior Columbia and Willamette River Basins. We identified units with similar vulnerability profiles using a hierarchical cluster analysis. Life history characteristics, especially freshwater and estuary residence times, interplayed with gradations in exposure from south to north and from coastal to interior regions to generate landscape-level patterns within each species. Nearly all listing units faced high exposures to projected increases in stream temperature, sea surface temperature, and ocean acidification, but other aspects of exposure peaked in particular regions. Anthropogenic factors, especially migration barriers, habitat degradation, and hatchery influence, have reduced the adaptive capacity of most steelhead and salmon populations. Enhancing adaptive capacity is essential to mitigate for the increasing threat of climate change. Collectively, these results provide a framework to support recovery planning that considers climate impacts on the majority of West Coast anadromous salmonids