Presidentval nästa år

Presidentval i USA om ett år. Hur det kan komma sig att det är ett val som alltid har intresserad mig vet jag inte.
Först s.k. primärval i februari då delegater ska nomineras. I Iowa hålls det första valet och den 14 juni det sista i Washington D.C (presidentkandidaterna nomineras på partikonventen). På partikonventet därefter ska den utsedde presidentkandidaten välja en vice president kandidat.  Både republikanerna och demokraterna håller sina konvent i Juli: republikanerna i Cleveland (Ohio) och demokraterna i Philadelphia (Pen.). Sedan  är et dags för de olika staternas utsedda delegater att rösta på favoritkandidaten. Den som får de flesta rösterna blir resp partis presidentkandiat. Presidentvalet hålls den 8e november. Man röstar fram elektorer och varje stat har ett antal elektorer beroende på sin folkmängd.  Elektorsystemet kan medföra att en president blir val trots att hen inte fått en majoritet av rösterna (minns farbror Georg W Bush år 2000).


Favoriter/demokraterna:
Bernie Sanders (bilden -74 år) och Hilary Clinton

Favoriter/republikanerna:
Ben Carson (bilden t.v. - 64 år), Donald Trump, Carly Florina, Jeb Bush och Marco Rubio.

Carly Florina (61 år)



  Donald Trump

Wikipedia om valet (rekommenderas); www.sv.wikipedia.org/wiki/Presidentvalet_i_USA_2016

PS

2015-2016 U.S. ELECTION CALENDAR NOVEMBER 6, 2015: Alabama - Filing Deadline NOVEMBER 9, 2015: Arkansas - Filing Deadline NOVEMBER 21, 2015: Louisiana - Gubernatorial & Statewide Run-Off (if needed) DECEMBER 14, 2015: Texas - Filing Deadline (Major Parties) DECEMBER 16, 2015: Ohio - Filing Deadline (Major Parties) FEBRUARY 1, 2016: Iowa - Presidential Caucuses FEBRUARY 9, 2016: New Hampshire - Presidential Primary FEBRUARY 20, 2016: South Carolina - Presidential Primary FEBRUARY 23, 2016: Nevada - Democratic Presidential Caucuses MARCH 1, 2016:Alabama - Presidential & State Primary Alaska - Republican Presidential Caucuses Arkansas - Presidential & State Primary Colorado - Democratic Presidential Caucuses Massachusetts - Presidential Primary Minnesota - Presidential Caucuses North Dakota - Republican Presidential Caucuses Oklahoma - Presidential Primary Tennessee - Presidential Primary Texas - Presidential & State Primary Vermont - Presidential Primary Virginia - Presidential Primary Wyoming - Republican Presidential Caucuses MARCH 5, 2016:Kansas - Presidential Caucuses Louisiana - Primary Election Maine - Presidential Caucuses Nebraska - Democratic Presidential Caucuses Washington - Republican Presidential Caucuses MARCH 8, 2016:Hawaii - Republican Presidential Caucuses Idaho - Republican Presidential Caucuses Michigan - Presidential Primary Mississippi - Presidential & State Primary MARCH 13, 2016: Puerto Rico - Primary Election MARCH 14, 2016: Ohio - Filing Deadline (Independents) MARCH 15, 2016: Florida - Presidential Primary Illinois - Presidential & State Primary Missouri - Presidential Primary North Carolina - Presidential Primary Ohio - Presidential & State Primary MARCH 22, 2016:Idaho - Democratic Presidential Caucuses Arizona - Presidential Primary Arkansas - Primary Runoff Utah - Presidential Caucuses MARCH 26, 2016: Alaska - Democratic Presidential Caucuses Hawaii - Democratic Presidential Caucuses Washington - Democratic Presidential Caucuses MARCH 29, 2016: Mississippi - Primary Runoff APRIL 5, 2016: Wisconsin - Presidential Primary APRIL 9, 2016: Wyoming - Democratic Presidential Caucuses APRIL 12, 2016: Alabama - Primary Runoff APRIL 13-16, 2016: Constitution Party Presidential Nominating Convention - Salt Lake City, Utah APRIL 19, 2016: New York - Presidential Primary APRIL 26, 2016: Connecticut - Presidential Primary Delaware - Presidential Primary Maryland - Presidential & State Primary Pennsylvania - Presidential & State Primary Rhode Island - Presidential Primary MAY 3, 2016: Indiana - Presidential & State Primary MAY 10, 2016: Nebraska - Republican Presidential & State Primary North Carolina - State Primary West Virginia - Presidential & State Primary MAY 17, 2016: Idaho - State Primary Kentucky - Presidential & State Primary Oregon - Presidential & State Primary MAY 24, 2016: Georgia - Presidential & State Primary Texas - Primary Runoff Washington - Republican Presidential Primary MAY 27-29, 2016: Libertarian Party Presidential Nominating Convention - Orlando, Florida JUNE 7, 2016: California - Presidential & State Primary Iowa - State Primary Montana - Presidential & State PrimaryNew Jersey - Presidential & State Primary New Mexico - Presidential & State Primary North Dakota - Democratic Presidential Caucuses South Dakota - Presidential & State Primary JUNE 14, 2016: District of Columbia - Presidential & District Primary Maine - State Primary North Dakota - State PrimaryNevada - State Primary South Carolina - State Primary Virginia - State Primary JUNE 28, 2016: Colorado - State Primary New York - Federal Offices Primary Oklahoma - State Primary South Carolina - Primary Runoff Utah - State Primary JULY 12, 2016: North Carolina - Primary Runoff JULY 18-21, 2016: Republican Presidential Nominating Convention - Cleveland, Ohio JULY 26, 2016: Georgia - Primary Runoff JULY 25-28, 2016: Democratic Presidential Nominating Convention - Philadelphia, Pennsylvania AUGUST 2, 2016: Kansas - State Primary Michigan - State Primary Missouri - State Primary Washington - State Primary AUGUST 4, 2016: Tennessee - State Primary AUGUST 4-7, 2016: Green Party Presidential Nominating Convention - Houston, Texas AUGUST 6, 2016: US Virgin Islands - Territorial Primary AUGUST 9, 2016: Connecticut - State Primary Minnesota - State Primary Vermont - State Primary Wisconsin - State Primary AUGUST 10, 2016: Ohio - Filing Deadline (Minor Parties) AUGUST 13, 2016: Hawaii - State Primary AUGUST 16, 2016: Alaska - State Primary Wyoming - State Primary AUGUST 23, 2016: Oklahoma - Primary Runoff AUGUST 25, 2016: Ohio - Filing Deadline (Write-Ins) AUGUST 27, 2016: Guam - Territorial Primary AUGUST 30, 2016: Arizona - State Primary Florida - State Primary SEPTEMBER 13, 2016: Delaware - State Primary Massachusetts - State Primary New Hampshire - State Primary New York - State Offices Primary Rhode Island - State Primary NOVEMBER 8, 2016: Election Day - Nationwide NOVEMBER 22, 2016: US Virgin Islands - Gubernatorial Runoff (if needed) NOVEMBER 25, 2016: US Northern Marianas Islands - Gubernatorial Runoff (if needed) DECEMBER 10, 2016: Louisiana - Federal Office Runoffs (if needed) JANUARY 10, 2017: Georgia - 2016 Federal Office Runoffs (if needed)

 
 
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Million-Dollar Donors in the 2016 Presidential Race /N Y Times

Mexico (N Y Times)

From Oct. 27th to Oct. 29thVenus, Jupiter and Mars will fit together inside a circle only 5^o wide (sky maps:#1, #2, #3). Super-bright Venus and Jupiter are visible even after the black pre-dawn sky turns cobalt blue. Once you find them, you will have little trouble locating the dimmer red planet Mars. 

Deep Dive into Enceladus Plume

NASA's Cassini spacecraft will sample the ocean of Saturn's moon Enceladus on Wednesday, Oct. 28, when it flies through the moon's plume of icy spray.

Read more: www.nasa.gov/feature/jpl/seven-key-facts-about-cassinis-oct-28-plume-dive

Pluto System
Scientist Pick: This image shows off Hubble’s resolution. This is the Pluto system — Pluto, Charon, and the four moons around them (Nix, Hydra, Kerberos, and Styx). Hubble is the only telescope that has such fine resolution to be able to see these tiny little dots around Pluto, way at the outer edge of our solar system. We have known about Pluto and Charon since 1986, but all four of those moons were discovered by Hubble within the last decade. Learn more --> www.hubblesite.org/newscenter/archive/releases/2012/32/image/a/

PS (Swedish)
Pluto och Charon har passerats av rymdsonden New Horizons (bilden), som sändes iväg 19 januari 2006. Den närmaste punkten innanför Charons bana nåddes den 14 juli 2015. Sonden gjorde en genomflygning av systemet, utan att gå in i omloppsbana, för att under omkring 10 timmar ta bilder och data från Pluto och Charon. Fotografier från de tidiga stadierna av genomflygningen har tolkats av NASA som att det kan finnas raviner och klippbildningar på Charon, vilket eventuellt kan avgöras med hjälp av ytterligare data från genomflygningen./Wikipedia

The New Horizons science payload consists of seven instruments – three optical instruments, two plasma instruments, a dust sensor and a radio science receiver/radiometer. This payload was designed to investigate the global geology, surface composition and temperature, and the atmospheric pressure, temperature and escape rate of Pluto and its moons.
If an extended mission is approved, the instruments will probe additional Kuiper Belt Objects that the spacecraft can reach.
The payload is incredibly power efficient – with the instruments collectively drawing less than 28 watts – and represents a degree of miniaturization that is unprecedented in planetary exploration. The instruments were designed specifically to handle the cold conditions and low light levels at Pluto and in the Kuiper Belt beyond.

Härligt med Hammarbys publikrekord i allsvenskan.

Tack och grattis från en icke-Hammarbyare.

Glöm inte Norrköpings Astronomiska Klubbs hemsida. Proffsklass.
www.nak.se/Default.aspx?sida=Artikel&id=133

Lika goda kålsupare

Dödstalet efter USA:s flygattack mot Läkare utan gränsers sjukhus i Kunduz i Afghanistan har nu stigit till 30. Tio av de döda var patienter, 13 var anställda vid sjukhuset och sju har ännu inte identifierats, enligt organisationen.

MORNING SKY SHOW

 /SpaceWeather/
Set your alarm for dawn. Venus, Jupiter and Mars are gathering for a three-way close encounter in the early morning sky.



The morning planet show is a worldwide event.  Pictured above is the view from Yading, China (credit: Jeff Dai).

"At 6 am, Venus, Jupiter and Mars were rising just above the Xianuodukji peak at Yading national natural reserve in the province of Sichuan," says Dai. "The view was spectacular."

It's about to become even more spectacular. From Oct. 24th to Oct. 29th the converging planets will fit together inside a circle only 5^o wide. This means you can see all three planets at once using typical binoculars. Of course, you can also see the three planets with the naked eye. It is extra-cool, however, to frame the planets in a single binocular field of view. Wake up early and check it out.

Anton Lundin Pettersson

prognos.

Upp till 190.000 asylsökande i år Mellan 140.000 och 190.000 människor, varav 29.000-40.000 ensamkommande barn väntas ha sökt asyl i Sverige innan årets slut, enligt Migrationsverkets prognos.

Vice President Joe Biden said Wednesday that he will not run for president in 2016, ending months of speculation about whether he would challenge Hillary Clinton for the Democratic nomination.

Krönikör Nygren i Sundsvalls Tidning läser med stigande irritation hur det i bostadsbristens Sundsvall enbart verkar nybyggas för 70-plussare som sålt sina sedan länge färdigamorterade villor på Haga och Södermalm och söker sig till den elefantkyrkogård, eller sista anhalten före Hospice, som Norra kajen och Inre hamnen utvecklas till.

Priser på runt 2, 5 miljoner för en standardtrea måste upplevas som ett hån för 25-åringar som tvingas bo hemma hos mamma och pappa, eftersom det inte går att hitta ens en hyresrätt med en rimlig månadskostnad.

Det byggs för Sundsvallsbor med tillräckligt stinna plånböcker, inte för förtidspensionärer, deltidsjobbare eller andra med begränsade ekonomiska resurser. Kommunpolitikerna, oavsett färg på slipsen eller knutblusen, knäböjer med närmast munkliknande ödmjukhet inför Mammons altare, mumlande mantran om att marknaden måste få styra.

Mitthems pågående bygge av ett så kallat trygghetsboende på Norra kajen riktar sig till friska pensionärer över 70 år, och en kvadratmetermässigt högst medioker trea beräknades vid presentationen att kosta 10 600 kronor - mer än vad en fattigpensionär har att röra sig med totalt en månad.

Och detta förbannade kackel om hur underbart det blir att bo nära vatten, i det här fallet ett tämligen slätstruket, intetsägande hamninlopp som inte längre erbjuder den exotiska anblicken av utländska fraktfartyg eller besökande lyxiga kryssningsfartyg utan enbart M/S Medvind.

Krönikör Nygren, som har ynnesten att husera i ett örnnäste på Södermalm med utsikt från groggverandan över större delar av stan, förundras över hur någon kan lockas att flytta till Skanskas planerade nybygge och pynta ett par mille för att få några gamla industribyggnader och Bolagsverkets hiskliga torrdockade finlandsfärjor som närmaste grannar. Ett solblekt, revigt Kalaspuffar-tält från 1960-talet upprest på Norra bergets sluttning verkar i undertecknads ögon tammefan mer tilltalande.

Dessa nybyggen ska bidra till illusionen att Sundsvall är en expanderande, livfull stad. Hur många nya bostadsrätter och annat det än klappas upp på Norra kajen och i Inre hamnen kan det aldrig bli annat än en 25-öresversion av Hammarby Sjöstad, lika lite som bron över Sundsvallsfjärden kan hävdas ha en slående likhet med San Franciscos Golden Gate Bridge.

Det är något patetiskt över allihop. Och skulle vara skrattretande, om man bortser från det faktum att x antal tusen Sundsvallsbor torrstampar i en ständigt växande bostadskö och att inga seriösa försök görs av politikerna att ändra på situationen. I en krönika i avsomnade Dagbladet efterlyste undertecknad en politiker med en symbolisk .357 Smith & Wesson Magnum, i stället för en glasspinne som heter Magnum.

Det finns ingen “Clintan” i kommunhuset.

Charon, Up Close

This mosaic of Pluto’s largest moon Charon was taken by the Long Range Reconnaissance Imager (LORRI) on New Horizons shortly before closest approach on July 14, 2015; it resolves details as small as 340 yards (310 meters). The scene at bottom is about 125 miles (200 kilometers) across. Credit: NASA / JHUAPL / SwRI

The sweeping mosaic above is made from the highest-resolution images that NASA’s New Horizons spacecraft will return of Charon. This view extends from the limb at left to the terminator, or day-night line, at right.

From the left, the view moves from rugged cratered terrain, across the great faulted canyons of the Serenity Chasma, and onto the resurfaced plains of Vulcan Planum, both informally named. The expanded view of Vulcan Planum at bottom, with its rilles (grooves or long, narrow depressions) and intermittently spaced impact craters, highlights a landscape reminiscent of the volcanic plains on Earth’s moon (lunar mare). However, while the lunar maria are made of basalt, these plains on Charon consist of water ice.

Last Updated: Oct. 16, 2015

Editor: Lillian Gipson

Floods & Landslides: ‘Typhoon Koppu’ slams into the Philippines

October 18

October 1867: The United States took possession of Alaska from Russia.

Aurora Borealis

Taken by Alessandro Dimai on October 15, 2015 @ Hoefn - Island



/SpaceWeather

BEAUTIFUL ERUPTION

  Earlier today, a massive and beautiful plume of plasma erupted near the sun's southeastern limb. The event could herald the approach of an active sunspot and an increase in solar activity this weekend.
 

         

NASA's Solar Dynamics Observatory photographed this eruption on Oct. 16, 2015./SpaceWeather

Award-Winning Photos Bring the Microscopic World to Life | DiscoverMagazine.com

Award-Winning Photos Bring the Microscopic World to Life | DiscoverMagazine.com

Whirlpool Galaxy and Companion

The graceful, winding arms of the majestic spiral galaxy M51 (NGC 5194) appear like a grand spiral staircase sweeping through space. They are actually long lanes of stars and gas laced with dust. Some astronomers believe that the Whirlpool's arms are so prominent because of the effects of a close encounter with NGC 5195, the small, yellowish galaxy at the outermost tip of one of the Whirlpool's arms.


From Hubble site (Picture Album)
www.hubblesite.org/gallery/album/

M51 hittas i Jakthundarna. Avstånd  minst 25 miljoner ljusår. Ålder omkr 10 miljarder år.

HOLE IN THE SUN'S ATMOSPHERE

A gigantic hole in the sun's atmosphere has opened up and it is spewing solar wind toward Earth. Because this "coronal hole" is unusually wide, Earth could be inside the emerging solar wind stream for days. Minor geomagnetic storms are already in progress around the Arctic Circle. /Spaceweather

Palestina-Israel konflikten. Ingen förändring.

The body of a Palestinian in the Pisgat Zeev section of East Jerusalem. Security forces shot him on Monday after he carried out a stabbing attack.Credit

Art Tatum 10/13/1909 - 11/5/1956

October 10, 1813: Composer Giuseppe Verdi was born in Le Roncole, Italy.

Teaching Topic Insomnia Disorder CLINICAL PRACTICE Insomnia Disorder J.W. Winkelman Insomnia is the most common sleep disorder, with a reported prevalence of 10 to 15%, depending on the diagnostic criteria used. Reductions in perceived health and quality of life, increases in workplace injuries and absenteeism, and even fatal injuries are all associated with chronic insomnia. Difficulty maintaining sleep is the most common symptom (affecting 61% of persons with insomnia), followed by early-morning awakening (52%) and difficulty falling asleep (38%); nearly half of those with insomnia have two or more of these symptoms. Clinical Pearls   What medical conditions have been associated with insomnia? Roughly 50% of those with insomnia have a psychiatric disorder, most commonly a mood disorder (e.g., major depressive disorder) or an anxiety disorder (e.g., generalized anxiety disorder or post-traumatic stress disorder). Various medical illnesses are also associated with insomnia, particularly those that cause shortness of breath, pain, nocturia, gastrointestinal disturbance, or limitations in mobility. Although roughly 80% of those with major depressive disorder have insomnia, in nearly one half of those cases, the insomnia predated the onset of the mood disorder. A meta-analysis of more than 20 studies concluded that persistent insomnia is associated with a doubling of the risk of incident major depression. Associations have also been reported between insomnia and increased risks of acute myocardial infarction and coronary heart disease, heart failure, hypertension, diabetes, and death, particularly when insomnia is accompanied by short total sleep duration (   Do the diagnostic criteria for insomnia distinguish between insomnia with and without coexisting psychiatric conditions? Older diagnostic systems attempted to distinguish “primary” from “secondary” insomnia on the basis of the inferred original cause of the sleeplessness. However, because causal relationships between different medical and psychiatric disorders and insomnia are often bidirectional, such conclusions are unreliable. In addition, owing to the poor reliability of insomnia subtyping based on phenotype or pathophysiology, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders takes a purely descriptive approach that is based on the frequency and duration of symptoms, allowing a diagnosis of insomnia disorder independent of, and in addition to, any coexisting psychiatric or medical disorders. The clinician should monitor whether treatment of such coexisting disorders normalizes sleep, and if not, treat the insomnia disorder independently. Table 1. Criteria for the Diagnosis of Insomnia Disorder. Morning Report Questions Q. How is insomnia evaluated? A. The evaluation of insomnia requires assessment of nocturnal and daytime sleep-related symptoms, their duration, and their temporal association with psychological or physiological stressors. Because there are many pathways to insomnia, a full evaluation includes a complete medical and psychiatric history as well as assessment for the presence of specific sleep disorders (e.g., sleep apnea or the restless legs syndrome). Questioning the patient regarding thoughts and behaviors in the hours before bedtime, while in bed attempting to sleep, and at any nocturnal awakenings may provide insight into processes interfering with sleep. A daily sleep diary documenting bedtime, any awakenings during the night, and final wake time over a period of 2 to 4 weeks can identify excessive time in bed and irregular, phase-delayed, or phase-advanced sleep patterns. Polysomnography is not indicated in the evaluation of insomnia unless sleep apnea, periodic limb movement disorder, or an injurious parasomnia (e.g., rapid-eye-movement [REM] sleep behavior disorder) is suspected or unless usual treatment approaches fail. Q. What are some treatment options for chronic insomnia? A. The choice of treatment of insomnia depends on the specific insomnia symptoms, their severity and expected duration, coexisting disorders, the willingness of the patient to engage in behavioral therapies, and the vulnerability of the patient to the adverse effects of medications. In patients with chronic insomnia, appropriate treatment of coexisting medical, psychiatric, and sleep disorders that contribute to insomnia is essential for improving sleep. Nevertheless, insomnia is often persistent even with proper treatment of these coexisting disorders. Treatment for chronic insomnia includes two complementary approaches: cognitive behavioral therapy (CBT) and pharmacologic treatments. CBT addresses dysfunctional behaviors and beliefs about sleep that contribute to the perpetuation of insomnia, and it is considered the first-line therapy for all patients with insomnia, including those with coexisting conditions. CBT is traditionally delivered in either individual or group settings over six to eight meetings. Several medications, with differing mechanisms of action, are used to treat insomnia. Benzodiazepine-receptor agonists include agents with a benzodiazepine chemical structure and “nonbenzodiazepines” without this structure. There is little convincing evidence from comparative trials that these two subtypes differ from each other in clinical efficacy or side effects. Because benzodiazepine-receptor agonists vary predominantly in their half-life, the specific choice of drug from this class is usually based on the insomnia symptom (e.g., difficulty initiating sleep vs. difficulty maintaining sleep). Regular reassessment of the benefits and risks of benzodiazepine-receptor agonists is recommended. The use of sedating antidepressants to treat insomnia takes advantage of the antihistaminergic, anticholinergic, and serotonergic and adrenergic antagonistic activity of these agents. At the low doses commonly used for insomnia, most have little antidepressant or anxiolytic effect. The orexin antagonist suvorexant, which was approved by the FDA in 2014 for the treatment of insomnia, showed decreased time to sleep onset, decreased time awake after sleep onset, and increased total sleep time in short-term randomized trials. Ramelteon is a melatonin-receptor agonist that is FDA-approved for the treatment of insomnia. Short-term studies as well as a controlled 6-month trial showed small-to-moderate benefits for time to sleep onset but no significant improvement in total sleep time or time awake after sleep onset. Meta-analyses of trials of melatonin for insomnia (at a wide range of doses and in immediate-release and controlled-release forms) showed small benefits for time to sleep onset and total sleep time. However, the quality control of over-the-counter melatonin products is unclear. Table 2. Components of Cognitive Behavioral Therapy for Insomnia. Table 3. Medications Commonly Used for Insomnia.

Teaching Topic Invasive Candidiasis REVIEW ARTICLE Invasive Candidiasis B.J. Kullberg and M.C. Arendrup

BLUE SKIES ON PLUTO:

Earth isn't the only planet with blue skies. Pluto has them, too. The first color images of Pluto's atmosphere were beamed back to Earth by NASA's New Horizons spacecraft just last week.

>> WWW.SPACEWEATHER.COM

Svaloras frihet och flykt ställs i kontrast till världens tröghet och människohjärtats tyngd (Karin Boye)

Ilande, pilande svalor, 

                      på vingarna vilande
högt i det vida blånande,
vindlätt i vinande kast
jordens tröghet hånande --
likt ett löje,
klart, lätt, klingande,
träffar er flykt våra hjärtans tyngd 

                                  med förakt,
likt ett jubel,
ur höjder springande,
bud om rymdernas egen
ljusgenomilade lekande makt...
Sol går ner,
men där uppe dröjer all dagens prakt,
runt kring er,
högt i en lekfullt vunnen,
luftig och lycklig trakt.

Caring for the Wave of Refugees in Munich

/NEJM/

Thomas Nicolai, M.D., Oliver Fuchs, M.D., and Erika von Mutius, M.D.

September 23, 2015DOI: 10.1056/NEJMp1512139

Article

Another train carrying about a thousand refugees has arrived at Munich's main station, and the passengers are quickly escorted to the medical reception tent. A pediatrician from the volunteer group examines his share of the arrivals, using a few words in hastily learned Arabic or broken English to take histories: a 14-year-old boy who has been tortured with 40 cigarette burns because he wanted to keep going to school in a region of Syria controlled by the Islamic State, a girl with an untreated jaw fracture from a car accident during her family's trek across the Balkans, patients with old shrapnel wounds and burns from bomb detonations, many people with sore feet from unimaginably long walks, and children who are dehydrated and hypothermic after long trips on crowded trains. Grown men are in tears, for fear of being sent to a hospital. A whole segment of society in the Middle East seems to have fled war and destruction.

The doctors and nurses in this tent are moved by the dignity that most arriving refugees have managed to maintain under these circumstances. The great flow of people that politicians and the media tend to describe only in numbers — or in terms such as swarm, threat, or problem to be somehow ignored or removed — has arrived at this medical facility and turns out to consist of individuals, many of whom have horrific personal histories.

The current so-called refugee crisis in Europe has drawn considerable media interest worldwide. According to the United Nations High Commissioner for Refugees (UNHCR), European countries received 714,000 asylum applications in 2014, an increase of 45% over 2013, and 2015 has seen an even steeper increase; the United States had 134,600 applications in 2014. Whereas in 2014 refugees and migrants came from diverse countries in the Middle East and Africa, in 2015 the intensifying civil war in Syria has caused a large number of people from that country and neighboring areas to flee across the Mediterranean or land borders to the European Union (EU). Germany alone has received asylum applications from 413,000 people in 2015, and 25% of those people arrived in August, according to the German interior ministry.

In theory, the new arrivals should be registered and medically screened at the point of entry into the EU, but owing to their sheer numbers, local facilities have been unable to cope with the task. So hundreds of thousands of people have made their way over land, with very limited resources, toward central and northern EU countries. This migration has led to the unexpected arrival of large numbers of people at points throughout Europe. Germany has waived Europe's previous political decision that asylum seekers should be hosted in the country in which they first arrive. In Germany, the southern Bavarian city of Munich (which has 1.5 million inhabitants) has seen the largest influx of refugees, most of whom arrive at its central station — as many as 20,000 people over a single weekend (see graphNumbers of Refugees Arriving at the Munich Central Station, August 31–September 13, 2015.). The way in which the medical needs of such a large number of arrivals have been handled may shed some light on the main difficulties that arise in such situations and possible solutions to them.

Aside from the administrative problems of registering and housing large numbers of arrivals, every refugee was offered a rapid medical screening procedure so that health care workers could identify patients with urgent medical needs or potentially contagious conditions that could pose a problem during further transport and housing. (A mandatory full medical exam was performed later, as part of the asylum application, to check for infectious diseases such as tuberculosis and to administer immunizations to the mostly unvaccinated arrivals, among other requirements.) Tents were erected adjacent to the central railway station (see photoMedical Checkup Tents for Arriving Refugees.), and the organization of the initial screening and transfer of identified patients was partly outsourced to private health care providers and emergency physicians' services. However, the need for doctors and nurses was met primarily by a great number of volunteers, most of them hospital staff working in the tents during their free time and often organized through local hospitals. To date, 137 doctors and 86 nurses and paramedics have participated in this effort. Only with this combination of resources was it possible to quickly screen the thousands of people arriving by train or bus at all hours of the day. Those identified as needing immediate medical attention were transferred to local hospitals.

Major challenges included communication, since most arrivals spoke neither English nor German, and even translators had problems with the various local dialects spoken by the refugees. Many people had preexisting disease that was obvious to examiners, but in most cases no documentation of earlier diagnoses or treatment was available. Hospitals and emergency departments caring for patients with medical problems identified through screening found the use of pictorial and symbol cards useful in explaining symptoms and diagnostic procedures, establishing medical histories, and giving prescriptions.

Families were understandably fearful about being separated if one member was found to need medical treatment. For that reason, some people had hidden even severe injuries sustained during a long trek or boat crossing and had remained untreated. Although local housing for such families had been established to avoid separation, that information was hard to convey convincingly, which sometimes made it difficult to initiate treatment.

Children may be the most medically vulnerable subpopulation in situations such as refugee crises. Although no representative data are available at this early point of the surge, the diagnoses made at our hospital, which is near Munich's central station, may offer some insight into the common medical complexities.

A considerable number of patients were unaccompanied minors, who required special attention. Many of these children appeared to be traumatized, and some fled as quickly as possible from the medical institutions to which they were brought. Many children were acutely dehydrated. Some neonates who were born during the flight and needed medical support were premature or small for gestational age, and some of them had feeding difficulties.

Conditions not normally seen today in developed countries included louseborne relapsing fever (one patient required intensive care treatment, intubation, and vasopressor support), severe tuberculosis, and other infections. A surprising number of children had preexisting conditions such as diabetes, asthma, arterial hypertension, cystic fibrosis, or renal failure — conditions that had been exacerbated by a lack of medication.

With the growing numbers of refugees and migrants worldwide, public health planners at least in Europe need to be aware of the possibility that great numbers of people may arrive at unexpected rates and in places distant from borders. Ideally, standard operating procedures should be established in advance for primary and secondary medical screening, vaccination programs, and pathways to provision of medical care for identified patients. Munich's experience suggests that volunteer work is key to the successful medical management of these situations.

The full range of medical expertise may be needed for individual patients, and it's important for knowledge of serious communicable infections to be maintained in the medical community — even if the prevalence of a given disease is low in the local resident population. Challenges in further management that the medical system will face include dealing with extensive multidrug-resistant tuberculosis and psychosocial care for traumatized patients.

Refugees are subsequently distributed within Germany to secondary housing centers according to a politically defined allocation formula. Many refugees are expected to settle in Germany, and many will remain in Munich. The city administration is working to create new housing, medical and psychosocial counseling institutions, language schools, and other integration steps and has set aside funding for this effort. A specific statute regulates the financing of health care requirements of refugees claiming asylum. All necessary medical follow-up care will be paid for by the public welfare system and will be administered by local medical practitioners and hospitals.

Grundläggande värden som vi länge tagit för givna är satta under press. De måste försvaras.
Jag står upp för medmänsklighet och humanitet.
Jag tar avstånd från alla former av hat, hot och rasism.
Kring alla människors lika värde finns inget utrymme för kompromiss.

/ Stig den 23 september 2015