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Prepositions: Health Care Costs Push A Staggering Number Of People Into Extreme Poverty

In this article, we will practice identifying prepositions. Each blank will be filled with a preposition.

Health Care Costs Push A Staggering Number Of People Into Extreme Poverty

There’s new — and shocking — evidence about the toll that health care costs are taking on the world’s most vulnerable. A joint report pulished in the journal Lancet Global Health this week 1.______ the World Bank and the World Health Organization estimates that each year more than 100 million people are pushed into extreme poverty in order to pay 2._____ health services — meaning that after covering their health bills, their income amounts to less than $1.90 a day.

Another 800 million people are spending at least 10 percent of their household budget 3._____  health care. And 3.5 billion people — accounting for more than half of the world’s population — are simply forced to go without most essential services.

The kind of care they are missing out on is life-saving but also often extremely basic, says Tim Evans, senior director of health, nutrition and population at the World Bank Group.

Nearly 20 million infants don’t receive the immunizations they need to protect them from diphtheria, tetanus and pertussis,” he says. “These are very common childhood infections that can be completely prevented through low-cost vaccination.”

Similarly, he adds, “more than a billion people live with uncontrolled high blood pressure — meaning they have no access to treatment.”

The problem is particularly acute in sub-Saharan Africa and parts of South Asia. And Evans says that to a large extent it’s due 4. ______ the lack of health infrastructure, personnel and supply chains to serve remote regions where there’s high poverty.

But he says just as problematic is the lack of health spending by governments. Many contribute very little toward subsidizing care for low-income people. There’s also often no viable system of health insurance.

Left to pay for care out of their own pocket, “people either don’t go when they need to, or they go too late,” says Evans.

The consequences can be especially severe when there’s a health emergency — say, someone is 5. ______ a car accident, or a pregnant woman needs a caesarean section. A hospital might agree to treat them. But a separate report by the London-based think tank Chatham House, also released this month, suggests that in cases where the patient can’t afford to pay, it’s surprisingly common 6. _______ hospitals to detain them until their families can cough up the money.

“Some of the most vulnerable people you can imagine are being kept prisoner, basically,” says Robert Yates, the lead author of that report.

“They’re locked up in a sort of secure area with security guards. They are then often not given ongoing medical care that they need, and maybe not given sufficient food. … It’s really quite brutal.”

It’s also technically illegal. That makes it difficult to determine just how widespread the practice is. But after an exhaustive review of local reports and news accounts across a large number of countries, Yates estimates that hundreds of thousands of people are subjected to this kind of medical detention each year. And once again the problem is most prevalent in sub-Saharan Africa.

As depressing as this picture may appear, says the World Bank’s Evans, the situation is far from hopeless.

Over the last 15 years, he notes, governments of low-income countries and the international community invested heavily to ensure that the world’s poorest wouldn’t have to cover the cost of high-priority diseases such as HIV/AIDS and malaria. The result is that “we saw some really spectacular increases in access to, for example HIV treatments. … So there’s reason to suggest the trend is moving 7. ______ the right direction.”

But paradoxically the increasing availability of care in areas where it was previously less common has also increased demand 8._____ it — even as people’s ability to pay has not.

This has put a growing number of people in an impossible position: “People need and want more care,” says Evans. “But the financing system hasn’t kept up. … So people will go to extreme lengths to afford it.”

Welcome to your Prepositions-Health Care Costs Push A Staggering Number Of People Into Extreme Poverty

  1. ________

2. _____
3. ______
4. ______
5. _____
6. _____
7. _____
8. ____

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Reading Comprehension: After Maria, Puerto Rico Struggles Under The Weight Of Its Own Garbage

This story is from NPR, National Public Radio. This is a National News channel in the United States. Below is the article in it’s entirety. Click here to also listen to the news story. (There are also some pictures on the site that show the devastation)

After Maria, Puerto Rico Struggles Under The Weight Of Its Own Garbage

Outside Puerto Rico’s capital, a three-story-high mountain of debris and waste sits smack in the middle of what was a suburban soccer field before Hurricane Maria devastated the island.

Blue bleachers peek out from the edge of the trash pile, as a line of trucks rolls in to dump even more tree branches and moldy furniture. Workmen wearing yellow hard hats operate diggers to add the new waste to the growing pile in the center of the field.

Puerto Rico is struggling under the weight of its own garbage. Even before Maria hit in September, the Environmental Protection Agency says, most of the island’s landfills were filled beyond capacity and that nearly half were under orders to close.

Puerto Rico’s Solid Waste Authority estimates that the powerful hurricane created 6.2 million cubic yards of waste and debris. That’s enough trash to fill about 43 football stadiums with piles of waste eight stories high, according to a measure used by FEMA.

And it has to go somewhere.

Workmen at the soccer field say the site became a makeshift dump because the landfill for the Toa Baja municipality, near San Juan, is so flooded with trash that wait times to dump debris can be hours. When the soccer site becomes too full, the workers say waste is then moved to the landfill in trucks.

In Maria’s wake, local governments are supposed to separate tree branches and other “green waste” for composting so that it doesn’t clog up landfills, says Antonio Rios, head of the Solid Waste Authority, the agency that sets the U.S. territory’s waste policy.

That composting process isn’t happening everywhere, Rios acknowledges. Green debris is still winding up in overflowing landfills across the island, though he says authorities are trying to divert additional material to landfills that have more room. Rios points out that the hurricane also has created other types of waste, things like broken kitchen appliances and food that went rotten because of a lack of electricity.

The landfill in Toa Baja is managed by the private firm Conwaste and takes in trash from at least four municipalities. It has been deeply troubled for years.

The site is supervised by 25-year-old Lionel Ruiz. Last month, he says, it accepted 36,000 tons of waste — that’s 70 percent more than the month before the hurricane. Ruiz points to trash-filled trucks waiting in a line that stretches down a dirt road and off into the distance.

“It’s more busy than usual,” Ruiz says. “You see the line? We never have that line in normal operation.”

In 2008, the EPA ordered the Toa Baja landfill to close by 2014 because it posed an “imminent and substantial endangerment to health and the environment.” The agency said environmental inspectors found evidence that the landfill did not have a system to control liquid seeping through the garbage pile and into the ground. The agency found that this substance, called leachate, could potentially contaminate a nearby aquifer and wetlands.

In 2012, the EPA permitted the landfill to delay the closure for an unspecified amount of time. It was also allowed to create a smaller area incorporating more environmental precautions — such as a lining to prevent seepage — and begin accepting waste there.

The problems are much the same across the lush tropical island of Puerto Rico. The EPA got directly involved in the island’s landfills in 2002, and has since ordered at least 12 of the approximately 29 landfills to close, which can be a years-long process.

It’s not immediately clear how many sites — most of which are already at capacity — have actually shut down.

Rios of the Solid Waste Authority estimates that at current recycling rates, all of the island’s landfills will be full in 20 to 25 years.

Even the newly added space in Toa Baja’s landfill is rapidly filling up, Ruiz says. Before the hurricane hit, he said he thought it would take five years for that area to fill up; Maria has sped up the timeline.

And he’s grappling with immediate problems. Birds and insects circle around what is currently a hot, rancid, open dump.

“This is the active area of the landfill, you will see a lot of uncovered material,” Ruiz says. Workers would normally cover the expansive mess with earth every day to comply with federal regulations, but he says they haven’t been able to do so for a week because the private trucks they use are now being used by FEMA.

The uncovered mounds of rotting garbage is upsetting to people down the hill in the neighborhood of Candelaria, people like 83-year-old Angelo Fernandez. “The smell, the stink!” he says, totally exasperated. “Every time they leave it open, the smell is awful.”

In his 41 years living here, he’s seen mountains of trash rise from the ground, parts of which are now covered with dirt and vegetation. But the waste lies just inches under the surface.

“It is getting bigger, it is getting bigger and bigger — that was never this height — never,” Fernandez says. “All that mountain you see there is garbage!”

He says people living in Candelaria suffer from asthma and other breathing problems because of the landfill. They cough a lot.

Actually closing a landfill is expensive, costing approximately $200,000 per acre, according to Rios. Puerto Rico is struggling with more than $120 billion in debt and pension obligations, and has filed for a bankruptcy-like procedure — and that was before the hurricane.

The EPA has acknowledged that the budget crisis is making it more difficult for local governments on the island to handle the garbage problem. The municipalities “have always had limited funds to implement the environmental and engineering controls required to improve, and ultimately close, the landfills,” the agency says. And Puerto Rico’s Environmental Quality Board hasn’t required municipalities to set money aside in case their landfills needed to close.

Another issue, Rios says, is that some of the landfills now under closure orders aren’t charging garbage trucks high enough fees to generate the money to actually shut down.

Ultimately, the troubled landfill system is “a public health issue and it’s about to collapse really soon,” says Agustín Carbo Lugo, former head of the Solid Waste Authority. He says Puerto Rico also needs to think beyond landfills rather than just open new ones. Recycling rates on the island are about half of what they are on the U.S. mainland.

“We need to look for different alternatives,” he says, particularly because Puerto Rico has limited space. That might include a number of other waste management techniques such as “waste-to-energy,” which uses methods like incineration to produce electricity and heat.

Most importantly, Carbo Lugo says, “people need to change their behavior and it’s quite complex, how you change that in a small island. But it can be done — it just, people need to understand what’s at stake here.”

Those stakes are clear to Fernandez, who lives next to the landfill. He says that if it closed for good, “I think it would be a better place to live. I know it would be.”


Welcome to your Reading Comprehension-After Maria, Puerto Rico Struggles Under The Weight Of Its Own Garbage

What's another way to say 'smack in the middle'?
How much trash did the hurricane create?
What does the word 'makeshift' mean?
What other types of waste were created by the hurricane? (choose all that apply)
What was found to be seeping into the ground in 2008?
According to Antonio Rios, he estimates that all of the island's landfills will be full in  ______________ years.
How much would it cost to close a landfill?
Recycling rates on the island are about ________ of what they are on the U.S. mainland.

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Merry Christmas!

I found this video on youtube that pretty accurately describes Christmas traditions in America. It’s about 10 minutes long but he’s very thorough so you’ll have a really good idea about the way we celebrate Christmas in America.

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Listening comprehension: Rudolph the Red Nosed Reindeer

Rudolph the Red Nosed Reindeer is one that has been played on national TV since my mother was a child. In this clip we see the elves at work in Santa’s workshop. Watch the clip then answer the questions below.

Welcome to your Elves at Santa's Workshop

What is another way of saying "getting ready"?
What is a 'nitwit'?
What does the expression "what's eaten' ya" mean?
Herbie doesn't want to be an elf, what does he want to be?

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Listening comprehension-The island of misfit toys (Rudolph the Red Nosed Reindeer)

Rudolph the Red Nosed Reindeer is one that has been played on national TV since my mother was a child. It is on every single year.

In this clip, we hear the story of the Island of Misfit toys. It’s 3:19. Watch the clip then answer the questions below.

Welcome to your Island of Misfit Toys

What happened to the boat?
What does 'misfit' mean?
What is the name of the Jack in the box?
Where are they?

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Listening comprehension: Interview with a novelist

This audio clip is from the book Cambridge English Grammar and Vocabulary for Advanced. In this clip you will hear an interview with a novelist. It is 3:50 long.

Welcome to your listening comprehension-interview with novelist

What is the author's first name?
What country is the author from?
What was his other job?
The interviewer asked, "Do you regret leaving your previous job?" What does 'regret' mean?
What time does the novelist wake up?
Where does the novelist write in his house?
Where does he do his research?
True (T) or False (F): The character, Elsa, is based on his mother. (Enter T or F)
What is a "last resort"?

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Listening comprehension-Rudolph the Red nosed Reindeer clip

This movie is one that has been played on national TV since my mother was a child. It is on every single year. Watch the video clip (it’s only 1 minute) and then take the short 2 question quiz after.


Welcome to your rudolph the red nosed reindeer

At the beginning of the clip, Rudolph says "she said I'm cute!". What does that mean?

What does the expression "for crying out loud" mean?


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Listening comprehension: Running

In this audio you will hear 3 speakers discuss their experiences with running. It lasts 3:50. You can take notes.

Here’s a quiz to see how well you understood the audio clip. Good luck! 🙂

Welcome to your listening comprehension-running

1) Speaker 1 took up running a few years ago. What does "to take up" mean?
2) What is a fun run?
3) What did speaker 2 do before she started running?
4) Which speaker had 3 older brothers?
5) True (T) or False (F): Speaker 1 no longer runs. (Enter T or F)
6) Which speaker started running at age 10? (Enter: Speaker 1,2, or 3)
7) Who runs in a running club?


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Phrasal verb: to bet on/to count on it

To bet on. This one is pretty easy. You can use this in the traditional sense of the word, such as to gamble. But if you are using it as a phrasal verb, it has a different meaning.

A similar phrasal verb is “to count on” but it does not have the same meaning as to gamble. I will explain to count on below.

Here are some examples.

  • Is Kevin coming to the party? Don’t bet on it/don’t count on it. (It means the probability is very low that Kevin will come)
  • Do you think Kaitlyn will pay me back (the money she owes me)? Don’t bet on it/don’t count on it. (It means the probability is very low that Kaitlyn will give you money)
  • Do you think Artie will call today? Don’t bet on it/don’t count on it. (It means the probability is very low that Artie will call)

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To count on:

You can count on a person. For example, if I need help with something I can call a friend to help me. I can count on him to help me.

  1. I can always count on my sister to help me.
  2. She can always count on her boyfriend to cheer her up after a hard day.
  3. Macey can count on her mom to help her when she is having a hard time.


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phrasal verb: to bend over backwards

To bend over backwards essentially means to go over the top in doing something for someone. “To go over the top” means to do everything you can possibly do to help someone and it’s not easy or fun for you to do.


  1. I’ll help him with his report, but I’m not going to bend over backwards.
  2. She bent over backwards to help me. I really appreciated it.
  3. We bent over backwards to make him comfortable in our home.



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