The TOI expose: Part 3 – Is MCI hand in glove with the erring colleges?

More from the Times of India- Times Now expose:

Even as questions swirl over the impunity with which private medical colleges are charging illegal donations the Medical Council of India (MCI) — themselves have strong links with the offending institutions. ( Watch )

Two senior officials of MCI, the authority tasked with keeping a vigil on medical education, are currently board members of one of the colleges caught demanding capitation fees in a TOI-Times Now investigation. MCI president Ketan Desai and vice-president P C Kesavankutty Nayar are on the board of management of Sri Ramachandra University, which demanded Rs 40 lakh from students seeking MBBS admission.

Incidentally, Desai was asked to step down from the MCI president’s post in 2001 following corruption charges, but was re-elected in March.

‘‘It’s not surprising that we have not had a strong reaction from MCI even three days after the expose,’’ said Dr Sunil Pandya, a member of the Forum for Medical Ethics Society based in Mumbai, which has been fighting for transparency in the functioning of MCI.

Asked about his presence on the SRU board, Desai denied any conflict of interest. ‘‘I am the UGC nominee and my colleague, Nayar, is the MCI nominee. It’s just like how the Dental Council of India members are on the board of several dental colleges. But I have never attended board meetings of SRU for at least three years now. We are there only as ex-officio members,’’ he said.

Dr Sunil Pandya, a member of the Forum for Medical Ethics Society based in Mumbai, which has been fighting for transparency in the functioning of MCI says that these connections are the root cause for the lack of adequate oversight in medical education. ‘‘Why should heads of MCI be members of any medical colleges? There will be bias. An undoctored version of the minutes of the meeting with regard to decisions taken on SRU will probably show how MCI is biased,’’ Dr Pandya said.

Interestingly, he is seconded by former Union health minister Anbumani Ramadoss, who agrees there is no need for MCI members to be on the board of any college. When asked why he had not made an attempt to reform the system during his tenure, he said, ‘‘I have won many battles including the one against the tobacco lobby. But I failed with a corrupt body like MCI.’’

MCI’s role in overseeing the sector includes issuing licenses of recognition, reviewing infrastructure and quality of faculty. The TOI bemoans the state of affairs thus:

Six years ago, the Supreme Court ordered an unambiguous ban on capitation fee. But as you can see, it is still thriving — seats in medical colleges are still being sold or even hawked to the highest bidder. This is making a mockery of merit in education and eroding trust in specialized studies in India. And all concerned parties seem to be complicit in this ugly money-making racket that passes off as education.

According to the Delhi High Court, MCI is a ‘den of corruption”, and yet the government has done nothing to clean it up and add moral fibre to the regulator.

Actually, the government is possibly more culpable than just being negligent. It has granted “deemed university” status to unproven and at times questionable educational bodies. The status of “deemed university” is usually given to an institution which has been attached to a university, and over a period of time, proved to be sufficiently efficient, mature and responsible to be able to work autonomously. There are now instances of educational institutions starting off as deemed universities! This makes sarkari recklessness, if not complicity, pretty apparent.

In 2002,Dr Sunil Pandya and Dr Samiran Nundy wrote a piece in the Issues in Medical Ethics . What they said then still holds true-

As is common knowledge, elections to our national and state-level medical councils are fought with just one aim: to enrich oneself personally. Expenditure of huge sums; a total lack of scruples; political connections; a compulsive desire to grab power by any means, both fair and foul and finally, ruthless pursuit of the goal of personal enrichment are absolute necessities.

Given these conditions, it is not surprising that our medical councils are hopelessly corrupt, incompetent and disinterested in the common good. No wonder, the Delhi High’ Court in a recent judgement labeled the Medical Council of India as ‘a den of corruption’.

The reported sum spent by candidates for election as President of the Medical Council of India exceeds a crore of rupees. Were the actual figure even a tenth of this amount it is easy to see how no honest individual can ever aspire to serve in this position. It is also obvious that a person spending such a huge sum will have as his primary goal the recovery of his capital investment along with ‘adequate’ returns on it in the shortest possible period. The seeds of corruption have already been sown.

People who are in this field are quite aware of all that happens in the domain of the MCI. A cursory look through the reader comments responding to the TOI article will be an eye opener. There are names of colleges, there are names of people— all in the open, but yet, nothing will be done. The puppeteer who handles the strings makes the decisions. And the puppeteer is corrupt!

What we knew all along (Part 2): Postgraduate admissions

The previous post on the TOI report on MBBS seats being barely exposes the tip of the iceberg. Here’s the next one:

The scam gets bigger, and more brazen as medical graduates embark on specializations that are necessary for a successful career.

The price this year for a post-graduate seat in radiology in most leading private colleges across the country is Rs 2 crore while in cardiology, gynaecology and orthopaedics are priced around Rs 1.5 crore.

We always knew that postgraduation seats were available for a hefty price. And if you had to succeed in your career, you had to get an MD or an MS after your name. The sad part is that a ‘plain MBBS’ is a nobody in Indian society today.

The main reason for such high rates is the dearth of seats for PG programmes. The average ratio of undergraduate (MBBS) seats to those for post-graduate is 100:29. In effect, nearly 32,000 doctors graduate from medical schools across the country every year, and the number of PG seats available to them is roughly one-third of the requirement.

Across India, there are 9,085 seats for clinical courses like cardiology, radiology, orthopaedics and gynaecology; a mere 662 seats for pre-clinical courses such as anatomy and physiology, and 1,303 seats in para-clinical programmes like pathology, micro-biology and forensic medicine. Of these, a large percentage are in private institutions which enjoy the freedom to charge hefty donations — which means, a bright MBBS graduate with no means to pay has few options.

Overall, less than 10% of the graduating medical batch gets PG seats through the general (government) pool. Most PG seats, in simple terms, are auctioned or sold to the highest bidder. It’s a system of exploitation that finds its eventual victim in the patient.

Another senior expert, who has held prestigious posts at the national level, says he has urged the UGC to hold centralized examinations like JEE for admissions to both MBBS and PG courses. “It’s a national shame to commercialize education. Besides, death of merit affects the quality of medical education. When money is paid, these colleges ensure that the exit is definite. The students pass, qualified or not,” he said

In a country which needs more doctors who will serve in rural areas and more family doctors; MBBS doctors are denied the prestige offered to their postgraduate counterparts. And in any case, being a general practitioner is far more difficult and requires a lot of ‘people skills’ than being a specialist is.

My own view is that general practitioners ought to be accorded more dignity, prestige and monetory benefits to attract more medical students to the profession. Look at the UK- they produce doctors in accordance with what they need. India’s strange policy means we have seats in specialities according to the number of guides. And quite obviously, the number of guides are more in subjects which are more paying. We need more community specialists than superspecialized doctors in medicine or surgery. Our needs assessment has never been done.

Until we treat MBBS doctors at par with postgraduates, this mad scramble for seats will continue.

India’s worst kept secret: Payment seats

Another tehelka style operation. This time by Times Now. Something we already knew. Just documented now for posterity.

It is a fact that merit takes a back seat in India. You can buy your way into becoming a doctor or an engineer. If you have enough dough to pay for your seat, your career is guaranteed.

Dhanya Rajendran’s report says it all (Watch) :

Less than a week after the Tamil Nadu state government put in place a system to curb the collection of capitation fees by private medical colleges, a TIMES NOW-Times of India joint investigation has caught the officials of two leading medical colleges demanding money to admit students.

In one of the most reputed deemed medical universities in Tamil Nadu, Sri Ramachandra University, the price of a seat here is anything between 40 and 75 lakh rupees. But we found out that is just the money to secure a seat. The advertised tuition fees of 18 lakh rupees is over and above this.

Now this is one of India’s worst kept secrets. And this is not the only college where this murder of merit occurs. These educational business places are in all the states. And yes, the people running them are bigshots- politicians, medical administrators, filthy rich people. With the right connections. Very influential and very powerful. Not very easily pinned down.

And we are all to blame. Not just the administrators in these colleges. The students and their parents who are willing to go any extent to secure seats are equal party to this ugly practice. And yes, we do know the kind of doctors that are being produced from these markets. What would you expect from a student who has paid so much for his education? Wouldn’t his first priority be to ‘recover’ that amount from his patients? Where does ethics, professionalism and transparency go now— out of the window, of course. My head hangs in shame. But till we accept this as a normal practice in society, I expect nothing to change.

Health Education Library for People

I had a few hours to stroll around the station, before it was time for my train from Mumbai to Sevagram. And just outside CST station, across the road, I spotted a tempting sign saying ‘the largest collection of medical books’. And that is how I discovered HELP, which is an acronym for Health Education Library for People.

It is a small quiet place, but it houses around 10000 books all on various facets of medicine. I spotted some wonderful titles as I browsed through the organized shelves. I was amazed at the manner in which books ranging from topics as wide as Parenting, Death, Public Health and Gynecology were neatly laid out. The friendly librarian also came forward to show us the amazing audiovisual library of video and audio CDs and DVDs.

This library is the brainchild of Dr Aniruddh and Dr Anjali Malpani. It is a veritable collection of health related resources. And the unique fact is that all of the books are for the layman. None of them are medical jargon. Belonging to the medical field, I for once, wanted some of my favourite textbooks there. But I realized that the target audience was not medical personnel,but the common man. And the small but interested readers in the reading room of the library showed that the idea was working.

I also found that that HELP regularly organizes seminars and health education talks for people on topic related to health, healing, yoga, ayurveda etc.

A marvellous effort indeed. To find out more visit http://www.healthlibrary.com/index.htm where they also have a blog.

The address of HELP is:

Health Education Library,Excelsior Business Center, National Insurance Building, Ground Floor, Near Excelsior Cinema, 206, Dr.D.N Road, CST
Mumbai 400 001.

Timings: Monday – Saturday, 10.00 am – 6.30 pm.

Mobile phones spread infections in hospitals

Mobile phones belonging to hospital staff were found to be tainted with bacteria — including the drug-resistant MRSA — and may be a
source of hospital-acquired infections, according to a study .

Researchers from the Ondokuz Mayis University in Turkey led by Fatma Ulger tested the phones and the dominant hands of 200 doctors and nurses working in hospital operating rooms and intensive care units.

Ninety-five per cent of the mobile phones were contaminated with at least one type of bacteria, with the potential to cause illness ranging from minor skin irritations to deadly disease.

Nearly 35% carried two types of bacteria, and more than 11% carried three or more different species of bugs, the study found.

Most worrying, one in eight of the handsets showed methicillin-resistant Staphylococcus aureus (MRSA), a virulent strain that has emerged as a major health threat in hospitals around the world.

Only 10% of staff regularly cleaned their phones, even if most followed hygiene guidelines for hand washing, the study noted.

Interestingly,Methicillin-resistant Staphylococcus aureus (MRSA) has emerged as a major clinical and epidemiological problem in hospitals in India as well. A study published in the National Medical Journal of India, Prabha Desikan et al found that:

MRSA continues to remain a major nosocomial pathogen. Nasal carriage of S. aureus or MRSA has been suggested as a risk factor for the development of nosocomial infections. In healthcare settings, telephones may get contaminated with MRSA from the anterior nares and act as fomites for transmission. Swabs were collected from the surfaces and bases of 100 telephone handsets. MRSA constituted 11.6% of the isolates. Both S. aureus and MRSA were isolated in large numbers mainly from the handsets of telephones. This may be due to repeated contamination of the mouthpiece by aerosols from the nose and mouth while using the phone. Contamination of telephones with S. aureus may indicate a considerable level of nasal carriage among persons using the phone. They may be staff, patients or relatives of patients.

The authors recommend daily cleaning and swabbing of telephones. Obviously, this is not enough, or is not done well enough, which may be due to lack of awareness of the instrument’s potential to act as a fomite. Infection control measures would therefore need to include creation of awareness among personnel regarding the possible role of telephone instruments as fomites in the transmission of nosocomial infections. The instruments need to be disinfected more frequently and thoroughly, with special attention to the mouthpiece.

India mulls growing medicinal plants as alternative to tobacco

India is committed to reduce production of tobacco by 50% in the next decade. The Centre has allocated Rs 1,000 crore for growing medicinal plants as an alternative to tobacco plantation

Union Health and Family Minister Anbumani Ramadoss said

India is committed to reduce tobacco production and manufacturing of its products by 50% by 2020 to comply with the UN Framework Convention on Tobacco Control. Growing medicinal plants as an alternative to tobacco plantation is a step in that direction and Rs 1,000 crore have been allocated for the same. A part of it has already been sanctioned.

Currently, 1,00,000 hectares of land is under tobacco cultivation. With food crisis increasing in the country, the government may ask farmers to grow food crops as an alternative to tobacco. The Centre is making all efforts to put this land under cultivation for medicinal plants and other crops so that the farmers do not lose their job. The Health Ministry is jointly working with Commerce and Labour Ministry for growing alternative crops as well as rehabilitate the bidi rollers in the small and cottage industries.

Tobacco use is expected to kill six million people worldwide and drain $500 billion from the global economy each year, reveals the latest edition of the “Tobacco Atlas”. In India and China, over half a billion people consume tobacco.

A whopping 81% of the Indian employees interviewed said that they had found a new place to smoke ever since the ban on smoking at workplaces was implemented on October 2, 2008. On the bright side, the survey showed that 37% of the Indian employees were trying to reduce the number of cigarettes they smoked in a day.

Dr P C Gupta, who is the president of the World Congress on Tobacco or Health and the head of Healis, has time and again underlined the need for an all-round implementation of the ban.

He had said that “By next year, smoking will cause about 9,30,000 adult deaths each year in India, up from about 700,000 deaths per year in 2004.” This, he had felt, was reason enough for local governments and public bodies to implement the law on tobacco control.

Digitization of medical records= Dehumanizing medical care?

US President, Barack Obama claims that modernizing health records by digitization will save lives and billions of dollars.

“To improve the quality of our health care while lowering its cost, we will make the immediate investments necessary to ensure that, within five years, all of America’s medical records are computerized,” Obama said in a speech from George Mason University. “This will cut waste, eliminate red tape and reduce the need to repeat expensive medical tests.”

“But it just won’t save billions of dollars and thousands of jobs; it will save lives by reducing the deadly but preventable medical errors that pervade our health-care system,” he said.

Obama’s plan will cost about $US100 billion, a huge chunk of the stimulus package, but some experts claim it will save two to three times that yearly. Those savings could go toward universal health care or simply flow back into the hospitals for better equipment. However not all doctors agree with this notion.

In a New York Times op-ed piece titled ‘The Computer will see you now’ , Dr. Anne Armstrong-Coben, a Columbia based pediatrician expresses concern that the modernisation of medical records may not be as obviously beneficial as it seems.

FOR 20 years, I practiced pediatric medicine with a “paper chart.” I would sit with my young patients and their families, chart in my lap, making eye contact and listening to their stories. I could take patients’ histories in the order they wanted to tell them or as I wanted to ask. I could draw pictures of birthmarks, rashes or injuries.

Now that I’ve been using a computer to keep patient records — a practice that I once looked forward to — my participation with patients too often consists of keeping them away from the keyboard while I’m working, for fear they’ll push a button that implodes all that I have just documented.

Dr Armstrong-Coben goes on to say that computers are major distractors which affect doctor-patient relationships.

Doctors in every specialty struggle daily to figure out a way to keep the computer from interfering with what should be going on in the exam room — making that crucial connection between doctor and patient. I find myself apologizing often, as I stare at a series of questions and boxes to be clicked on the screen and try to adapt them to the patient sitting before me. I am forced to bring up questions in the order they appear, to ask the parents of a laughing 2-year-old if she is “in pain,” and to restrain my potty mouth when the computer malfunctions or the screen locks up. I advise teenagers to limit computer time as I sit before one myself for hours each day until my own eyes twitch and my neck starts to spasm.

In short, the computer depersonalizes medicine. It ignores nuances that we do not measure but clearly influence care. In the past, I could pick up a chart and flip through it easily. Looking at a note, I could picture the visit and recall the story. Now a chart is a generic outline, screens filled with clicked boxes. Room is provided for text, but in the computer’s font, important points often get lost. I have half-joked with residents that they could type “child has no head” in the middle of a computer record — and it might be missed.

A box clicked unintentionally is as detrimental as an order written illegibly — maybe worse because it looks official. It takes more effort and thought to write a prescription than to pull up a menu of medications and click a box. I have seen how choosing the wrong box can lead to the wrong drug being prescribed.

Older generations of doctors may have trouble adjusting to a totally digital system, and there are bound to be mistakes made by even the computer-savvy before digitisation becomes ubiquitous.

Like everything else in this world, computers have a good side and a bad side. How we manage to use them to our advantage without allowing them to depersonalize medicine is a challenge. But to wish away computers is silly. They are here to stay and how we make the most out of them is up to us and our creativity.

DNB now equivalent to MD/MS/MCh/DM degrees

The Diplomate of National Board (DNB) degrees have finally been equated with MD/MS and DM/M.Ch for teaching jobs. The DNB degrees in broad specialities will be completely equivalent to the MD/MS degree; and the DNB degree in super-specialities will be equivalent to the DM/M.Ch degree.The latest notification from the Government of India can be downloaded from here.

The Union Ministry of Health and Family Welfare (MoHFW) and the Medical Council of India (MCI) were earlier in a standoff. The MCI guidelines were formulated by the Post-graduate Medical Education Committee (the PG Committee) constituted under Section 20 of the Indian Medical Council Act, 1956. It was on the basis of the recommendation made by the PG Committee in 1993 that the Government stipulated in October 1994 that for teaching appointments in broad specialities, a DNB degree holder was required to have at least one year’s experience as tutor/ registrar/ demonstrator, or an equivalent post, in a recognised undergraduate medical college. Similarly, for teaching posts in super specialities, a DNB awardee was required to undergo two years’ training in a recognised medical college with recognised post-graduate degree course in the concerned speciality. The Health Ministry had said that its Diplomate of National Board degrees will be treated on a par with the MD/MS and DM/M.Ch degrees awarded by Indian medical institutions for the purpose of all appointments including teaching posts in medical institutions.

Every year, there are about 25,000 medical graduates of whom 9,000 obtain MCI-approved post-graduate degrees and about 3,000 qualify with DNB degrees. But employment opportunities in medical institutions were significantly limited for DNB degree holders because of the MCI guidelines. There was also scope for at least doubling the number and also institute national programmes in areas where there is shortage of faculty. But the MCI directives prevented many institutions from offering their facilities for training DNB students.

While the Indian Medical Council Act only mandates the MCI to prescribe under-graduate courses and degrees, as well as approve the corresponding institutions offering them, it has only advisory and recommendatory powers as regards post-graduate courses and degrees. However, according to the NBE, the MCI had in recent years begun to impose guidelines for post-graduate education as well. These guidelines, as formulated by the PG Committee, rendered a whole cadre of DNB-qualified post-graduate medical students ineligible for teaching posts in medical institutions. This assumed authority, the NBE contended, went beyond the provisions of the Indian Medical Council Act.

The requirement of additional experience was reasonable earlier because DNB students did not do any dissertation for their degrees. But now since DNB students also have to do dissertations, there is no rationale any longer for insisting on additional teaching experience. Moreover, all over the world the paradigm of medical education has advanced and today it is integrated with clinical science.

In 2003, the MCI enumerated specific reasons why it could not accept the equivalence of DNB degrees with MD/MS and DM/M.Ch degrees. However, both the Government and the NBE find no merit in the MCI’s arguments and have rejected them. In August 2004, and again in September 2005, the MoHFW notified that institutions conducting MCI-approved post-graduate courses were also permitted to run DNB courses. However, in November 2005, the MCI unilaterally instructed all medical institutions to refrain from this practice without seeking the Government’s consent as required.

The National Board of Examinations (NBE) was established in 1975 with the aim of elevating standards of post-graduate medical examinations and ensuring uniformity across the country. The NBE became an independent autonomous body under the MoHFW in 1982. The Board has a system of accreditation of hospitals and institutions having adequate trained manpower and infrastructure for training students towards post-graduate and post-doctoral degrees of the Board.

Entry to the DNB programme is through a very stringent qualifying Central Entrance Test and an institutional-level speciality-specific aptitude evaluation. Qualifying for the degree is through an extremely rigorous evaluation both in theory and clinical knowledge in which the pass percentage is only about 30-35 per cent.

Medical experts say that, by enabling the large number of NBE-qualified post-graduate medical students to enter the country’s mainstream health care system, this move would help offset to a great extent the shortage of teachers in medical institutions that could arise as a result of the envisaged expansion. In fact, this shortage is in some sense artificial because the guidelines of the Medical Council of India (MCI) rendered a whole cadre of qualified doctors ineligible for teaching posts.

Google Health: Facebook for Healthcare?

Google is letting patients share electronic medical records with loved ones or care providers who may be needed to help in emergencies. Google Health has quietly launched an application for secure sharing of your online medical records:

The Google solution, introduced without fanfare, solves many confidentiality issues by putting the patient in control of medical record sharing. Call it “Facebook for Healthcare”. You invite those who you believe should see your medical information and you can disinvite them at anytime.

The decision to let people selectively allow others to glimpse medical profiles results from feedback it has gotten since Google Health medical records service was launched in May 2008.

“One issue we hear regularly is that people want help coordinating their care and the care of loved ones,” Google product manager Sameer Samat said in a message posted at the California firm’s website. “They want the ability to share their medical records and personal health information with trusted family members, friends, and doctors in their care network.”

Google Health now has a “share this profile” feature that permits chosen people to view, but not alter, online medical records.

Privacy advocates worry that online medical information is vulnerable to tampering or snooping, possibly from insurance companies or employers out to reduce liabilities by shunning those with health issues. Google said it built a secure computer platform separate from its search system to host medical records as part of an emphasis on keeping health information protected.

Google vice president of search product and user experience Marissa Mayer said at the launch of Health that it was built with “our highest level of security.”

Google Health has links to pharmacies, clinics and diagnostic labs. The service is free and enables people to have electronic copies of information such as prescriptions, lab test results, hospital stays, and medical conditions stored on Google computers. People can link heart monitors to Google Health so vital statistics can be fed to a heart attack assessment services online. A “virtual pillbox” will also automatically send alerts to people’s mobile telephones, reminding them when it is time to take medicines.

We really do seem to be moving into an era where patients control their own health data, order their own diagnostic tests (e.g. direct-to-consumer genetic tests), and increasingly make their own decisions about their healthcare. Whether this will actually result in better health outcomes remains to be seen; but there is no question that it will seriously disrupt the traditional medical model.

Dirty needles: A sore point

A mutant strain of hepatitis B has now killed more than 70 people in Gujarat in what is now becoming one of India’s biggest medical scandals. The outbreak has been traced to used and dirty hypodermic needles which should have been incinerated but instead were simply washed, repackaged and sold back into the medical industry for reuse.

Within the past week, police have discovered a staggering 75 tonnes of neatly packaged waste – including needles, paediatric droppers and syringes – waiting to be resold to private medical clinics. Police describe the waste scandal as a “serious organised crime racket”. Authorities admit they have no idea how many thousands of dirty needles may already be in use in medical clinics across the state – they say that they are unlikely to find them all.

There is no law forcing the 13,000 private medical practitioners across Gujarat to reveal where they bought their equipment. Police said many were “refusing to co-operate and admit if they bought these dangerous tools or not”.

So far the list of those supplying needles has included pharmaceutical companies, individual doctors and a state hospital. At that hospital, dangerous medical waste that had been left out for incineration was collected by cleaners and porters and then sold on to gangs who traded in it. “Everyone got their cut,” said a police spokesman.

In 2004 a study was conducted at 84 centres by the IndiaCLEN (International Clinical Epidemiology Network) to estimate the burden and safety of injection use in India.Interviews were carried out with over 24,021 households and 3,562 health facilities across India. 17,844 injection processes and 24,030 client-provider interactions were observed.

The study found that nearly 62.9% of injections were unsafe. Nearly one-third of administered injections carried the risk of spreading blood-borne viruses and nearly 44.8% of health facilities didn’t have proper injection disposal

According to World Health Organisation estimates, there are an estimated 30,000 HIV infections and over 21,000,000 Hepatitis B infections every year due to unsafe injections. However, Dr Narendra Arora, executive director of INCLEN (International Clinical Epidemiology Network) which had conducted the 2004 study chose to differ.

“There is a great need to improve the quality of our injections and the way they are administered, but a lot has been done since the study. The government has introduced auto-disposable syringes in all immunisation programmes, which are much safer than the glass syringes used earlier,” Dr Arora said. Experts agreed that only 17% of injections come under the immunisation programme, the rest are given for curative purposes, a sector that isn’t as well regulated. “We have also set up 20 model injection centres across the country for training medical professionals on how to give injections in a safe manner,” said Dr Arora.

The state of biomedical waste management is a joke in this country. Doctors can no longer feign ignorance for what is clearly an act of omission. Coupled with rampant unawareness of the need for disposable syringes and needles, the conniving black market only serves to promote these death godowns. Clearly in these dire times, lots more needs to be done.