A Speech to the HIV/AIDS and "Next Wave" Countries Conference, the Centre for Strategic and International Studies Washington, DC, October 4, 2002, on the US National Intelligence Council report, 'The Next Wave of HIV/AIDS: Nigeria, Ethiopia, Russia, India and China', published September 1 2002.*
For more than a decade now, those who have chronicled the sweep of the pandemic have warned about the excruciating consequences of societies falling apart. Now, more than ever, we have groups coming together to fashion scenarios of what will happen in the future. The Next Wave study repeats in several places, that: "The rise of HIV/AIDS in the next wave countries is likely to have significant economic, social, political and military implications". That seems to me to be unarguable.
But if the present teaches anything about the future, then just draw back and look at what is happening in Southern Africa. It has been established that 14.4 million people are at risk of starvation in six countries: Zimbabwe, Zambia, Lesotho, Swaziland, Malawi and Mozambique. Now allow me to be personal for a moment. Last week, I met with Mr. James Morris, head of the World Food Programme, who had just returned from a mission, as Special Envoy, to the six beleaguered countries. He was a man physically and emotionally reeling from what he'd seen. He had instantly recognized that food was only part of the problem; the heart of the problem was AIDS.
That should ring one of the most piercing alarm bells that we've yet heard during the course of the pandemic. If you read the Mission report, it's like a revelation: "What the mission team found was shocking. There is a dramatic and complex crisis unfolding in Southern Africa. Erratic rainfall and drought can be identified as contributing factors to acute vulnerability, but in many cases the causes of the crisis can be linked to other sources. Worst of all, Southern Africa is being devastated by the HIV/AIDS pandemic. HIV/AIDS is a fundamental, underlying cause of vulnerability in the region, and represents the single largest threat to its people and societies".
And then, over and over again, in country after country, the report chronicles the way in which AIDS exacerbates the crisis. The language is startling, allow me to quote one other section: "The relationship between the HIV/AIDS pandemic and the reduced capacity of the people and governments of Southern Africa to cope with the current crisis is striking. In every country of the region, HIV/AIDS is causing agricultural productivity to decline, forcing children to drop out of school, and placing an extraordinary burden on families and health systems".
I've read the report carefully. I've talked to numerous colleagues. I've discussed the matter with three people who were on the UN mission. I've consulted a notable academic who is the pre-eminent scholar on AIDS in Southern Africa. Let me tell you what I think - I obviously cannot prove - but what I think has happened. I think it is reasonable to argue that AIDS has caused the famine; that what we all feared one day would happen, is happening. So many people, particularly women, have died, or are desperately ill, or whose immune systems are like shrinking parchment, that there simply aren't enough farmers left to plant the seeds, till the soil, harvest the crops, provide the food. We may be witness to one of those appalling, traumatic societal upheavals where the world shifts on its axis.
We've been predicting that you can't ravage the 15 to 49 year-old productive age group forever, without reaping the whirlwind. The whirlwind is in Southern Africa. And surely that has huge implications for the next wave. If you watch while your educational systems are shattered, your health infrastructure is frayed, your agriculturalists are dying, your militaries and police have astronomic levels of infection, your private sector is atrophying, then it becomes impossible to escape the economic and social and political and military consequences. For the so-called next wave countries, there is no time left to contemplate. There is only time left to act. Southern Africa is the canary in the pandemic […]
I want to re-emphasize my conviction that this pandemic, in all its multivarious forms in the countries with which we're dealing, can be turned around. There is tremendous knowledge and selflessness at the grass-roots; it just has to be given a chance. We - and it's the royal, generic 'we' - know a great deal, if only we can apply it. We know how to go about Voluntary Counselling and Testing; we know ways in which to reduce, dramatically, vertical (mother-to-child) transmission; we know how to administer anti-retroviral treatment; we know of excellent preventive interventions; we know the world of care at community level, provided by the women, and rooted in faith-based and community-based organizations; we know the knowledge and expertise that can be brought to bear by People Living with AIDS. We know, as well, the huge challenges of mobilizing the political leadership, galvanizing the religious leadership, fighting the curse of stigma and strengthening advocacy on all fronts.
What we don't have is the means to do it with. We don't have the dollars. I've knocked this particular nail through the wall so many times that even I feel a certain ad nauseam quality merely to mention it; in fact, I feel like a minor clone of Jeffrey Sachs. But the truth is that what's literally killing the women and men and children of Africa is the lack of resources.
Just two weeks ago, I was meeting in Arusha, Tanzania, with a group of women living with AIDS. I asked them, as I always do, to tell me what they most needed and wanted, and as always the same replies came back: food, because everyone is hungry, especially the children; money for school fees, and some kind of guarantee to keep their kids in school, because when they die they want their children to be assured of an education. And drugs. Anti-retroviral drugs to prolong life ... so as not to leave their children so prematurely-orphaned. To be quite honest, I never know what to say in such a situation. I'm strangled by the double standard between developed and developing countries. I'm haunted by the monies available for the war on terrorism, and doubtless to be available for the war on Iraq, but somehow never available for the human imperative.
I believe that all the things those women asked for could be provided, or at least provided in large measure, if we had the money. Next weekend, the Global Fund will pronounce on its financial needs. There will then ensue a tenacious, indefatigable effort to round up the dollars. I have no idea what to expect.
I know only that if the Next Wave is to escape the wretched fate of the last wave, then the world and its governments will have to come to their senses.
* 'The Next Wave of HIV/AIDS: Nigeria, Ethiopia, Russia, India and China', prepared for the National Intelligence Council of the CIA, highlights the rising HIV/AIDS problem in five countries of strategic importance to the United States: Nigeria, Ethiopia, Russia, India and China. It is available as a pdf file at: <a href=http://www.cia.gov/nic/pubs/other_products/ICA%20HIV-AIDS%20unclassified%20092302POSTGERBER.pdf>http://www.cia.gov/nic/pubs/other_products/ICA%20HIV-AIDS%20unclassified%20092302POSTGERBER.pdf<a/>
1. Editorial
We, the SADC Health Ministers gathered at Roodevallei, Pretoria, on 30 August 2002 deliberated over the severe famine facing the SADC region [...]
We, the SADC Health Ministers [...] recognize that the famine is super-imposed on an already severe HIV/AIDS pandemic in the region. Both the famine and HIV will lead to deeper impoverishment of the people of the region, and further compound the magnitude of premature death of vulnerable groups namely children and women, from diseases aggravated by poverty like HIV/AIDS and malnutrition, such as malaria, TB and diarrhoeal diseases.
Notwithstanding the effect of the famine on productivity, combined with the HIV/AIDS pandemic household food security through reduced productivity is further compromised and an additional burden placed on already overstretched health systems.
We, the Ministers, recognise the current severe shortfall in food production and food availability in the region, with a cereal deficit of 4,071,300 metric tonnes (MTs) in the region. We also recognise the complex causes of the famine but identify the high levels of poverty in the region as a key factor underlying the current disaster. In the countries affected by the famine, between 1996 and 2001, the number of people living below the poverty line has stayed the same or increased, with on average 68% of the population living below the poverty line in 2001. We further recognise that poor people are most vulnerable to any adverse events.
We note with great concern, the environmental and agricultural factors as a cause of the drought and famine in Africa, with an estimated 500 million hectares affected by soil degradation since 1950, including as much as 65% of agricultural land. A combination of inequitable distribution of land, poor farming methods and unfavourable land tenure and ownership systems have led to the decline in productivity of grazing land, falling crops and diminishing returns from water supplied. Nearly two- thirds of Africa is semi -arid, and Southern Africa is one of the sub regions that is most affected. This dryness makes the land vulnerable to degradation.
Economic factors contribute significantly to this situation. High debt burdens and unequal trade have undermined effective responses by Southern African countries. In particular, greatly increased subsidies to U.S. and European farmers threaten the viability of farming in the region [...]
2. Equity in Health
European Union officials have unveiled a plan to ensure that discounted antiretroviral drugs and other medicines earmarked for developing nations are not diverted back to wealthier nations to be sold at higher prices, the AP/Wall Street Journal reports. Under the proposal, pharmaceutical companies would have the option of registering and placing logos on shipments of discounted drugs slated for developing countries. The different packaging would help distinguish the cheaper drugs from higher-priced medicines destined for pharmacies in wealthier nations.
After an initial burst of high-profile donations and pledges, the Global Fund to Fight AIDS, TB, and Malaria is now running low on funds necessary to finance programmes against the epidemics which kill an estimated 16 000 people per day. A board meeting said the fund would need an additional US$2 billion next year, and an additional $4.6 billion in 2004 as a result of the growing capacity of countries to absorb the resources and expand effective programmes.
Slowing the spread of HIV/AIDS in Malawi and preventing the nation's already high maternal mortality rate from climbing must be addressed as an integral part of the humanitarian response to Southern Africa's famine, the U.N. Population Fund have warned. Widespread hunger and a related cholera epidemic have caused maternal death rates to rise sharply this year.
Senegal President Abdoulaye Wade has announced the dismissal of Latif Gueye, a Senegalese citizen and head of the humanitarian organization -Africa Helps Africa, on national television, accusing him of committing "extremely serious errors" for his alleged role in trafficking AIDS drugs that were meant for Africa but were sold in Europe. "It is unfortunate that medicine meant for African AIDS patients is diverted and sold at higher prices in Europe," Wade has said
Eastern and Southern Africa continues to be plagued by deepening poverty, continued armed conflicts and an increasingly devastating HIV/AIDS catastrophe. Given current trends the Millennium Development Goals will not be achieved in the region, or in sub-Saharan Africa as a whole. And that means that these goals, endorsed by so many conferences, will not be achieved globally. In addition to all this, Southern Africa is experiencing a terrible crisis, manifested by extreme food shortages. It is important to understand that these different crises are interconnected and constantly reinforcing each other.
It is still not clear whether people living with HIV/AIDS in KwaZulu-Natal will ever see any of the $72-million granted to the province in April by the Global Fund to Fight HIV/AIDS, TB and Malaria (GFATM). The Global Fund has indicated that from this week it will start to disburse money to projects approved in its first round of applications – but unless procedural problems surrounding the KZN grant are cleared up, this province’s money will not come through. Health Minister Dr Manto Tshabalala- Msimang wants the $72-million to be distributed to all nine provinces and says the Global Fund violated its own rules by awarding the money directly to the KZN consortium, the Enhancing Care Initiative, when the application should have gone through the SA National AIDS Council (SANAC).
Life-saving medicines are not available to one-third of the world's population despite a long international campaign for wider access to essential drugs, the World Health Organization have said. In the 25 years since WHO drew up its essential drugs and medicines list, the number of people able to obtain those medicines has doubled, but there remains "a huge unfinished agenda," said Jonathan Quick, the head of the U.N. agency's project.
The Bush administration, embroiling itself in a new fight at the United Nations, has threatened to withdraw its sup- port for a landmark family planning agreement that the United States helped write eight years ago. The reason for the threat is contained in two terms that the administration contends can be construed as promoting abortion. The terms - reproductive health services and reproductive rights - figure in the final declaration of the United Nations population conference in 1994 in Cairo, which embraced a new concept of population policy based on improving the legal rights and economic status of women. The declara- tion has since been endorsed by 179 nations. But during a population and development conference in Bangkok this week, the American delega- tion announced that Washington would not reaffirm its support for the Cairo "program of action" unless the disputed words were changed or removed, United States and United Nations officials said.
Unsafe sex is the second-largest health risk worldwide, according to a World Health Organization report released recently. The report, titled "Reducing Risks, Promoting Healthy Life," lists the top 10 major health risks worldwide that together account for approximately 40% of all deaths. The number one international health risk is being underweight, which results from a lack of food and can contribute to low birthweight infants and other health problems. According to the report, both underweight and unsafe sex are "far more prevalent" in developing nations than in developed nations.
The World Health Report 2002, officially launched on 30 October, represents one of the largest research projects ever undertaken by the World Health Organization. The report, subtitled Reducing risks, promoting healthy life, measures the amount of disease, disability and death in the world today that can be attributed to some of the most important risks to human health. It then goes on to calculate how much of this present burden could be avoided in the next 20 years, opening the door to a healthier future for people in all countries.
3. Human Resources
It is widely believed that children who are directly affected by AIDS are greatly disadvantaged at school and that teachers are a high risk group for HIV infection. Research in Botswana, Malawi and Uganda suggests that the situation is much more complex. An international team of researchers surveyed 41 primary and secondary schools across the three countries and interviewed education managers, teachers and other stakeholders. They investigated the effectiveness of HIV prevention programmes and the impact of the AIDS epidemic on pupils and teachers. They found little evidence that education on HIV/AIDS, sexual and reproductive health (SRH) and life skills has a major impact on behaviour. Economic and social pressures that fuel unsafe sexual practices among adolescents remain high. Teachers lack the training and commitment to integrate HIV/AIDS education into carrier subjects. The study identified an urgent need for full-time SRH/life skills teachers in both primary and secondary schools giving regular timetabled lessons.
What does it mean to be a young orphan? Why and how are numbers burgeoning? Why are orphans socially excluded and how might education support their inclusion? This study investigates the lives of orphans in an area of Malawi, suggests why the numbers of orphans are exploding and indicates how the social unrest that may follow could be avoided. This small project conceives of education in the broadest possible sense to include what the orphans need to know to survive in the short term, to fruitfully participate in their surroundings in the medium term, and to prosper in the long term. It attempts to build a picture of their lives and aspirations, the particular perceptions of female orphans and also of their carers, organised in state registered, community level Orphan Care Groups (OCGs).
An expanding body of evidence challenges the conventional hypothesis that sexual transmission is responsible for more than 90% of adult HIV infections in Africa. Differences in epidemic trajectories across Africa do not correspond to differences in sexual behaviour. Studies among African couples find low rates of heterosexual transmission, as in developed countries. Many studies report HIV infections in African adults with no sexual exposure to HIV and in children with HIV-negative mothers. Unexplained high rates of HIV incidence have been observed in African women during antenatal and postpartum periods. Many studies show 20%-40% of HIV infections in African adults associated with injections (though direction of causation is unknown). These and other findings that challenge the conventional hypothesis point to the possibility that HIV transmission through unsafe medical care may be an important factor in Africa's HIV epidemic. More research is warranted to clarify risks for HIV transmission through health care.
High rates of TB and HIV infection in sub-Saharan Africa increase the risk of healthworkers of catching TB from their patients. In mid-1998, Malawi’s National Tuberculosis Control Programme produced guidelines for hospitals on TB control. Are hospitals sticking to the guidelines? Are they having any effect?
4. Public-Private Mix
This report, produced by Population Action International, argues that condom promotion and provision is one of the most effective methods for preventing HIV/AIDS. They state that 8 billion would have been the minimum number of condoms to have made a difference to the spread of HIV in 2000, and that the 950 million provided by donors were therefore hugely inadequate. The report says that a number of different interventions are necessary for effective prevention programmes: the authors highlight the need for addressing poverty, gender inequity and promoting the 'ABCs' of abstinence, fidelity and condom use. However, they state that the mix of interventions must always include condoms. In calling for universal access to condoms, the report states that public/private partnerships will be necessary and that market segmentation, whereby those who can afford to pay more than the poorest, should be encouraged.
Edited by Alexander S. Preker , David M. Dror, World Bank
Traditional sources of health care financing are often inadequate leaving many of the 1.3 billion poor people in low- and middle-income countries without access to the most basic health services. Governments in these countries have tried to reach these excluded populations through public clinics and hospitals. To help pay for these services, governments often use a combination of broad-based general revenues, contributions from the formal labor force, and user fees, similar to the financing mechanisms used by Western industrial countries. However, these mechanisms are not always effective in many developing countries, leaving many of the poor without essential health care or financial protection against the cost of illness. Social Reinsurance details community-based approaches to insuring people against medical risk not based on individual risk rating as in private insurance, but rather using decentralized social insurance based on the average risk.
5. Resource allocation and health financing
Unless there is a coordinated international response to the HIV/AIDS crisis there will be 45 million new infections by 2010, says a report in the latest Population Bulletin. The report says that even as HIV/AIDS continues its rapid spread most countries still lack the will, the commitment, and the resources to create effective HIV/AIDS programs. "It seems inconceivable that an infectious disease could so quickly reverse gains in health and development of the past five decades in less developed countries, but it is happening. It is even more astounding that the world has been so slow to react to the threat," the report states.
One aim agreed at the United Nations General Assembly Special Session on HIV/AIDS (UNGASS) was a 25 per cent reduction in HIV-1 prevalence among young people - by 2005 in the most affected countries and by 2010 globally. Is this achievable? What strategies and resources are needed?
The Stop TB Partnership has announced the publication of the Global Plan to Stop TB. The document describes the action and resources needed over the next five years to expand, adapt and improve directly-observed treatment, short-course (DOTS) - meeting the 2005 global targets to Stop TB, and setting the world on the road to the elimination of TB. Nine billion dollars is needed to fulfill the objectives of the Plan, and with a gap of nearly four billion dollars, much work is needed to mobilise more resources. The Global Plan has been prepared over the last two years by a team from Partners in Health and the Stop TB Partnership secretariat, with funding from the Soros Foundation and USAID. It incorporates contributions from over 150 writers around the world, and the backing of the WHO, the World Bank and other partners.
6. Governance and participation in health
Urban services specialists are coming to realise that sustainability of infrastructure interventions depends on community engagement in operation and maintenance (O&M). But what progress has been made in getting urban communities involved in the planning, construction, repair and maintenance of water supply and sewerage systems? Are projects demand-driven and are communities willing to pay to look after them?
7. Monitoring equity and research policy
The Directory of Training Programs in Health Services Research and Health Policy provides key information about U.S., Canadian, and European post-baccalaureate certificate, master's, doctoral, and postdoctoral programs in the fields of health services research and health policy. Each program profile lists: program objectives, program focus, degree(s) offered, program director(s), senior faculty and primary research interests, tuition, financial aid, average completion time, average number of students, start date, program structure, language of instruction, application requirements, and contact information. The training directory is an online resource that is updated continuously as we receive new and updated program information.
Neal Halfon and Miles Hochstein, The Milbank Quarterly, 2002
This article describes the Life Course Health Development (LCHD) framework, which was created to explain how health trajectories develop over an individual’s lifetime and how this knowledge can guide new approaches to policy and research. Based on the relationship between experience and the biology and psychology of development, the LCHD framework offers a conceptual model for health development and a more powerful approach to understanding diseases. The article illustrates how risk factors, protective factors, and early-life experiences affect people’s long-term health and disease outcomes. A better understanding of health development should enable us to manipulate early risk factors and protective factors and help shift our emphasis on treatment in the later stages of disease to the promotion of earlier, more effective preventive strategies and interventions focused on maximizing optimal health development.
This paper describes and analyses three major programmes that utilise the South African national mass media platform for HIV/AIDS prevention. These are the Beyond Awareness II campaign, the multimedia edutainment programme Soul City and the youth programme loveLife. Overall, the author finds that there are strengths and weaknesses in the application of theory and research in South African campaigns. A number of recommendations are made to help programmes: Improve the sharing of expertise across programmes; Develop best practice in new areas beyond prevention, namely human rights, stigma and care and support; Commission a review to establish what is happening in rural and very poor communities to ensure that they do not remain behind in prevention indices and to identify media gaps.
8. Useful Resources
James A Macinko , Barbara Starfield
The purposes of this bibliography are to present an overview of the published literature on equity in health and to summarize key articles relevant to the mission of the International Society for Equity in Health (ISEqH). The intent is to show the directions being taken in health equity research including theories, methods, and interventions to understand the genesis of inequities and their remediation. Therefore, the bibliography includes articles from the health equity literature that focus on mechanisms by which inequities in health arise and approaches to reducing them where and when they exist.
This substantial health and development portal for the Africa region has just launched. It aims to raise living standards in Africa by promoting communication and access to information needed to improve health and wellbeing. The site offers a unique one-stop source for diverse, up-to-date and credible health resources including: news,
disease outbreaks, health alerts, information on diseases and condi- tions, research reports, policy and reform oriented editorials, ask- expert services, as well as reports and best practices in RH and HIV/AIDS, 24/7 TI/HIV/AIDS/TB live help line, lively community com- munication services, Online continuing medical education training and training in advocacy and policy analysis.
The Stop TB Partnership is pleased to announce the publication of the Global Plan to Stop TB. Please click on the links below to access the report. Note that the full report has been broken up in to different sections as otherwise it is too heavy to open online.
The Health InterNetwork was created to bridge the "digital divide" in health, ensuring that relevant information - and the technologies to deliver it - are widely available and effectively used by health personnel: professionals, researchers and scientists, and policy makers. As the first phase of making vital health content available, the Health InterNetwork provides here a vast library of the latest and best information on public health: more than 2,000 scientific publications, one of the world's largest collections of biomedical literature.
This is a CD ROM containing over 5,000 pages of text related to prevention, diagnosis, treatment and care of HIV infected women and children. Designed for ease of use for those who are seeking to establish, or have established, programs for women and children with HIV. Topics include counseling and testing, primary prevention, care of women, perinatal interventions, nutrition and infant feeding, care of children, rape and violence, orphans and families affected by HIV. Within each topic there are overviews, guidelines and policy analyses (WHO, CDC, NIH), community education information, research journal articles and reports, listings of organizations and related Internet sites. Included are sample model brochures and healthcare training instructions. Adobe Acrobat and a browser are included to allow for printing and searching.
9. Jobs and Announcements
16 - 20 December 2002, Arusha International Conference Centre, Tanzania
Tanzania AIDS Society and Tanzania Commission for AIDS in collaboration with the National AIDS Control Programme in the Ministry of Health and Universities and other Higher Learning Institutions in the country, International Development Partners on AIDS in Tanzania (DAC- HIV/AIDS), Community based organizations, non governmental organizations, civil societies and several other national institutions have seen it appropriate to organize the 2nd Multisectoral AIDS Conference in order to review the progress being made in responding to the AIDS crisis and deliberate on how the fight against AIDS can be intensified in the future. The conference will offer policy makers, professionals involved in HIV/AIDS prevention and control, researchers, private and business sectors, people living with HIV/AIDS (PLHA), the affected communities, faith groups, international development partners including the United Nations system and other interested groups and individuals the opportunity to share the latest advances in knowledge, experiences, skills and technology in responding to the challenges brought about by the HIV/AIDS crisis.
The Global Equity Gauge Alliance is expanding its activities, and are looking for an experienced person to coordinate our global advocacy activities. The 2-year contract position for Advocacy Coordinator would be located in Durban, South Africa within the GEGA Secretariat, and would involve frequent international travel. For more details contact Lexi Bambas, Coordinator of the Global Equity Gauge Alliance.
The Lancet is starting an internet discussion on the election of DG Brundtlands successor, at next WHO Executive Board meeting in January 2002. Nominations will close in November. There are several persons who announced candidacy including Dr. Mocumbi, Peter Piot of UNAIDS and Bernard Kouchner of Medecin Sans Frontiere. There may be others who name yet to be known. The Lancet has devoted a special section to the election campaign. The Lancet writes: "We want to foster greater debate about the direction of global health in the 21st century and WHO's role in steering the best course. To start that debate, we invite readers to send in their comments (e-mail:whodg@lancet.com). All messages sent to this address will be posted on our website each week. Those individuals with the privilege of electing the next Director-General of WHO also carry a great responsibility--we hope that our coverage and your comments can help inform their decision."
Senior Research Fellow - 1 year contract (renewable). Health Economics and HIV/AIDS Research Division (HEARD). HEARD was founded in 1998 under the Directorship of Professor Alan Whiteside. It has gained an international reputation for research and management planning on the socio-economic aspects of the HIV/AIDS pandemic, particularly in Africa. HEARD is a self-funding, dynamic organisation with eight research posts. The Senior Research Fellow will: Undertake research into the Socio-Economic causes and consequences of HIV/AIDS in Africa; Guide research staff in the field of HIV/AIDS and Health Economics; Develop and run projects, including commissioned, academic and funded research projects; Liaise with the Research Director on the research agenda of HEARD. For further information about HEARD please consult Tim Quinlan, Research Director <quinlant@nu.ac.za> or Samantha Willan, Project Director <willans@nu.ac.za> or visit our website.
Prof Jerry Coovadia, Chairperson of the 13th International AIDS Conference held in Durban July 2000 announces the launch of the South African AIDS Conference 2003. The Conference will be held at the ICC Durban from 4 - 8 August 2003. Chairperson of the first South African AIDS Conference 2003, Prof Jerry Coovadia, says, "There is a complaint, probably justifiable, that there are too many meetings and conferences on HIV/AIDS. While this may seem to be so, we in South Africa are exposed to a catastrophe of massive proportions. This conference aims at nothing less than providing a comprehensive, holistic and precisely relevant programme for all stakeholders, including community representatives, business and the media. There is no equivalent meeting serving such a purpose. This conference leads directly from the hugely successful and landmark AIDS 2000; and one has the organisers promise of a worthy successor to the 2000 conference."