The Ultimate Testing Laboratory
FEBRUARY 7, 2013
Kampala, Uganda
At the Mulago National Referral Hospital, Dr. Brian Westerberg, a Canadian surgeon on a volunteer mission, examined a very sick thirteen-year-old boy. He had a fever and chills and was vomiting. Fluid oozed from his ear canal, the likely source of infection. Westerberg suspected bacterial meningitis, though he couldn’t confirm his diagnosis because the CT scanner had broken down again. The boy was given intravenous ceftriaxone, a broad-spectrum antibiotic that Westerberg believed would kill the bacteria and reduce the swelling around his brain. He was confident that the boy would be cured.
For the sixteen years that Westerberg had worked volunteer missions at the Mulago hospital, scarcity had been the norm. The throng of patients usually exceeded the 1,500 allotted beds. Running water was once cut off when the debt-ridden hospital was unable to pay its bills. For years, medicine had been scarce, forcing Westerberg to bring his own drug supplies from Canada. But more recently, low-cost generics had become widely available through the local government and international aid agencies, a hopeful development that Westerberg saw as a step in the right direction.
But after four days of treatment, the boy was still sick. His headache was even worse, and the “draining ear” had turned into a pussy, boil-like mass. Westerberg prepped for surgery, assuming that he would have to slice into the child’s ear and scoop out the infected tissue. Right before the procedure, the boy had a seizure. The hospital’s CT scanner had started to work again, so Westerberg sent the boy for an urgent scan, which revealed small abscesses in his brain, likely caused by the infection.
A hospital neurosurgeon looked at the images and confidently told Westerberg, “We’re not going to operate.” He was sure that the swelling and abscesses would abate with effective antibiotic treatment. This confused Westerberg. They had already treated the boy with antibiotics—the intravenous ceftriaxone—and it had failed to beat back his infection. Westerberg’s confusion deepened when his colleague suggested that they switch the boy to a more expensive version of the same drug. “Why swap one ceftriaxone for another?” Westerberg wondered. But he would soon learn that the hospital’s drug supply was plagued by a phenomenon that Ugandan doctors knew all too well.
In a world of scarcity, Africa was saturated with Indian- and Chinese-made generic drugs that too often didn’t work. Doctors throughout the continent had adjusted their medical treatment in response, sometimes doubling or tripling recommended doses to produce a therapeutic effect. Many hospitals kept a stash of what they called “fancy drugs”—either brand-name drugs or higher-quality generics—to treat patients who should have recovered after a round of treatment but didn’t.
Westerberg’s colleagues were prepared with a backup stash of ceftriaxone purchased outside the hospital. They swapped in the more expensive version and added two more drugs to the boy’s treatment plan. They did not operate fully, but Westerberg did clean out the draining ear. The treatment might have been effective, but was administered too late. The boy never recovered. On the eleventh day of his treatment, he was declared brain-dead.
The Ugandan doctors were not surprised by the death of the thirteen-year-old boy. Their patients frequently died when treated with drugs that should have saved them. Even though doctors turned to backup reserves of “fancy” drugs, there were not enough to go around, making every day an exercise in pharmaceutical triage. “We are tired, honestly,” as one doctor in western Uganda put it. She found it hard to keep track of which generics were safe and which were not to be trusted. “It’s anesthesia today, ceftriaxone tomorrow, amoxicillin the next day.”
Each time Peter Baker inspected a new manufacturing plant, his sole job was to focus on the drugs headed for the U.S. market and protect Americans who would be taking them. But as he documented fraud and manufacturing failures in India’s plants, he noticed with increasing alarm that the drugs bound for developing markets were even worse than those headed for the United States.
In May 2013, he arrived at a manufacturing plant south of Hyderabad, run by an Indian generic company. There, he saw vials of a chemotherapy drug, gemcitabine, which had improperly sealed caps and therefore weren’t sterile. “What the heck did you do with this?” he asked officials. The answer: “We sent it to Africa.” At another plant, he saw drug ingredients that the FDA had restricted from import into the United States and asked where those were headed. The Ukraine, he was told. He passed that information to the Ukrainian government but didn’t hear back.
Baker slowly began to see a map of the world similar to the one that had so shocked Dinesh Thakur when he uncovered it at Ranbaxy. Companies claimed that they produced the same high-quality drugs for every world market. At Ranbaxy, Thakur exposed this as a lie by uncovering fraudulent data. Baker was looking at the actual medicine. At plant after plant, he found the most blatant fraud and the most egregious quality lapses in the manufacture of drugs bound for the least-regulated markets: Africa, eastern Europe, Asia, and South America. One reason he rarely saw a rejected batch in India was that, no matter how evidently defective the drug, there was always some world market where it could be sent.
What Thakur and Baker had stumbled into was not a glitch or exception but rather common practice in the generic drug industry. The unequal production standards had interchangeable names: “dual-track,” “multi-tier,” or “row A/row B production.” Companies routinely adjusted their manufacturing quality depending on the country buying their drugs. They sent their highest-quality drugs to markets with the most vigilant regulators and their worst drugs to countries with the weakest review. In an industry with slim margins, companies slashed costs by using lower-quality ingredients, fewer manufacturing steps, and lower standards, then sold those drugs in poorly regulated countries.
Racism undoubtedly played a role, as it had at Ranbaxy when the medical director said of the poor-quality AIDS drugs bound for Africa, “Who cares? It’s just blacks dying.” But at root, a cold calculation drove the disparate standards: companies could make their cheapest drugs for markets where they would be least likely to get caught. When asked, the companies insisted that they made drugs of different standards because quality standards differed from market to market. But Patrick H. Lukulay, former vice president of global health impact programs for the USP, the world’s top pharmaceutical standard-setting organization, called that argument “totally garbage.” For any given drug, he said, “There’s only one standard, and that standard was set by the originator,” meaning the brand-name company that developed the product.
Baker had no control or authority over the drugs sold to patients anywhere outside the United States. But he wrote up his findings in his inspection reports nonetheless. Those reports became a roadmap of warnings for regulators in other countries, some of whom followed up on his findings. Baker was documenting the tip of a much larger public health crisis. He couldn’t be sure what was happening to patients in other countries, but the generics pouring into the developing world were of such low quality that he assumed the consequences had to be dire, nothing short of a “ticking time bomb.”
In Uganda, Dr. Westerberg was shaken by his newfound knowledge that patients were dying after taking substandard drugs. He flew back to Canada and teamed up with a Canadian respiratory therapist, Jason Nickerson, who’d had similar experiences with bad medicine in Ghana. They decided to test the chemical properties of the generic ceftriaxone that had been implicated in the Ugandan boy’s death.
Westerberg’s colleague brought him a vial of the suspect ceftriaxone from the pharmacy at the Mulago hospital. The drug had been made in China’s Hebei province by an international drug company, CSPC Zhongnuo Pharmaceutical, which also exported to the United States and other developed markets. But when they tested the ceftriaxone at Nickerson’s lab, it contained less than half the active drug ingredient stated on the label.
Both Westerberg and Nickerson were shocked. At such low concentration, the drug was basically useless and would not have cured a single patient, said Nickerson. He and Westerberg published a case report in the CDC’s Morbidity and Mortality Weekly Report. Although they couldn’t say with certainty that substandard ceftriaxone had killed the boy, their report offered compelling evidence that it had.
CSPC Zhongnuo Pharmaceutical had a track record of quality failures. In 2009, Jackson Lauwo, a professor at the University of Papua New Guinea’s School of Medicine and Health Sciences, grew concerned about the quality of drugs in the country and contacted a pharmaceutical scientist in Frankfurt, Germany, Jennifer Dressman, to ask if she would be willing to test drug samples in her lab. She agreed to help, so Lauwo collected samples of the anti-infective drugs amodiaquine and amoxicillin made by different manufacturers from five registered pharmacies in the capital city of Port Moresby. He brought them to Dressman’s lab. After several months the results were in: every single sample failed quality evaluations.
Three of the fourteen samples were counterfeit: entirely fake pills made by criminals. The rest were substandard, meaning that they appeared to have been manufactured by legitimate firms intentionally making a low-quality product. One such sample came from CSPC Zhongnuo Pharmaceutical.
Even the company’s drug products for the U.S. market were of poor quality. Since 2013, the FDA has cited the company four times for quality violations. Peter Baker inspected the company’s plant northeast of Beijing and found blatant data manipulation. He discovered that failed tests were routinely deleted and samples were retested until they yielded passing results.
The United States has the resources to send investigators abroad. Poorer countries like Uganda and Papua New Guinea typically import drugs from the lowest bidder and don’t have the regulatory apparatus to check quality. Minimal oversight by countries buying the drugs, coupled with weak laws and poor regulation in countries manufacturing them, have allowed dual-track production to flourish.
India’s regulators, for example, won’t take legal action unless a company is making a drug with less than 70 percent of the required active ingredient, which is far below the acceptable standards set by the FDA, the World Health Organization, and other major drug regulators. Dual-track production is not illegal in India, said Anant Phadke of the All India Drug Action Network, an Indian organization that works to increase access to essential medicines. “Whether morally this is correct or not is open for interpretation.”
The same year Westerberg treated the boy in Uganda, Dr. Sean Runnels, an American anesthesiologist from Utah, arrived in Rwanda to work in the country’s national health care system. One of the first things he noticed was that many generic drugs supplied by Rwanda’s health care program “simply didn’t work.” Back then, the country did not have an official drug agency to test the medicine it was buying and could not verify its quality.
At the University Hospital of Kigali, in the nation’s capital, Runnels realized that he could no longer count on anesthesia to put patients to sleep and on antibiotics to fend off infections. He watched as new mothers, after giving birth by cesarean section, succumbed to bacterial infections despite taking a full course of antibiotics. In lieu of effective medication, Runnels and his colleagues resorted to surgery, flushing out women’s abdomens and cutting out infected tissue in a last-ditch effort to save their lives. “Very few of them survived,” he said.
Runnels was initially flabbergasted to discover such variable drug quality, but like the doctors in Uganda, his Rwandan colleagues were accustomed to the problem and had a system to address it. If a generic wasn’t working, they tried to find another version produced by a different manufacturer, or they switched to another type of drug. If neither option was available, they increased the dose of the substandard generic in an effort to achieve a therapeutic effect.
Wealthy patients were lucky. They could escape the quagmire by purchasing brand-name medicine from private pharmacies. The difference was astonishing. “As soon as you saw a brand-name drug, those are the patients that would suddenly get better,” Runnels said. It was a phenomenon so pronounced that he started calling it “the Lazarus Effect,” after the biblical character who rose from the dead.
Over the past decade, Africa’s pharmaceutical problems changed dramatically. Previously, the continent’s drugs came largely from more-developed countries, through donations and small purchases. The biggest problems were the high costs and resulting scarcity. By 2004, Indian drug reps started arriving throughout Africa, offering cheap generics. In Ghana, though the initial feeling was positive, the result was not, recalled Dr. Anita Appiah, coordinator of community and institutional care for the National Catholic Health Service. Africa became an avenue “to send anything at all,” said Professor Kwabena Ofori-Kwakya, head of the Pharmaceutics Department at the Kwame Nkrumah University of Science and Technology in Kumasi, Ghana. The adverse impact on health has been “astronomical,” he said. The poor quality has affected every type of medication.
Dr. Gordon Donnir, a psychiatrist who heads the Psychiatry Department at the Komfo Anoyke Teaching Hospital in Kumasi and treats middle-class Ghanaians in his private practice, said that he and his colleagues are bedeviled by low-quality medicine in all sectors. Almost all of the generic drugs he prescribes—olanzapine, risperidone, diazepam—are substandard. The situation has forced him to increase dosages. To treat psychosis, his colleagues from Europe typically prescribe 2.5 milligrams of haloperidol, the generic version of Haldol, several times a day. They are shocked to learn that he’ll prescribe 10 milligrams, three times a day, because he knows that the 2.5 milligram dose “won’t do anything.” Those initially shocked colleagues become converts once they realize they have to increase doses to get an effect. Donnir once gave ten times the typical dose of diazepam, an anti-anxiety drug, to a fifteen-year old boy, an amount that should have knocked him out. The patient was “still smiling,” said Donnir.
Though data is scarce, in 2012 the Ghana Food and Drugs Authority, with help from the USP and USAID, tested the quality of maternal health drugs on the market. They zeroed in on oxytocin and ergometrine, both essential medicines used to prevent postpartum hemorrhaging. The results were devastating. The report, published in 2013, found that over half of all the oxytocin samples, and almost three-quarters of the ergometrine injection samples, made by various generic companies, failed. All of the ergometrine tablets failed—that is, they produced no effect at all. Some samples contained no active ingredient, and others failed sterility tests, results that pointed to only one conclusion: substandard manufacturing. The drugs, almost all of which came from India and China, were a death sentence for women bleeding due to childbirth.
Most of the time, Ghana’s patients have no idea what kind of medicine they take or who manufactures it. The culture in Ghana is faith-based, explained Bright Simons, a technology innovator: “People actually pray [their] medicine will work.”
In 2008, Alexandra Graham, an African scientist, opened LaGray Chemical Co., a drug manufacturing company outside Ghana’s capital, Accra, with the goal of making high-quality drugs that would follow international standards for good manufacturing practices. Graham, who is Nigerian, and her Ghanaian husband, Paul Lartey, had ideal backgrounds for the effort. They met while working at Abbott Laboratories in Chicago, she as a chemist and manager of the Specialty Products Division, and he, also a chemist, as director of the company’s infectious disease drug discovery unit. Initially, they looked to India’s generic drug industry as a model for manufacturing high-quality drugs in a low-cost environment. It was the model that Dr. Yusuf Hamied at Cipla had set for the world.
Graham traveled to India to learn how the country had accomplished such a feat. Instead of being inspired, she was shocked by what she saw. Graham toured a manufacturing facility so decrepit that it was essentially a house with “little bedrooms that were the manufacturing sites.” The site lacked the quality controls needed to prevent cross-contamination. “There was no air conditioning, no [ventilation] system, dust everywhere,” she recalled. As she left, she noticed the security guard packaging the drugs, which were destined for Nigeria and Kenya. They were not even approved for sale in India.
Graham resolved to run her business differently, but doing so was a formidable challenge. With unreliable electricity, it was difficult to keep the lights on, much less run complex chemical reactions with sensitive equipment. But the bigger challenge came from competition abroad. With Indian and Chinese drug representatives “aggressively coming into the country,” selling cheap medicine, and “offering all sorts of incentives and bribes,” Graham said, her company struggled to compete. Corrupt local wholesalers even negotiated with the drug companies to sell drugs with reduced amounts of active ingredient, making them cheaper.
Seeking help, Graham turned to a respected colleague, the CEO and chairman of a major Indian drug maker. His advice perturbed her. He suggested that she set up one “good factory” capable of producing a “showpiece product” and a second factory that met “local standards.” It became clear to Graham that the idea of high quality at low cost was a myth. Companies that flaunted their factories as “US-FDA inspected” or “WHO-certified” happily sold a cheaper, second-tier product to Africans. Graham found herself caught in a vise. Even if she insisted on making drugs of one high standard only, she couldn’t guarantee that the companies supplying her with active ingredients were doing the same.
In 2014, to buy the active ingredients for HIV drugs, Graham turned to the Chinese firm Shanghai Desano, whose factory in Binhai had been inspected and approved by the WHO. Early in negotiations, a Desano sales rep offered LaGray a discounted product reserved for “African customers.” The ingredients were cheaper, the sales rep explained, because they were not produced at the WHO-approved Binhai plant, but at a clandestine plant in Puxin, China. Graham was furious. She dashed out an email to the company’s vice president, exclaiming, “Whatever is good for any other market is appropriate for Ghana!”
Graham’s standards were expensive, and her refusal to prioritize profit over quality did not sit well with her investors, who began to sell their shares. By 2016, her company had closed and the manufacturing plant outside Accra was “overgrown with grasses,” she said. Without strong regulatory reform in Africa, India, and China, she cannot imagine a way to rein in substandard drug production. “The landscape is such that there are no incentives for quality,” she said. “When you’re playing by the rules, you just cannot survive.”
Public health experts first began to expose the problem of dual-track manufacturing years earlier. In 2003, an international aid worker and pharmacist, Jean-Michel Caudron, decided to visit the international generic drug companies to observe the production process. Gaining access to the manufacturing sites was “quite simple,” said Caudron. “At the time, I was working with Doctors Without Borders and UNICEF, and we were purchasing a lot of medicines . . . so I was welcome [to] visit.” Caudron was treated like a potential customer, and he and his colleagues were granted extraordinary access to manufacturing facilities in India and other parts of the world, where he witnessed multi-tiered production. “I heard the managers of a famous company in India explaining that they were very proud to be validated by the US FDA and Europe, [then] they said very clearly they were producing different quality for non-regulated countries,” Caudron recalled. When he asked a manager why the company would produce different standards for different markets, the manager replied, “Oh, those markets in Africa and Asia? They don’t ask for proof of safety.”
After cataloging dual-track production at 180 facilities over a four-year period, Caudron and his colleagues published a landmark paper in the European Journal of Tropical Medicine and International Health. It described the alarmingly common business tactic of undercutting quality for less-regulated markets, effectively creating “one standard for the rich, another for the poor.”
As international researchers grapple with the problem of dual-track production, an increasing number are linking the phenomenon to another global catastrophe: drug resistance, in which bacterial and other infections evolve to resist the very medicine designed to treat them. It is exactly the sort of ticking time bomb that Peter Baker feared. In 2014, the British government commissioned an ambitious effort to map the harm of drug resistance and propose possible solutions. The first of a series of reports estimated that if current trends continue, 10 million people will die every year from drug-resistant infections by 2050. “If we fail to act,” said the former British prime minister David Cameron, “we are looking at an almost unthinkable scenario where antibiotics no longer work and we are cast back into the dark ages of medicine.”
Ultimately, the project culminated in nine major reports, most of which blamed three factors typically associated with drug resistance: pollution from drug manufacturing in developing countries, which spews medicine into lakes and rivers; the widespread overuse of antibiotics in livestock; and medication misuse, when patients don’t take their medicine exactly as prescribed. But one of those reports blamed a fourth factor: substandard generics that are systematically underdosing wide populations in the developing world. Researchers working in developing countries, where poor-quality generic drugs and drug resistance are both prevalent, have increasingly examined a link between the two.
Low-income countries are plagued by poor-quality medicine: counterfeit pills made by criminal gangs and substandard generics made by second-rate drug companies. Though counterfeit drugs look like genuine products, they often contain no active ingredients. By contrast, substandard drugs typically contain active ingredients, but they do not contain enough, or are not formulated well enough, to be effective. Though counterfeit medicine attracts the lion’s share of political outrage and media attention, some experts now argue that substandard drugs are actually a greater threat to public health. Often, substandard drugs do not contain enough active ingredient to effectively treat sick patients. But they do contain enough to kill off the weakest microbes while leaving the strongest intact. These surviving microbes go on to reproduce, creating a new generation of pathogens capable of resisting even fully potent, properly made medicine.
In 2011, during an outbreak of drug-resistant malaria on the Thailand-Cambodia border, American public health expert Christopher Raymond fingered substandard drugs as a culprit. Treating patients with drugs that contain a little bit of active ingredient is like “putting out fire with gasoline,” said Raymond, former chief of party for the USP in Indonesia. From his vantage point in Southeast Asia, Raymond could see a clear correlation between regions with high volumes of substandard drugs and “hotspots” of drug resistance.
Paul Newton, a British malaria expert who works in Southeast Asia, has observed the overlapping problems of substandard antimalarial drugs and emerging resistance for nearly two decades. In 2016, he coauthored an editorial that explained that drugs containing “sub-lethal” concentrations of antimalarial medicine create a “survival advantage” for the parasites that can withstand a subpotent dose. Still, he cautioned that the connection, although logical and highly likely, was not yet backed by robust scientific evidence.
By 2017, with circumstantial evidence piling up, the nonprofit group USP launched a new center called the Quality Institute, which funds research into the link between drug quality and resistance. In late 2018, that funding bore fruit. Dr. Muhammad Zaman at Boston University coauthored the first study to link substandard drugs to antimicrobial resistance. Working in a laboratory, Zaman studied a commonly used antibiotic called rifampicin. If it’s not manufactured properly, it can yield an impurity as it degrades called rifampicin quinone. When Zaman subjected bacteria to the impurity, it developed mutations that helped it resist rifampicin and other similar drugs. Zaman hopes his laboratory work will help convince policymakers that substandard drugs are an “independent pillar” in the global menace of drug resistance, potentially on par with poor adherence and prescription misuse.
Elizabeth Pisani, an epidemiologist who has studied drug quality in Indonesia, wrote in a 2015 report, “Antimicrobial Resistance: What Does Medicine Quality Have to Do with It,” that subpotent drugs are fueling a crisis of drug resistance in lower-income countries that rich countries soon won’t be able to ignore: “The fact is, pathogens know no borders.”
When a pathogen evolves to resist every known treatment, every patient in the world becomes a potential victim. In August 2016, a Nevada woman in her seventies returned home from an extended trip to India, where she had broken her femur. An infection that had started in her thigh bone soon spread to her hip. She checked into a Reno hospital, where doctors immediately tested her for multi-drug-resistant bacteria. The CDC confirmed that she had carbapenem-resistant Enterobacteriaceae (CRE), a “nightmare bacteria” with no known cure, as Thomas Frieden, the CDC’s former director, described it at a news conference.
In Nevada, there wasn’t much doctors could do to save the woman. Their bigger concern was saving other patients from the same fate. The hospital immediately set up an isolation room so that the infection wouldn’t spread, and the staff donned masks, gloves, and gowns while caring for the woman. In less than a month, she was dead.
What started in Mahatma Gandhi’s ashram as a campaign of Indian self-reliance had morphed into a pharmaceutical rescue mission for the world’s most unfortunate patients. Dr. Hamied’s revolution, as it thundered along, offered generic drug companies the chance to act as global equalizers and make the same cures available to the wealthy and impoverished alike. But what Thakur had first documented on a spreadsheet at Ranbaxy, and what Baker observed in manufacturing plants throughout India, was not the fulfillment of that ideal. It was the ultimate subversion and exploitation of it—making the worst medicine for the poorest patients, with life-and-death consequences for us all.
In Ghana, the technology innovator Bright Simons summed up the stark reality: “All medicines are poisonous. It’s only under the most controlled conditions that they do good.” Only a drug accompanied by data that traces a minute-by-minute path through the manufacturing process can be trusted to work properly. How could anyone guarantee that standard in an underpoliced global marketplace? Only one-tenth of African countries had effective regulators, and two-fifths lacked laboratories capable of routinely testing medicine quality.
Those deficits brought Dr. Patrick H. Lukulay to Ghana’s capital, where he set out to train a generation of African Peter Bakers. In Accra, he ran the Center for Pharmaceutical Advancement and Training (CePAT), an outpost of the USP that opened in 2013. Located down an unpaved dirt lane and set behind a long metal gate, the facility appears unremarkable from the outside. Inside, however, it’s a marvel: door locks are controlled by biometric fingerprint readers, a state-of-the-art microbiology lab is full of costly HPLC machines, and a stability room has specialized refrigerators that test how quickly drugs degrade.
The center runs the continent’s only dedicated program for training African drug regulators and also operates a fully accredited laboratory to test drug quality. With these resources, Lukulay hoped to lift the quality of medicine across Africa. It did little good for one country to up its game, said Lukulay, when “its neighbors are all screwed up.”
A highly trained scientist with a commanding though kindly air, Lukulay was uniquely suited for his mission in Ghana. He grew up in an impoverished village in Sierra Leone, where his father, the village chief, had twenty-five children. Lukulay studied by kerosene lantern and slept on a bed of palm leaves. Through stellar academic performance and sheer grit, he propelled himself to a school in Sierra Leone’s capital, Freetown, and ultimately to graduate studies at Michigan State University. He went on to work at Pfizer and Wyeth in the United States before moving to the USP. His childhood experiences left him with an indelible sense of the obstacles in Africa.
In March 2016, several dozen young regulators who worked for various African governments, including Mozambique, Swaziland, Rwanda, Zambia and Liberia, arrived at CePAT for a training workshop. They spent two weeks learning how to more rigorously vet the dossiers submitted by drug companies and think critically about their claims, as one of their trainers put it, instead of running through a perfunctory checklist. The training program’s graduation ceremony was solemn, to emphasize to the regulators their critical role as the first line of defense against poor-quality medicine. Lukulay’s colleague urged them to “go forth like living water” into Africa, the “ultimate testing laboratory.”
Lukulay then stepped forward, wearing a ceremonial outfit of a long tunic, flowing pants, and embroidered cap. “You are soldiers of the state,” he told the graduates. “You have been given ammunition, you have been equipped to do battle with those who want to kill our people.” Expecting them to encounter corruption or political interference at some point, he emphasized that their jobs were “noble” and “ethical.” But most importantly, he emphasized, when they had a dossier before them, they had to ask: “Am I going to check the boxes, or am I going to be a real assessor?”