DISASTER RELIEF
Again, the unexpected. As I have mentioned, it is one of the reasons that I advise students against developing a life plan. The world changes so fast that there is no way to predict what opportunities—or disasters—will appear.
Civil war continued to rage in Nigeria, and both sides found sources of arms that prolonged the fighting. The rebels were surrounded, so they developed a system of dangerous night flights into the Biafra enclave: planes turned on their lights to land on a road only at the last moment to reduce the chance of being bombed by Nigerian planes.
The International Committee of the Red Cross
Soon stories of starvation were reported from the “Republic of Biafra.” Ordinarily, the League of the Red Cross responds to such conditions. The League was established in 1919 to represent National Red Cross societies around the world. However, since there was now a Nigerian Red Cross and a Biafran Red Cross, the League could not be a neutral representative. In cases such as this, the International Committee of the Red Cross (ICRC) becomes responsible. The two groups (the League and the ICRC) are often confused, especially because both have headquarters in Geneva, Switzerland. But ICRC is much older, dating to 1863, and it is actually a private organization, established by Swiss citizens. It represents victims of war and has a stellar reputation, which has led to Nobel Prizes on three occasions.
Wolfgang Bulle had been appointed field coordinator in Nigeria by the ICRC. In late summer 1968, I received a telegram asking whether I would join Wolf as deputy field coordinator of relief activities in Nigeria. I showed the telegram to Don Millar, my supervisor. Strongly irritated, he told me I would have to decide whether I was still working for the mission or whether I was now working for the CDC. With that he left the room.
I was disturbed throughout the day as I weighed the request, knowing he was correct. To complicate the situation, our son Michael had just recovered from croup, which had required hospitalization. He was frightened, and when the doctors made rounds they found that Paula had actually climbed into his oxygen tent to hold him. He required minor surgery to insert a tube into his trachea to allow him to breathe. Seeing him breathing easily again was such a relief, but the poignant memory of him, unable to speak, lying in bed with tears rolling down his cheeks continued to haunt me. It reminded me of thousands of mothers in Nigeria who would have no place to turn to get help for their own children. I felt a need to respond.
Millar returned in the afternoon to say, “I am afraid you are going to decide to go back. Could we figure out a way to make this a win for all of us? Why don’t you go back for ninety days and develop a program to respond to the needs of refugees in war areas and the CDC could agree to provide a series of people to continue implementing the program?”
Millar was a creative administrator, and the idea was potentially a good solution. In September 1968, Paula and I returned to Nigeria with sons David and Michael for an intense and disturbing three months.
At least Nigeria was familiar. I did not need to start from scratch. We moved into an apartment in Lagos, at that time the capital of Nigeria, registered David in school, and began living in conditions superior to any we had known during our previous times in Nigeria. We not only had electricity and running water but also air-conditioning. We contacted Lawrence Atutu, who had worked with us when we lived in Ogoja Province, to see whether he would help us for three months. He was eager to help but reluctant to fly to Lagos. He finally agreed to, which made it much easier to establish a temporary household in Lagos.
His reluctance to fly had a history. The Ogoja area, where we had previously lived, had no airstrip at that time so planes were only viewed as they occasionally flew over the area. One day a pilot was ferrying a small plane from Lagos to the Republic of Cameroon when he realized his fuel consumption exceeded his expectations. He began searching for a place to land and decided the soccer field in Ogoja town would be adequate. On landing, his wheel hit the top of a yam hill just before the intended touchdown. The plane flipped on its back and skidded down the soccer field on its top. The pilot exited the plane unhurt, but the local children, Lawrence included, thought that was the way planes landed, and he wanted no part of that experience.
Not only were we entering a known environment but also the CDC Smallpox Regional Office was in Lagos, so I could count on help from familiar CDC faces, such as George Lythcott, public health advisor Jim Hicks, and Rafe Henderson. Rafe was fluent in French, well spoken, and persuasive and would later introduce rigorous evaluation techniques into the program. After smallpox, he headed up the WHO global immunization program.
We lived in Lagos, but the actual fieldwork was in Eastern Nigeria. I divided my time between the ICRC headquarters in Lagos and refugee programs at the perimeter of the war area.
Never have I lived amid such chaos. Telephones rarely worked in Lagos, so in-person conversations required driving to another office. Traffic was heavy, making travel such a time-consuming process that essential communications were often lacking. Getting real-time information from the field was difficult, so planners and logistics experts were always working with old information. Military requirements of the Nigerian army received top priority for transportation and communications; local government bureaucrats and military commanders regarded relief work as a burden.
The essential information needed to plan relief operations was unknown. This included such factors as the number of people in each location, their nutritional status, availability of water, amount of food in storage or in transit to each place, a system for decisions on food distribution, number of people in homes versus refugee camps, the presence of infectious diseases such as measles, tuberculosis or meningitis, malaria transmission, and the like. When I saw an order for intravenous protein solutions (an approach already shown to be ineffective and inefficient in times of famine by Ancel Keys during World War II), I realized I needed more knowledge if there was any chance of becoming part of the solution.
In my hurry to get to Nigeria, I only had time to contact some knowledgeable people to ask what information I needed. During World War II, Dr. Keys, at the University of Minnesota, had conducted studies with conscientious objectors to understand the speed of starvation effects but also the best ways of rehabilitation. I collected more information than I could read, hoping to review it on the trip and while in Nigeria. I also collected information on the well-documented famine in the Netherlands during World War II and the incredibly detailed information available on starvation in Leningrad in 1941 and 1942. A major portion of my luggage was eventually occupied by literature on malnutrition, infectious disease outbreaks during famine, and the results of past relief operations. The feeling of being in over my head was becoming familiar. It was the same feeling I had when I started my internship, the EIS program, the smallpox investigation in New Mexico, my stint as Peace Corps physician in India, the immersion into a rural health program in Nigeria, and now a relief operation.
Despite the pressures to make decisions, I deliberately went into seclusion for thirty-six hours and read all of the materials in my suitcase. After that, I felt more confident about what needed to be done but not more confident that it could be done.
Surveillance Systems
We began a public health approach to famine and developed forms to be completed by a refugee worker each week at each location. Setting up a surveillance system was daunting. In a relief action, everyone is overstretched and suspicious of extra work or directives coming from elsewhere. Everyone uses surveillance systems all the time to evaluate what they are and should be doing, but they don’t think of them as surveillance systems. And they may not realize the importance of a system that cannot only provide information on trends over time but also allow for comparison with other geographic areas. If workers in relief efforts have never worked with public health programs, they may not realize that knowing the truth is the first lesson in appropriate reactions.
The forms were simple because we knew these workers were overworked and would have no patience for requests for any information that they felt was not needed. The forms called for estimates of the number of people in their catchment area, divided by adults and children, in camps or in villages, and the number they were actually feeding. The forms asked for information on the amount of food distributed, children versus adults, the kinds of food, and the amount in storage. Also included was a table of diseases asking for a tally of the number of cases seen that week for adults and children. We included only the diseases for which a response was possible. Of course, we wanted much more information, but if we could not respond we could not ask them to take time to report. It was essential that we know whether smallpox cases were seen (none were during the war because we had stopped the last outbreak in that area the week that fighting started). Information on measles was needed because of the high mortality from that disease in malnourished children. If a response to a reported case of measles would be needed, we could get measles vaccine, jet injectors, and knowledgeable operators. We could also respond to meningitis with antibiotics and isolation, diarrheal disease with oral rehydration therapy, and malaria with chloroquine. The list was short but essential.
I should note that two cases of suspected smallpox were reported from within the enclave of Biafra, but, in both instances, specimens from the patients were flown out on the night flights that provided food. In both cases, the rash was found to be due to vaccinia rather than smallpox. (Both cases were shown to be the result of the strain of vaccine used in the area.)
In this area of Nigeria, measles had routinely killed about 7 percent of all children born, even during peacetime. Mortality rates as high as 25 percent had been reported during the seasonal famine period, that is, during the weeks before first harvest, when food supplies were often scarce. Mortality rates as high as 50 percent had been reported during major famine periods. A vaccine had been tested during the previous decade in Africa; it was so effective that it had been included as the second arm of the Smallpox Eradication Program that the CDC was implementing in West and Central Africa. Because of that program, headquartered in Lagos, we knew we would have no problem in responding quickly. Indeed, when measles was reported in one camp, the response was so rapid that the outbreak was halted within weeks, perhaps the first time a measles outbreak had been aborted as the result of a vaccine response.
Providing food is not a simple task. There is a common belief that if you are hungry enough you will eat anything. The fact is that, in severe starvation, unaccustomed foods will often lead to nausea, vomiting, and diarrhea. However, the preferred food in the area, yams, was so heavy that it was difficult to provide logistically. Grains were donated by many countries and became a staple of the operation. Dried fish from Scandinavian countries was high in protein, easy to incorporate into soups, and similar to prefamine diets (and therefore well liked). Often countries and organizations would send what was readily available with no knowledge of its acceptability. A shipment of ambrosia (not the food for the Gods depicted in Homer but, rather, a tinned fruit salad) was not well tolerated by starving people unaccustomed to the food. It was one of the few donations that could be stored anyplace without a requirement for locks or security. Even hungry people did not steal it.
The surveillance system helped to bring some order to where food would be shipped and helped document how it would be used. But there was no shortage of problems. How would we measure malnutrition with enough precision to use the result to allocate scarce supplies? How would we decide on the use of those supplies? To target certain groups within a geographic area could lead to conflict. To bypass some geographic areas could also lead to conflict.
Height-and-weight tables are helpful in measuring malnutrition in children. Some felt we could only use them if we had height-and-weight tables that were specific for Nigeria. It was soon accepted that they would differ from Western standards only if chronic malnutrition were involved; getting that information might identify the actual nutritional status but would provide no help in meeting the current problem. The relief action could only respond to the current crisis; it could not reverse chronic malnutrition.
Estimates of the malnutrition status of a population could be obtained in several ways. One sign of malnutrition involves swelling of the ankles as serum protein levels decline and the permeability of capillaries increases. Edema surveys by age and sex are useful indicators of the nutritional status of the population in general, under famine conditions. They won’t always identify those who are in need of nutritional supplements, however, as edema can be caused by conditions other than malnutrition. Nonetheless, an edema survey is a good tool for estimating the nutritional status of a population in times of severe food shortages.
Another approach is to have the nutritional status of children under about 6 years of age serve as a surrogate for the nutritional status of the population. Cultural factors intervene to some degree. In West Africa, children would often suffer more during the seasonal famine period because adults had to have a certain nutritional level to work the fields and harvest crops if the children were to be fed. The Netherlands, however, spared children as much as possible during the famine that accompanied World War II. The Dutch kept exquisite records of their attempts to respond to the famine. Their results became useful as we struggled to help in Nigeria.
In Eastern Nigeria, the amount of food available during the war years never came close to meeting the needs of the people. A triage system that had some objectivity had to be developed. In refugee camps, all of the people would get food, but at basic minimal levels. Providing shelter, waste disposal, and safe water was also important.
But what could be done for people still living in villages, who had less food than usual and less support of other kinds? It was to everyone’s advantage to help them stay in their villages to reduce their risk of illness. Refugee camps often spawn infectious disease outbreaks because of crowding. In villages, it was decided to use children as the indicator of food needs for the family. Children under about 6 years of age were the measurement target.
To understand the nutritional status of children, three measurements are needed—height, weight, and age. Children short for their age are classified as chronically malnourished. Children below weight for their height are acutely malnourished. And children short for their age and underweight for their height have both chronic and acute malnutrition. The problem, of course, is determining the age of most children in African war areas is not possible. However, whatever the past history of malnutrition, children below a certain weight for their height are acutely malnourished, and that is the condition to which relief groups can respond. So the absence of age turned out to be no problem in relief operations.
The measurement techniques were admittedly crude. We would enter a village and set up four stations. At the first station, a child was given a slip of paper and, by means of a carpenter’s ruler attached to a wall, the child’s height was measured and recorded on the slip. At the second station, the child’s weight, as recorded on a bathroom scale, was entered on the paper. At the third station, which used a table that compared heights and weights, children were provided with a food card if their weight fell below a standard for their height. This card permitted food for the child’s entire family. At the fourth station, a child received a smallpox vaccination with a jet injector. Jet injectors provided a reliable delivery system, and the child was effectively marked for several weeks or more, as a pustule and then a scab formed, which excluded admission to the line again in that village or a neighboring village, in an attempt to get another food card.
Errors were likely, but the thinking was that if a child was sufficiently nourished, the family had figured out a system for obtaining food. They might even have been diverting it from the relief operations. But whatever the reason, they were not in the dire straits of children falling below that nutritional threshold. A Quaker team later simplified these steps by using arm circumference as a surrogate for weight, thus avoiding the need for scales. They called it the QUAC stick (Quaker arm circumference measuring stick) method.
With a system in place, the next need was to establish continuity in the public health approach to famine. The CDC agreed to replace me with Dr. Lyle Conrad and thereafter with EIS officers. Lyle was the perfect choice since he had worked in Nigeria with the Peace Corps and was the supervisor of the EIS field staff. This connection allowed him to choose officers and share his own experience with them as he briefed them for the assignment. It provided continuity beyond 1968, through 1969, and through the end of the war in January 1970. It was a proud moment for the EIS Program as officers provided assistance under difficult conditions. It was also a sad moment as the EIS lost its first officer in the line of duty, when Dr. Paul Schnitker died in a plane crash on November 20, 1969, as his plane approached Lagos.
The CDC provided two dozen EIS officers over almost two years to maintain the operation. It was the first large-scale international disaster response by the EIS and an experience that led some into pursuing global health careers after their EIS years. Alex Langmuir, at the next EIS conference, rose at the end of my presentation on the program and said he had been opposed to using EIS officers in this way, but he had now become a convert. He now felt it was appropriate and that the introduction of applied epidemiology and surveillance had made a difference in the approach to famine in Nigeria and for future famines.
Most of the CDC people worked in areas that had been retaken by the federal troops. However, during this time, Karl Western, an EIS officer from the class of 1967, volunteered to fly into the enclave. The area of Biafra was slowly being reduced in size. Western was to evaluate the nutritional status in the areas still held by Biafra. His studies showed alarming rates of malnutrition in all age groups. While malnutrition was a serious problem in areas now held by the federal government, the conditions within Biafra were unbelievably serious.
The US State Department was strongly inclined to discount this degree of malnutrition. The thinking seemed to be that, if the problem were as bad as reported, the United States would need to respond; yet, it had sided with Nigeria’s federal government. Therefore, the State Department did not want to respond to the nutritional crisis within rebel-held areas.
I was traveling to areas now in the hands of federal troops to evaluate how the relief action was coping. Malnutrition was rampant; many children showed signs of kwashiorkor. (This term, from Ghana, describes protein/calorie malnutrition in small children, often resulting in a reddish tint to their hair.) On my return to Lagos from one such trip, I was asked to join embassy members and a visiting State Department official for lunch. The State Department official took me totally by surprise as he informed the embassy staff that much of what was written in the media concerning the plight of civilians in Eastern Nigeria was erroneous. He assumed a false air of authority as he talked about a tribe in Africa that had red hair naturally rather than as the result of malnutrition. He said photographers had taken pictures in that area and then presented them as being taken of children with kwashiorkor in Eastern Nigeria.
I could not have been more astonished by this lack of knowledge and attempt to fabricate. I pulled from my pocket two Polaroid pictures of a boy of perhaps 10 years of age. He had one of the most severe cases of malnutrition I had ever seen in someone still standing. He lacked visible muscle mass and appeared to literally have skin stretched over bones; every detail of his knee and pelvic bones was revealed. His eyes stared out from a skull that had patches of discolored hair. I passed the pictures around and said, “I took these pictures three days ago. Starvation in Eastern Nigeria is real.” It hurt to know State Department intelligence could be so driven by ideology rather than the facts.
Child in refugee camp, Nigeria, 1968. Photo by the author
Years later, I visited the Central Intelligence Agency (CIA) to ascertain what information it might have on smallpox that we were missing. The result was that we discovered we had more information than the CIA did. In the process of discussions, I mentioned my concern about the information the State Department received during the Nigerian Civil War. I told CIA agents that I was happy to have never been debriefed because we always worried about CDC workers being thought of as interested in politics rather than in health. Nevertheless, I said that, to my knowledge, I was the only American in the areas just liberated, and I was curious why no one ever asked for a debriefing. Two of the CIA employees glanced at each other in a way that let me know there was a story. They then told me they had gone to my superior, David Sencer, director of the CDC, for permission to talk to me. He declined, saying that the CDC had to protect its reputation as concerned with health only, not politics or US policy. I was proud of him and proud of the CIA for not pursuing the approach.
The work was gut-wrenching in many ways. Starving people are too weak to revolt. They are lethargic and unable to rouse themselves to effective action. To step over the body of a child who lies where he died is unlike any experience in medicine. I had the constant feeling that I was letting people down.
And there is fear. On one occasion, a small group of Red Cross workers found themselves detained by federal troops. As things appeared to be getting sorted out regarding their authority and where they were working, a soldier suddenly opened fire on them and killed them. This was in my mind as I rounded a corner one day in a Land Rover and a machine gun opened up. There is no good and logical decision in such a case. Stopping and backing up leaves one vulnerable but so does continuing on. We continued on and made it with only our nerves shot.
Another time, I was flying to Enugu as the only passenger in a small plane. We flew over areas of fighting, but the pilot was nonchalant. At one point, he fell asleep. Later, when I pointed out that we were being shot at and tracers were visible, he shrugged it off, saying, “They are terrible shots.”
On another occasion, I secured a ride on a DC-6 from Port Harcourt back to Lagos. The plane was returning wounded from the war zone to military hospitals. There were no seats, and the wounded lay on pallets on the floor. I settled in, sitting on the floor with my back against the wall and began reading before takeoff. The copilot came back and advised me to move forward because I was close to the door, and he said it had opened during flights on several occasions.
A young man kept pacing the plane, stepping between the wounded, and he looked agitated. I got up to talk to him and learned that he was a mechanic on contract from Germany. His agitation was caused by the fact that they would not give him time to adequately do repairs. For example, he said, this plane with four engines has only one good generator, and they would not halt long enough for him to repair the other three. He said he had only a few weeks left on his contract, and he was concerned he would not complete the time without an accident. In fact this plane crashed on takeoff some weeks later when the only functioning generator failed, killing all on board.
In 1969, Karl Western, Dave Sencer, and I were asked to brief Dr. Henry Kissinger, at that time the national security advisor to President Richard Nixon, on the medical conditions in the Nigerian War area. We were scheduled to see him in the late afternoon, but he fell behind, and we did not actually get a chance to brief him until about 7 p.m. I expected we would be hurried through so he could get back on track, but I was surprised at his deliberate approach in hearing us out as he asked questions.
Kissinger then did something that impressed me beyond belief. He sat down in an easy chair, rubbed his eyes, and said, “For me, those are simply numbers. For you, they must be faces.”
The US government became more vocal about starvation in the war areas, and I was sent back to Lagos to brief the ambassador on the Kissinger meeting. I arrived early on a Sunday morning, was picked up at the airport, and was given no opportunity to go to a hotel to wash up. Instead, I was driven directly to the ambassador’s residence to brief him that morning. This new interest by the US government was welcomed by those in the relief action, but it actually came too late in the war to have the desired impact on deaths from starvation.
One postscript to this story. I took the Kissinger remark to heart and often told CDC workers to always see faces behind the graphs. Some years later, in 1978, a global health conference was held in Alma Ata in the Soviet Union. It became famous as the place where the slogan “Health for all by the year 2000” was designed; that slogan was used by the WHO for many years. Senator Edward Kennedy had been invited to deliver a major talk at the conference. I was in Washington, DC, for a meeting when the senator’s health staffer, Larry Horowitz, called me to tell me about the meeting and to ask whether I would come by his office to review the senator’s speech to make comments and suggestions. He said they could not let a copy out of the office. I agreed to stop on my way to the airport.
I reviewed the speech and suggested some additions to consider, and the Kissinger remark came to mind. It is unlikely that a Democratic senator would have quoted Dr. Kissinger, but the thought was so good that I wanted to see it used. So I wrote into the speech, “As a philosopher once said, ‘For me, those are simply numbers, but for you in the audience they must be faces.’ ” They liked it and retained the line.
Some years later, we were having dinner in Atlanta at the home of Gisela and Wolf Bulle. Stuart Kingma, who worked with the World Council of Churches on its health programs, attended. During a summary of his work, Kingma happened to mention attending the Alma Ata meeting and hearing Senator Kennedy speak. He said he couldn’t remember much about the speech, but it had been worth attending because of one phrase, “For me, those are simply numbers, but for you in the audience they must be faces.” He said Senator Kennedy had nailed it!
Forty years later, much has changed in famine and disaster response, and much remains the same. The changes include attempts to predict famine by monitoring food prices, rain forecasts, and food stocks. Famines today are person made, that is, the result of a political defect such as war, not nature, and because of that, they can largely be predicted, and the world has the capacity to respond. Where response is inadequate, it usually points to a political defect or war.
Bangladesh Cyclone
It has also become standard to evaluate rapidly through quick-and-dirty surveys to understand what is needed before unleashing major responses. Soon after the Nigerian Civil War, a cyclone in Bangladesh almost led to a major US response with field hospitals and X-ray machines. Dave Sencer, at the CDC headquarters in Atlanta, and Henry Mosley and Al Sommer, in Dacca (both former EIS officers), were able to do a fast field survey. They found that, unlike with earthquakes or other disasters, the problems from cyclones were not usually injuries. These researchers did find what Al Sommer termed a cyclone syndrome. This consisted of abrasions on the chest and inner arms and thighs due to clinging to trees during the storm. Mosley and Sommer also found that shelter, food, farm implements, and means of rebuilding were lacking after cyclone disasters. The surveyors recommended a response of shelter, hand tools for farmers, seed and fertilizer, and supplies to restock medical facilities to get the society responding quickly. Field hospitals would have had limited usefulness, they noted.
Sencer, Mosley, and Sommer then conducted a more sophisticated survey to better describe the problem and its geographic extent. Their survey was based on years of development at the CDC. Polling is now so common that we often forget the history and the science behind it. People often dismiss political polls, for example, saying, “No one has ever polled me.” And yet these polls are able, on the basis of a few thousand interviews, to predict how millions will vote within a relatively small margin of error.
Two statisticians at the CDC, Robert E. Serfling and Ida L. Sherman, had developed ways of taking random samples of people to predict, for example, recent illness, beliefs about immunization, and vaccination levels. When Rafe Henderson was about to conduct a survey of smallpox vaccination rates in Northern Nigeria in the late 1960s, he sought the help of Don Eddins, a statistician working with the Smallpox Eradication Program at the CDC. Eddins had been raised in Texas and had lightning reflexes. He likely could have played major league baseball, but he decided to apply his reflexes to statistics.
Sherman and Serfling based their approach on studying census information, tax records, financial data, and other evidence mined by population statisticians. Eddins transferred their basic approach to areas that lacked street addresses or census numbers and suggested studying people in random clusters rather than identifying random people. A cluster was identified by selecting a random spot on the map. The nearest village was visited, and rules were established on how to choose the first household and the following households in the cluster. Eddins’s method became a standard approach in health programs in Africa. Years later when I visited a clinic in Congo Brazzaville and asked how they knew the immunization rates that were posted on the wall, they answered that they used the Henderson method, which was really the Henderson-Eddins method.
Mosley and others now used this approach in the cyclone-hit areas of Bangladesh, with a ferry as base and speedboats to find the clusters. Their survey indicated that 250,000 persons had died in one night because of the cyclone. Deaths were far more frequent than nonfatal injuries. These results reinforced the need for food, shelter, utensils, and farm animals to rebuild the area.
The use of surveillance (including surveys), analysis, and appropriate response has become ingrained in disaster relief. What has not changed is the overwhelming response from countries and nongovernmental organizations (NGOs) that often cause gridlock at airports, often with materials that are of no use for the disaster. Such materials, in fact, become one more burden for relief workers. Human nature dictates competition to get supplies to the area of need and publicizing the work for the benefit of donors. The government, however, not only has an unprecedented disaster to deal with but now politics as well. Such situations often lead to government workers, who should be focused on the disaster, instead attempting to meet the needs of foreign diplomats and representatives of NGOs, who are seeking an audience with those in charge of the disaster.
A lesson that seems difficult to learn is that all resources from outside of the disaster area should be coordinated by one outside person. Often the best person to consider is a military logistician accustomed to moving large volumes of material as efficiently as possible. The government response in the affected country should also be centralized under a single person. These two people—one representing the government, the other representing all outside agencies—could coordinate for maximum effectiveness. Sufficient examples of how to do this exist, as, for example, in the coordination of North Atlantic Treaty Organization (NATO) troops. Yet disasters often catch governments by surprise, and they do not easily respond in an efficient manner. The West African Ebola outbreak is the latest example of the inability of public health and disaster agencies to learn the lessons that seem second nature to military organizations.