No Jab, No Pay: Australia’s Misguided Approach to Vaccine Refusal

Australia’s recently announced “no jab, no pay” policy offers a potent reminder of the all-too-common tendency to penalize vulnerable populations for public health problems. Like many other countries, Australia has experienced a worrisome increase in the number of families deciding not to vaccinate their children.  In response, the government of Prime Minister Tony Abbott has announced a program of carrots and sticks. The carrots include increased payments to physicians to incentivize them to urge families to vaccinate their children. The sticks include tightening the religious exemption (Australia does not provide an exemption for personal belief) and the “no jab, no policy” which will deny families whose children aren’t vaccinated certain income-based childcare and family tax benefits.

Governments have long used the denial of public benefits – traditionally public education – to push parents to vaccinate their children.  Studies have shown that laws conditioning attendance in schools and daycares on vaccination can increase vaccination rates, although the particular formulation of the law (especially how difficult it is to receive an exemption) matters.

To be sure, laws that require children to be vaccinated to attend schools or daycare impose heavier burdens on poor families who are more apt to need daycare and are less able to homeschool their children. Still, these laws reach broadly, especially when they apply to private schools. Homeschooling remains relatively rare. Significantly, school-based vaccine laws do not single out low-income families.

The “no jab, no pay” policy is different in that it targets the most vulnerable families. Upper income families need not worry about the rise of vaccine preventable diseases. The policy doesn’t apply to them. Nor is there any equivalent financial penalty aimed at upper-income families.

By tying welfare to vaccination, the “no jab, no pay” policy sends the message that rising rates of vaccination resistance are due to the failure of low income parents to vaccinate their children. That’s not true. In Australia, as in the U.S., vaccine resistance is disproportionately found in more affluent communities.

Without question, recent outbreaks of vaccine-preventable diseases suggest the need for more effective vaccination laws. The California legislature is now debating a measure to end the personal belief exemption from that state’s school-related vaccine mandate.  Much of the debate has centered around the disparate impact the measure would have on middle and low income families who can less readily escape the requirement by homeschooling their children. Less noticed is the fact that California, like Australia, ties welfare to immunization. Unlike Australia, however, welfare recipients in California can seek a personal belief exemption to the immunization requirement. If the state were to abolish that exemption, California would also have a “no jab, no pay” policy.

In her recent book On Immunity: An Inoculation, Eula Biss describes vaccination as a selfless act, one that is undertaken by the majority to help those who are especially vulnerable to disease. Ideally vaccine laws reinforce that solidarity, binding everyone within a jurisdiction to act for the greater good. “No jab, no pay” policies sever that bond. They blame those who are most vulnerable for vaccine-preventable disease while granting immunity to those who are most privileged.

Harvard U Effective Altruism presents: Derek Parfit discusses altruistic giving

PArfitFacebook RSVP

When: Tuesday, April 21, 6:00pm Where: Harvard campus, Science Center E

Oxford and Harvard philosopher Derek Parfit is described by Encyclopaedia Britannica as “the most important moral philosopher of the 20th and early 21st centuries”.  The New Yorker called his books “the most important works to be written in the field in more than a century.”  He will be discussing personal identity, future generations, ethics  and Effective Altruism in a fireside chat moderated by ethicist Nir Eyal, Associate Professor of Global Health and Population at the Harvard T.H. Chan School of Public Health.

This event is co-sponsored by Harvard University Effective Altruism (HUEA) and Harvard College Effective Altruism (HCEA), and is open to the public.

Mainstreaming Medical Legal Partnerships (MLPs)

Last week, I had the opportunity to speak at the 10th Annual Summit of the National Center for Medical Legal Partnership in McLean, Virginia. The summit brought together more than 400 people working to “mainstream” medical legal partnerships (MLPs). The theory of change is that through these partnerships, the health care sector can begin to more systematically address social, behavioral and environmental determinants of health. Particularly on behalf of patients who are low-income, legal professionals address root causes of illness by working with utilities companies, landlords, social service agencies and the court system.

Concretely, MLPs are programs in which civil legal aid agencies, health care organizations and public health departments cooperate to train their staffs, treat individuals and identify population level problems. Most often, it is civil legal aid agencies that provide expertise in the laws around housing and public benefits, and spend their resources to ensure access to housing subsidies, food benefits, health insurance and employment. Some law firms also contribute pro bono time to the cause, as do some law schools in the form of clinics.

Continue reading

Highlights from the Consortium of Universities for Global Health Conference: Part III

By Guest Blogger Dan Traficonte 

In this third blog post covering my visit to the Consortium of Universities for Global Health Conference, I highlight some research from the conference focused on the importance of considering local social practices and belief systems into health policies and interventions.

Faduma Gure, a Master’s student in Interdisciplinary Health Sciences at the University of Ottowa, conducted fieldwork in Somalia to explore awareness of and attitudes to emergency contraception and their implications for health interventions. Somalia’s high fertility rate, high maternal mortality ratio, and low contraceptive prevalence rate coupled with restrictive abortion laws make addressing the lack of family planning services an extreme challenge. In conflict or post-conflict settings like Somalia, emergency contraception can be critical for pregnancy prevention, yet Somalia remains one of the few countries in the world without a registered progestin-only emergency contraceptive pill.

Ms. Gure conducted a qualitative, multi-methods study comprised of structured interviews with key informants, including physicians, non-governmental officials, government officials, local Somali pharmacists, and married and unmarried Somali women. Most participants showed little knowledge of existing family planning methods or emergency contraception, however, once contraception was described, all participants expressed tremendous enthusiasm for expanding access to post-coital contraceptive methods in Somalia. All participants expressed that an available emergency contraceptive would fill a major gap in reproductive health service delivery, and all government officials interviewed indicated that emergency contraception could easily be incorporated into the existing health system.

It is a common belief—and often a misconception—that people in conflict-torn and impoverished countries like Somalia reject modern medical technologies due to conflicting local practices and beliefs. Ms. Gure’s preliminary research indicates that the lack of emergency contraception in Somalia does not result from local beliefs, but from lack of knowledge and access to the technology.

Dan Traficonte is a 1L at Harvard Law School interested in the intersection of global health and international development.

Highlights from the Consortium of Universities for Global Health Conference: Part II

By Guest Blogger Dan Traficonte 

In this second blog post covering my visit to the Consortium of Universities for Global Health Conference, I highlight some fascinating new research on the relationship between global poverty and population health.

Dr. Joseph Dieleman from the Institute for Health Metrics and Evaluation at the University of Washington presented his research on national poverty rates of 129 countries and their effect on mortality. Typically in the global health literature, a country’s wealth serves as a predictor of population health outcomes—that is, wealth means health. However, the relationship between poverty and health outcomes has not been systematically evaluated in cross-country studies because of insufficient data. Dr. Dieleman sought to address this relationship and show how poverty can explain variation in health using 22 complete poverty and health data series.

Building on the World Bank’s International Comparison Program dataset of 800+ household surveys, Dr. Dieleman used covariates and intertemporal trends to generate a complete data series for 129 countries for 1990-2013. To predict national poverty rates at 51 different income thresholds, 20 variants of three models were supported by out-of-sample validation to choose the best model. Finally, Dr. Dieleman incorporated health data into his model using fixed-effects linear regression techniques to test how national poverty rates are associated with changes in adult and child mortality. Continue reading

Highlights from the Consortium of Universities for Global Health Conference: Part I

By Guest Blogger Dan Traficonte

Recently, the Petrie-Flom Center sent me to the 6th Annual Consortium of Universities for Global Health Conference in downtown Boston, where students, researchers and health professionals from around the world gathered to network and share ideas. The conference’s focus covered a broad range of pressing global health issues, including the Ebola crisis of 2014, food security, and the impact of climate change on the health of populations worldwide. I was able to meet and chat with many people doing fascinating work in the global health field, and I will highlight here a few of the most interesting presentations linked directly to issues of law, governance, and health policy.

Dr. Pooja Agrawal from the Yale School of Medicine presented her research on the impact of the Affordable Care Act on health insurance access, coverage, and costs for refugees resettled in the United States. Dr. Agrawal’s research sought to assess the relationship between refugee resettlement patterns and improvements to health insurance access created by the ACA—specifically, are refugees in the United States generally able to benefit from the enactment of Medicaid expansion and implementation of healthcare insurance exchanges?

Using a cross-sectional analysis of 2012 refugee resettlement data from all 50 states, Dr. Agrawal compared resettlement trends for states that have expanded Medicaid and implemented exchange schemes and those states that have not. The results of this analysis indicate that in 2012, more refugees were resettled to states that have not expanded Medicaid or created state health insurance exchanges. Though there is currently no data on the effect of these differences on refugee health outcomes, these results implicate important policy concerns: specifically, the architects of refugee resettlement policies may choose to consider between-state variation in access to insurance as a result of the ACA in devising resettlement strategies. Dr. Agrawal’s research highlights an often-underemphasized area of intersection of law and social policy, and calls for more research on the impact of the ACA on refugee populations in the United States.

Dan Traficonte is a 1L at Harvard Law School interested in the intersection of global health and international development.

Making Connections & Collaborating for the Future of Public Health

As part of the Public Health Law Research program’s participation in National Public Health Week 2015, we have been sharing materials and resources under the daily themes. Today’s theme, Building Broader Connections, is about expanding partnerships and making connections to benefit public health.

We spoke with Laura Hitchcock, JD, Policy Research & Development Specialist for Public Health – Seattle & King County and the King County Executive/Department of Executive Services Partnerships Initiative Lead. We asked her to offer some insight from her work as a lawyer and researcher in a public health department.

PHLR: What role can researchers play in building partnerships with health departments and contributing to the policy-making discussion?

Laura Hitchcock, JD

Laura Hitchcock, JD

LH: Public health researchers can help to support development and refinement of evidence-based policies. Because policies are created in a political process, it is important for public health departments to continue to offer their scientific knowledge to support creation of effective policies, including repeal of ineffective policies or refinement of existing policies to better result in a healthy population by 2030. Health departments may need help to define local or state-focused areas for policy evaluation by working together with researchers, and should contribute to development of research agendas by identifying areas where policy makers, communities, medical professionals and others have concerns about the public’s health, and are likely to need support from researchers to know how to ‘plug in’ to research agenda development. Continue reading

Hopkins faces $1B lawsuit over role in government study that gave subjects STDs

The Petrie-Flom Center’s Executive Director Holly Fernandez Lynch and Faculty Director I. Glenn Cohen weigh in on the issue in the

Nearly 800 former research subjects and their families filed a billion-dollar lawsuit Wednesday against the Johns Hopkins University, blaming the institution for its role in 1940s government experiments in Guatemala that infected hundreds with syphilis, gonorrhea and other sexually transmitted diseases. […]

Legal experts said the lawsuit’s arguments could be a stretch. Today, professors who frequently serve on a volunteer basis with the National Institutes of Health, for example, are generally considered to be acting independently and not in their capacity as university faculty, said Holly Fernandez Lynch, executive director of the Petrie-Flom Center for Health Law Policy, Biotechnology and Bioethics at Harvard University Law School.

[…] Because the experiments occurred so long ago, most if not all of the subjects are dead, and it could be difficult for someone to prove that a relative was part of the study, Lynch said. She and colleague I. Glenn Cohen, a professor at Harvard Law School, argued in a 2012 New York Times opinion piece that the Tuskegee experiment and others provide precedent for a fair recourse.

In the Tuskegee case, a legal settlement included lifetime medical benefits for study subjects and their wives, widows and children, as well as federal grants to promote research and health care ethics, they said. U.S. aid applied directly to Guatemalan health could be appropriate in this case, Lynch said.

“Congress and the [Obama] administration must step up more than they have, by offering financial restitution to Guatemalans with plausible claims of harm,” Lynch and Cohen wrote. “Even if the lawsuits were appropriately dismissed, justice has not been done.”

Continue reading

New browser app shines light on conflicts of interest

By: Christine Baugh

A new Google Chrome extension puts the spotlight on conflicts of interest. The browser app, available for free download here, was created at the Hacking iCorruption hackathon event held March 27-29 in Cambridge, MA. The event, co-sponsored by the Edmond J. Safra Center for Ethics at Harvard University and the MIT Center for Civic Media (hosted at the MIT Media Lab) brought together individuals with a variety of backgrounds and skills to work toward the common mission of fighting institutional corruption, in this case by creating practical tools. This project was one of several exciting tools created at the hackathon (information about other projects available here), and it won first prize among the projects.

The Chrome extension, called Unearth, puts funding and conflict of interest information on the abstract page of PubMed research articles. Christopher Robertson, Associate Professor of Law at the University of Arizona James E. Rodgers College of Law and Edmond J. Safra Center Fellow who was a member of the Unearth team, explains the rationale for the browser extension in this Youtube video. In short, conflict of interest and funding disclosures are often placed at the end of a research article and are generally unavailable on the abstract page. This makes it impractical for physicians and other research scientists to pay appropriate attention to this important information. Research from the Cochrane Collaboration has demonstrated that research studies funded by industry generally describe “greater benefits and fewer harmful side effects” than their non-industry funded counterparts. Thus, taking the source of research funding into account when reading a new research study is critical. Although the extension currently only works for open access articles from PubMed Central, this includes several million research articles for which funding and conflict of interest information was previously much more difficult to obtain. Additionally, the developers plan on expanding the breadth of coverage in the coming weeks. Continue reading

Is concussion protection in Florida too much, too soon?

Today’s New York Times featured a long exploration of “Headgear Rule for Girls’ Lacrosse Ignites Outcry.” As a former lacrosse player and health policy researcher, I read the piece with interest.

Essentially what’s happened is that Florida has instituted a headgear rule ahead of the sport’s national governing body. Florida made this decision in advance of this season based on statistics that show that female lacrosse players experience the fifth-highest rate of concussions of any high school athlete. If you’ve ever held a lacrosse ball, this won’t surprise you.

Still, it is not immediately clear what the actual rate of concussions is in Florida. Identifying girls lacrosse as coming in 5th place doesn’t help the reader judge how pervasive the risk really is if we consider that there could be large gaps between the ordinal rankings. Florida officials have suggested that if even one injury is prevented by the introduction of headgear, the rule would be worth it. I’m not sure I’m so risk-averse. Continue reading

Harvard Undergraduate Bioethics Society event: Big Brother Is Watching–Paternalism and Bioethics

 You are invited to the Harvard Undergraduate Bioethics Society 2015 Conference:

“Big Brother Is Watching: Paternalism and Bioethics”

Saturday, March 28th, 3.30-6.30pm, Harvard Hall 104

RSVP Here

Coffee and desserts will be served

A panel discussion and talks by

David Buchanan, PhD

University of Massachusetts, Amherst

Professor and Chair of the Department of Health Promotion & Policy, and Director of the Institute for Global Health

Sarah Conly, PhD

Bowdoin College

Associate Professor of Philosophy

Wendy Mariner, JD MPH LLM

Edward R. Utley Professor of Health Law at Boston University School of Public Health

Professor of Law at Boston University School of Law

Professor of Socio-Medical Sciences at Boston University School of Medicine

Steven Ralston, MD

Harvard Medical School

Associate Professor of Obstetrics, Gynecology and Reproductive Biology

 

REGISTER NOW: ReSourcing Big Data – A Symposium and Collaboration Opportunity (3/23)

From Harvard Catalyst:

REGISTER NOW!

March 23: Symposium
9:00 AM – 5:00 PM
Joseph B. Martin Conference Center
Harvard Medical School

Extant data is an inexhaustible resource that is not yet very well understood and is underutilized. The focus of this symposium is to explore this area from various perspectives – privacy and security, policy, open clinical trial data, systems and disease-oriented synthetic efforts and individually-provided, aggregated crowd-sourced data. The goal is to engage our biomedical and public health research community in a more nuanced appreciation of these and similar issues.

Topics include: data aggregation, access, annotation, refocusing on novel or unanticipated questions, and recombination with diverse demographic/epidemiologic data. Continue reading

TOMORROW (3/11): Identified versus Statistical Lives: An Interdisciplinary Approach Book Launch

Identified_Lives_posterBook Launch: Identified versus Statistical Lives: An Interdisciplinary Approach

March 11, 2015 12:00 PM

Wasserstein Hall, Room 2012 Harvard Law School, 1585 Massachusetts Ave., Cambridge, MA

Identified versus Statistical Lives: An Interdisciplinary Approach is an edited volume that grew out of the 2012 conference “Identified versus Statistical Lives: Ethics and Public Policy,” cosponsored by the Petrie-Flom Center, Edmond J. Safra Center for Ethics, and the Harvard Global Health Institute. The essays address the identified lives effect, which describes the fact that people demonstrate a stronger inclination to assist persons and groups identified as at high risk of great harm than those who will or already suffer similar harm, but endure unidentified. As a result of this effect, we allocate resources reactively rather than proactively, prioritizing treatment over prevention. Such bias raises practical and ethical questions that extend to almost every aspect of human life and politics.

The book talk and discussion will feature:

  • I. Glenn Cohen, co-editor, Petrie-Flom Faculty Director, Professor of Law at Harvard Law School
  • Norman Daniels, co-editor, Professor of Population Ethics and Professor of Ethics and Population Health, Harvard School of Public Health
  • Nir Eyal, co-editor, Professor of Global Health and Social Medicine (Medical Ethics), Harvard Medical School

Co-sponsored by the Harvard Law School Library, with support from the Harvard Global Health Institute.

Pakistan’s “Last-Ditch Effort” To Eradicate Polio

Allison M. Whelan, J.D.
Senior Fellow, Center for Biotechnology & Global Health Policy, University of California, Irvine School of Law
Guest Blogger

In a previous post, I discussed three possible methods of increasing vaccination and decreasing vaccine refusals in the United States. One of these options was using tort law and allowing lawsuits against parents for refusing/failing to vaccinate their children. The Pakistani government has recently taken it one step further, arresting and issuing arrest warrants for parents refusing to vaccinate their children against polio. Last week,  approximately 512 people, 471 in Peshawar and 41 in Nowshera, were arrested and jailed and arrest warrants were issued for 1,200 more parents for refusing to vaccinate their children.

Currently, the government allows parents to be released from jail and return home if they sign an affidavit promising to vaccinate their children. Despite the fact there is no law requiring polio vaccination, some view the recent crackdown as “a blessing in disguise” for unvaccinated children. This drastic approach responds to high rates of refusal, a contributing factor to Pakistan’s significant number of polio cases. According to the World Health Organization, in the period since March 2014 Pakistan registered 296 polio cases, the most in the world and drastically higher than even the second-highest rate of 26 cases registered by Afghanistan. Why is Pakistan’s vaccination rate so low? For many reasons, including religious beliefs, attacks on medical workers, displacement of individuals due to ongoing military operations, and a lack of trust in health care workers and the vaccine. Continue reading

Bioethicist Art Caplan: Why Are Guns a Taboo Topic on Campaign Trail?

A new piece by contributor Art Caplan on NBC News:

Guns are a medical issue — no matter how often the NRA denies it. Eight national health groups, including the American Academy of Pediatrics, just released a joint statement echoing that sentiment.

But among the barrage of media questions leveled at politicians on the presidential campaign trail, no one is asking the contenders about firearms. The topic appears to be strangely and entirely off limits.

Everything else seems to be fair game: Do you think President Obama loves this country? What do you think about vaccines? Do you believe in evolution? Did you embellish anything on your resume? Do embryos have rights? Are you too old, fat, short, ill-tempered, religious, atheistic, feminist, or in the pocket of your donors to make a good President? […]

Continue reading here.

Naturopaths — Not What The Doctor Ordered For Vaccine Exemptions

A new piece by contributor Art Caplan in Forbes:

There are lots of reasons why measles, having gone to Disneyland, is enjoying a comeback around the United States and Canada. Unfounded fears of autism scare some parents. Others buy the daffy conspiracy theory that pharmaceutical companies are just pushing vaccination to make a buck. Some parents invoke religious concerns despite that fact that hardly any religions think vaccination is bad and most teach that it is an obligation in order to protect children and the vulnerable in the community.

One key reason behind falling vaccination rates is that if you believe any of the above untruths it is very easy to get an exemption. Most states let you out on religious or philosophical grounds. Every state excuses you or your kids for health reasons. So you might presume those ducking vaccines get approval to dodge vaccination from physicians. Uh uh. In 17 states, D.C. and Puerto Rico naturopaths, healers who believe in a mishmash of nutritional medicine, botanical medicine, naturopathic physical medicine including chiropractic manipulative therapy, rolfing, iridology, and homeopathy among other New Agey philosophies can get licenses in their state. There are thousands practicing in the United States. Put aside the issue of why states are recognizing these ‘healers’ who rely on an evidence base only a few steps above astrology and palm-reading. The fact is in many states a naturopath can excuse a child from vaccination. And since many naturopaths take a pretty dim view of vaccination they give a lot of exemptions. […]

Read the full article here.

An Opening for Measles: Anti-Vaccination Trend a Growing Concern

An article in the Harvard Gazette about our panel “Measles, Vaccines, and Protecting Public Health,” convened on February 25, 2015:

The numbers paint a telling picture. In the United States of the 1950s there were between 3 million and 4 million annual cases of measles, a highly infectious virus that causes severe flu-like symptoms and a spreading red rash. Roughly 48,000 of those infected each year were hospitalized, and 400 to 500 died.

By 2000, through an effective and widely used vaccine, measles was essentially eliminated in the United States.

But for the last several years, the Centers for Disease Control and Prevention has reported a significant uptick. Last year, the CDC recorded more than 644 cases from 27 states, the worst since 2000. Only two months into 2015 the United States is facing more than 150 cases reported across the country, many of them tied to a December outbreak at Disneyland in California.

The resurgence involves measles-stricken travelers and American parents who don’t vaccinate their children. […]

Continue reading here.

Hospital-Based Active Shooter Incidents: Sanctuary Under Fire

Petrie-Flom Faculty Director I. Glenn Cohen has published a new co-authored article in the The Journal of the American Medical Association on active shooter incidents in hospital settings. From the article:

On January 20, 2015, Michael J. Davidson, MD, a cardiothoracic surgeon, was fatally shot on the premises of the Brigham and Women’s Hospital in Boston, Massachusetts. In the year leading up to this tragic day, a total of 14 active shooter incidents occurred in hospitals throughout the United States, leaving 15 fatalities in their wake. This reality and its potential amplification by copycats has reignited the debate over the adequacy of current and future hospital security arrangements. In this Viewpoint, we discuss the evolving frequency of hospital-based active shooter incidents, the relevant legal framework, and the role of hospitals and physicians in countering this threat.

As defined by the US Department of Homeland Security, an active shooter incident is one wherein “an individual is actively engaged in killing or attempting to kill people in a confined and populated area.” By several accounts, the overall prevalence of this otherwise rare occurrence is increasing. A study by the Federal Bureau of Investigation (FBI) reveals the overall number of active shooter incidents to have increased from 6.4 per year (2000-2006) to 16.4 per year (2007-2013). Similar rates have been reported for the hospital setting wherein the average number of active shooter incidents has increased from 9 per year (2000-2005) to 16.7 per year (2006-2011), claiming 161 lives in the process. It would thus appear that the frequency of hospital-based active shooter incidents has evolved to constitute at least a monthly occurrence. […]

The political paralysis plaguing gun laws notwithstanding, hospitals are not without recourse in seeking to mitigate the threat of active shooter incidents. On the local advocacy front, advancing and enacting bills for gun-free zones in health care settings constitutes a worthy effort in that a comparable federal statute remains unlikely. Concurrently, selective locale-specific enhancement of hospital security arrangements may increase deterrence, thereby mitigating risk and civil liability. […]

Read the full article here.

Experts Talk Vaccine Opt-Out Parameters

An article in the Harvard Crimson about our panel “Measles, Vaccines, and Protecting Public Health,” convened on February 25, 2015:

There is a delicate balance between preserving individual rights and protecting public health when it comes to vaccines, experts argued at a panel discussion at Harvard Law School on Wednesday.

In the wake of the recent outbreak of measles in California, the panel emphasized the need for Americans to be more informed in their decisions for or against vaccination. While allowing an opt-out option to remain in place, the panel proposed making the opt-out process for vaccines more difficult. […]

To read the full article, click here.

What Happens When A Retail Pharmacy Decides To Stop Selling Cigarettes?

A new post by Andrew Sussman on the Health Affairs Blog, as part of a series stemming from the Third Annual Health Law Year in P/Review event held at Harvard Law School on Friday, January 30, 2015.

The sale of cigarettes and tobacco products at retailers with pharmacies has received considerable attention over the past year. The national debate reignited in February 2014, when CVS/pharmacy announced that we would quit the sale of cigarettes and tobacco products in our 7,800 pharmacies nationwide. In September 2014, we announced we were officially tobacco free — one month earlier than planned. This was met with kudos from the media, public health officials, and even the President of the United States.

But one question that did not receive anywhere near that level of attention was whether or not our actions would make a difference in the prevalence of smoking and, ultimately, in the public health.

Read the full post here.