THE BATTLE OVER COUNTING PILLS AND GLOBAL TRENDS

Sibling rivalry is a common phenomenon in professional practice as is in families. For years, pharmacy professionals in Kenya were entangled in a tag of professional war.  This year, it escalated not only to confrontational outbursts but public altercations and total dress down in social and traditional media - So much for professionalism. The war is between two professional pharmacy advocacy groups.

One group, Pharmaceutical Society of Kenya (PSK) represents Pharmacy practitioners with Bachelor of Pharmacy degree. The second group, Kenya Pharmaceutical Association (KPA), represents Pharmacy practitioners with Pharmacy Diploma. But one clarification must be made.

Ostensibly, the term pharmacy practitioner is used to describe both groups in full recognition that one group or the other might find it offensive at least in the Kenyan context. However, it should be on record that the use of the term Pharmacy practitioner doesn’t dilute the authenticity of any of the group’s academic qualifications.  That set aside, then what provokes the intractable disaffection between the two advocacy groups?

Behind the white-coat facade is insecurity, superiority contest, commercial interests and greed all coalesced into one improvised explosive that detonates right in the middle of the Pharmacy profession. That leaves behind a trail of shuttered profession that in many ways doesn’t contribute to the wellbeing of patients and to the populace.

The recent duel was provoked by the proposed amendments to the Pharmacy and Poisons Act, Cap 244 - National assembly bill no.14 of 2018. The Bill is neither ominous nor ambiguous.  It doesn’t restrict or offer any privilege to any of the practitioners. It reaffirms the difference between a Diploma practitioner and a Degree Practitioner. Arguably, its weakness is in its failure to capture the contemporary global practice standards. And that is because the legislative process was neither comprehensively engaging nor exhaustively consultative in seeking professional perspectives. A short background on the History of Pharmacy in Kenya will go along way.

The first semblance of Pharmacy practice came in the form of   Compounders in 1926. As has been the case under British colonial dominance across the Globe, this was a copy-paste professional practice. By 1971, the increasing demand for skilled practitioners forced the upgrade of Compounders to a more rigorous formal course work and externship. The completion of the new curricula offered Pharmacy Diploma. Though the Diploma College started churning out a good number of skilled graduates, it was not near enough for the market demand.

The Diploma graduates are recognized and adopted as Pharmaceutical Technologists in Chapter 244 of the Constitution of Kenya under the Pharmacy and Poisons Act.  By 1978, the University of Nairobi introduced Faculty of Pharmacy and has earnestly begun training Pharmacy Professionals with Bachelors degree.

Great majority of Pharmacists from the University of Nairobi were absorbed into the job market by Pharmaceutical manufactures and distributors. However, a few do practice behind the Pharmacy counter and have direct patient interaction.

Fast forward. In Kenya, Today, there are myriads of Colleges and Universities offering both Bachelors Degree and Diploma in Pharmacy. At least six Universities are offering degree in pharmacy most of whose curricula is essentially the mirror image of Nairobi University’s curricula. The formidable question of quality against quantity arises when one considers the increase in number of Universities and colleges in such very short period. 

Members of PSK claim right to privileges in accordance to their lengthy training. While that argument can be lent some credence, it subordinates members of KPA and that could be one of the unsettling discomforts between the two sides.

For instance, importation, wholesale and manufacturing of pharmaceutical products is an exclusive affair to Degree Pharmacist. Retail ownership is the only level-playing field for both groups. By pursing these exclusive privileges, PSK has in effect drawn a line between their members and those of KPA.

KPA members on their part remain belligerent against been treated as the professional underdogs while PSK leadership argues their attitude toward KPA is nothing more than perception.

PSK membership is 4,000 while KPA membership is a dwarfing 10,000. Combined, they are a total of 14,000 Pharmacy practitioners. Put in perspective, for every 3,500 Kenyans, there is only one Pharmacy practitioner.  Even when both groups are combined, the ratios remain ludicrously below the World Health Organization’s recommendations.

The entry of PSK and its members into a profession dominated by Pharmaceutical Technologists was a potent threat and insecurity.  Like the old lion King who must cede territory to the younger energetic male lion, PSK has portrayed the mucho man entitlement by pushing out the old privileged diploma folks. It is the norm that the old lion, though not a pushover, cedes ground in the end. That is not to suggest that any group must cede ground because the reality remains - KPA is determined to pushback on every inch against PSK.

At the backdrop of this seismic battle, could there be a third and better alternative that works for everyone - a win-win-win situation? A win for KPA, a win for PSK and a win for the patients.  It’s prudent to step out on the balcony and consider the current global trend in Pharmacy profession. The global trend is neither within the purview of KPA nor PSK. It is a complete departure from the two competing narratives.

The profession can be considered as spectrum where one end is Compounding drugs as it was in early 1900s and the other end is patient-centered-care as it is today. Everything else such as supplier, wholesaler, importer, entrepreneur pharmacist is in the middle and is only evolutionary toward today’s needs of Patient-centered-care. Both PSK and KPA are somewhere in the middle of the spectrum. There is a compelling need to move toward today’s end of the spectrum in the context of the profession. That is the reality that every Pharmacy practitioner in Kenya and elsewhere in the world must come to understand and begin to embrace.

Patient-Centered-Care popularly known as Pharmaceutical Care means the pharmacist is now taking on direct responsibility for the patient. According to the World Health Organization (WHO), by reorienting the Pharmacy Profession around Pharmaceutical Care, it means the pharmacist’s new task is to ensure patient’s drug therapy is appropriately indicated, the most effective available, safest possible and convenient for the patient (WHO). Ideally, this approach is self-evident in that the pharmacist’s new responsibility will immensely contribute toward the patient’s overall outcome and quality of life.

In its quest to increasingly improve Health care, WHO has introduced the concept of seven-star pharmacist, adopted by International Pharmaceutical Federation (FIP) in 2000, in its policy statement on Good Pharmacy Education Practice. Accordingly, the pharmacist is a caregiver, communicator, decision maker, teacher, life-long learner, leader and manager.

Unfortunately, in most countries, Pharmacy education of current pharmacists was based on the old skill-set of pharmaceutical product focus.

Then where should the discourse begin? If the Pharmacists are to contribute effectively to the new patient centered Pharmaceutical care practice, The Knowledge base of pharmacy graduates must be reoriented to reflect this new focus.  The reorientation process must include providing an opportunity to old pharmacy practitioners in all cadres. Progressively, then it becomes obvious that the profession will refit itself within the definitions of pharmaceutical care. And everyone will have won.

 In its aspirations to embrace the changing needs of the pharmacy profession, United Kingdom has recently started stakeholder’s consultative engagement. It concludes that both Bachelor of Pharmacy (Bpharm) and Master of Pharmacy (Mpharm) training is neither effective nor efficient in the delivery of care needed by patients today. It finds the United States terminal Doctor of Pharmacy (PharmD) as the most appropriately oriented Patient centered program that can deliver to the clinical focus required.

Subsequently, many countries in pursuit of Pharmaceutical care adopted the Doctor of Pharmacy  (PharmD) Program. These new paradigm is sweeping across the globe - Canada, many Eurozone nations, Sub-Saharan Africa and Asia have adopted the Doctor of Pharmacy (PharmD).  Consequently, it becomes axiomatic that the global standard for Pharmacy Education is headed in one common direction; The Doctor of Pharmacy Education Program. 

Dr. Ali M. Mahmud, PharmD, MBA

Member, International Pharmacetical Federation (FIP)

alimaly@gmail.com

My Neighbor is my Clan

The African continent is rife with Tribalism, clanism, nepotism and ethnicity all used in the most pervasive negative manners. Many of African civil wars, rebellions and infighting are clan associated. In many years past, myriads of theories to explain and understand the real connection between clan and conflicts have spawned. For instance, some conflict theorists belief that with increased literacy, conflicts decline. whether that is true or not, we cannot establish and needs an extensive research. However, it is clear that the most literate nations in Africa have the same number of conflicts or even more as those with low literacy levels. A good example is Kenya.

Kenya's literacy level is an aggregate 90%. Remember 2007 post election violence! Some of the most educated personalities, media professionals, doctors, lawyers and politicians aligned themselves with their ethnic groups. All the quantum physicists, pathologists, the IT Gurus and the greatest minds became mouth piece for their clans not their nation - they were agents of their clans and sub-clans.It appears, despite all the knowledge and experiences amassed from the various professional backgrounds, alignment to the clan still towers.

Interestingly, deep inside, the elitists and supper educated are aware that war and conflict is retrogressive.

In this era, we should convert clanism to neighborism (Yes, new terminology by this blogger in the spirit of leading change). You are guaranteed conflicts related to clanism will wane and wither away. Just say "my neighbor is my clan". If you are in an urban or semi urban residence, your neighbor is probably not your clan. But think of it. You share many things. You are in the same court, kids are in the same school, shop in the same market, use neighborhood petrol station and even your optic fiber runs on the same line. That is the more reason you should say my neighbor is my clan.

Nyumba Kumi (10 houses), with all its doubters out there is an innovative and profound way of promoting neighborism. The intent of this initiative is to enhance security by promoting community policing. The unintended impact is creating bonds within the community, promote ownership of neighborhood, appreciate each other and ultimately caring about the welfare of your neighbors. That is how it should have been - promoting neighborism as an ideology like we do with democracy should be the responsibility of everyone.

And finally, my neighbor is my clan - the neighborism ideology!!

Who Benefits from the Economic Buzz?

There is a global buzz about the economic boom in Africa. Economic analysts talk about 6% growth. Even for some few countries like Ethiopia and Nigeria, double-digit growth is projected in the years to come. But the question is, are the likely big gainers going to be Africans themselves or foreign investors? That is the one million dollar question.

 Many African entrepreneurs and governments are on the full glare of the growth opportunities that there is in the continent. Many have already begun to take advantage by founding new innovative companies that are already on success path. Indeed, some African governments are even encouraging investment in neighboring countries where opportunities are stronger. In Kenya for instance, you will find South African firms in the media and entertainment industry or Libyan Oil companies so ubiquitous one will think it is the ideal industry to invest in.

Nonetheless, it will be disingenuous not to recognize the growing interest of young innovative entrepreneurially tactful Africans eager to take advantage of the new economic dawn in the continent. Although, by and large, the continent was not prepared for this growth in terms of infrastructure and managerial skills, lots of young Africans are yet boldly and conspicuously embracing these opportunities. Many business schools are now on the rush to accommodate people seeking management and technological skills that are currently sub-optimal. However, besides the managerial and technical needs, the other big challenge for the African entrepreneur is the capital investment required to take off. Local banks are obviously still lurking in risk managing the loan opportunities and are quite frankly still latching on the past where prohibitive interest rates are swaying capital seekers to find other alternatives.

Unfortunately, these alternatives come with significant dichotomous short-term and long-term cost to the African entrepreneur seeking capital for either start-up or for strategic market expansion. On the one hand, Billions of dollars in foreign private equities are flooding the market scouting for investment opportunities. From the outset, this is great because with direct investment there is job creation and other activities that spur economic growth.

On the flip-side, to start a business local entrepreneurs require capital. Private equities hardly provide direct borrowing opportunities typically seen in the banks. Most are interested in existing ventures - very few show interest in start-ups.  Generally, Foreign Investors find some comfort and security in buying out or partnering in established ventures - tested and proven. This approach eliminates both the founding entrepreneur and the risk involved with starting a new business. To the founding entrepreneur, the short-term benefit is to dispose the business at relatively good cash not considering real success is indeed the long-term. Those are investors often from the West and Middle East.

on the other hand, there are the Chinese whose investment and business approach is diametrically opposed to the conventional ways. Their targeted investments are massive public and semi-private contracts. Contrary to western investors, they import both intangible and tangible products and skills, technology and capital and only turn Africa into behemoth consumer with negligible socially responsible corporate deliveries - with absolutely nothing green on their investment menu.  By green investment in this context, we refer to conscious awakening to both sustainability and socially responsible investments. Yet corruption abounds in their dealings.

From Large private and public infrastructural contracts to small retailers, the Chinese are so ubiquitous across Africa. In Kenya for instance, after the Anglo-Leasing and the Goldenberg scandals, the Chinese are the new kids on the block when it comes to towering corrupt mega deals. In a nutshell, the Chinese investment is of no value to the mainstream African entrepreneur. They are beneficiaries unto themselves and their home country. Foreign Private equities and other form of non-Chinese foreign investors are engaged in full ownership that in the long-term eliminates local ownership ultimately leaving behind little benefit. It then begs the question, who is truly benefiting from this economic buzz in the continent?

Counterfeiting is not a new business but when it comes to human health it poses serious Health risk. With the rise of globalization and its effect felt everywhere in the world, counterfeiters are riding at the crest of the tide. Kenya’s Pharmaceutical market embodies the best example of proliferation of counterfeit drugs.




In a snapshot definition, a counterfeit drug has no active ingredient or contains harmful substance and is intentionally and fraudulently mislabeled as representation of a genuine brand or generic medication. These commonly include expired drugs often remarketed with new expiration dates or dilution of medications to increase quantity or manufacture of fake, spurious and substandard drugs labeled with misleading information. Its effects can cause serious damage that goes beyond harming individual patient to society. And true to form, it is growing at an alarming rate particularly in the developing world.



Although monetary estimates of counterfeit drug market is approaching well above US$75 billion per year worldwide, over 75% is in the developing world with the African continent accounting for the highest consumption followed by East Asian countries. Kenya is a giant actor both as a source of supply to the rest of the continent and a huge consumer market. In Kenya, pharmaceutical and medical regulations are scantly evident, weak and at its best unreliable.



At the backdrop of lackluster regulations severed by corruption, pharmacy owners, operators, importers, exporters and local drug makers are thriving and laughing all the way to their bank accounts in a sad trade of poisoning and preying on innocent Kenyan public.



Pharmacies in Kenya are rarely manned by trained personnel. According to Kenya Pharmacy and Poisons board quarter page policy, to operate a pharmacy, there are two critical elements from professional stand point; there should be a registered pharmacist and duly inspected premises with a license registered under the pharmacist. Usually, the former is conspicuously absent and the later explicitly hangs somewhere in the pharmacy accruing leased income for the pharmacist.



Pharmacist rent their licenses to the owners of drugstores knowing pharmacies licensed to them are managed and operated by unskilled pharmacy personnel. This is an act that extends beyond moral and ethical issue and certainly teetering at criminality given the fatal consequences it may lead to. And yes, the Pharmacy and Poisons board is often aware of this business. Negligence at the board level and illegal trade in pharmaceutical licensing is the most important underpinning factor providing counterfeiters with the opportunities they need.



When you purchase a medication from a drugstore in Nairobi for a simple ailment such as cold, there is high chance you will suffer a great deal from taking the drug. Paradoxically, the natural progression of the illness is never interrupted by the medication at all.



A cold medication is usually meant to suppress your symptoms until such a time your body’s immunity cleanse it all. But in your honest pursuit to relief yourself of nuisance cough, dripping nose and teary eyes you buy a 12-pill pack imprinted with Cold-Relief. You take this medication and nothing happens.



Indeed your symptoms manifest deeply and intensely – Constant hacking cough teetering at loss of consciousness, your nose too runny and too tender to wipe, sneezes nearly exploding the eardrums and your eyes red hot. What happened to the cold relief therapy?

 

Is there such a thing as "Freedom of Movement"?

I did it again this year to see if anything has changed. Last year it was by Bus. In October of this year (2010), I traveled from Madera to Wajir, purposefully by Kabber (Land Cruiser used to carry Chat). Three days before, I flew from Nairobi to Mandera and asked my driver to meet me in Wajir. The Kabberr unloaded a day before and was on its way to Maua. In the cabin were the driver, my niece who just completed standard eight and me. We departed at 10 am.

After traveling for an estimated half-kilometer, the driver came to a screeching stop in front of a shop. He shouted for his turnboy to come down. He handed him about 10,000 Kenya Shillings. It was all in 1000 shilling bill. The day was so hot...so hot and dry that no amount of water can cool you down. It was made worse by sitting and waiting in idling car. Five minutes later, the young man returned with hands to chest full of 100 shilling notes. Instantly, the driver accelerated with a thrust leaving behind a gigantic trail of dust. That made us very nervous. But, the thought of the huge stuck of notes clouded my discomfort with a seemingly irresponsible driving. I could not hold my curiosity back. I asked the driver why he needed so much cash in small bills. He retorted "for the road". That was an idiomatic response but I suspect he meant for the police (road) as I had seen it happen in the Bus.

We came to Arabia, the immediate settlement after Mandera. The policeman waved at us to stop. There was a roadblock, so there was no reason for waving. Perhaps, he was too excited to see us. He came to the driver's side, leaned on the door and as he exchanged greetings, the driver pulled a couple notes (Ksh. 200) from the stuck of money on the side of his seat. He folded the notes and extended his hand for unsuspicious handshake. I could see the policeman's arm drop to his pocket and almost instantly conclude the conversation. The Policeman cleared our way and we headed on.

Next, we came to Fino. The policeman waved again. We stopped. And soon, he was on the driver's door and the Metal Bar was up in minutes. The whole thing appeared to have some procedural pattern to it; a roadblock, a wave, leaning on the driver's door, a handshake and moving the roadblock. At Lafey, Elwak (twice), Borehole-11, Wargadud, Kutulo-Mandera, Kutulo-Wajir, Tarbaj the drama replayed over and over and over. I asked the driver what will happen if he didn't pay these guys. He said they will detain the vehicle and its passengers for hours if not days with no law to turn to. Seriously, that is an abuse of people’s rights

I was not shocked as much as surprised that this was not only in the Buses plying through these routes but applies to all travelers - even Lorries. It is like a toll station, only this time it is in every small village. By the way, these roads are murram and no evidence of gravelling or paving ever occurred here.

Most leaders will tell you the police checks are for security purpose. But does this really entail any form of security check? If it is for security reasons, why do it in every single village? Can't this be done in Arabia then at Wajir then Garissa? Even that is too much.

I had a similar experience in a Bus from Mandera to Wajir last year. I heard these stories many times but wanted to experience it for myself. Just outside Mandera, we were stopped. Everyone was asked to come down. We complied. They asked for Identity shouting "kipande, kipande!!". They checked everyone and we boarded again with no incident. My eyes were keen on the interaction between the police and the conductor. They stood on the side, engaged in some kind of negotiation and he handed them something. I am guessing something more than couple hundred.

Then at Rhamu, we were stopped and checked. On the seat just behind me, the policeman shouted "shuka haraka wewe! shuka!!!". I turned and it was a young lady with a sick child on her lap. He held her ID card firmly on his hand. She stepped down with the child strapped on her back. Again, I was watching this incident very closely. I asked the passenger sitting next to her if she knew what was going on. They accused her of using a fake Identity card. Not satisfied with this information, I talked to the conductor who was hanging on the entrance bar. He told me that everything is ok. It is not fake ID card; they just need "something".

I started self-debate. If they just need "something" why don't they ask for it? Why did they pick on the most vulnerable of the passengers- a young lady, with a sick child? How can she defend herself if they insist the ID is fake even though it is genuine? What can I do to stop the evil advances of these guys?

I gathered courage, stepped down and confronted the policemen. I introduced myself. "Habari wazee? I am Dr. Ali and this is my relative. Is there a problem with her identity?" One of them lit his flash-light on my face. I politely asked him not to do that again. He yelled that I go back to the Bus. I asked him if I can go back with the lady and her child. He literally started charging at me before he was restrained by his colleague. I warned him that his behavior could cause serious damage to his job and his person. It turned into a scene. The conductor, the driver and more passengers gathered around us. Then the more emotionally sober policeman started apologizing and asked everyone including the lady and her child board the Bus again. We left.

At Elwak, we were checked again. Even after ensuring everyone had an ID, they still wanted their "something". At least, this time, they did not accuse anyone of anything. The conductor took care of them. At Wargadud, Kutulos, Tarbaj the story was the same. Then you wonder; is there such a thing as 'freedom of movement?" Not in the Northern part of Kenya.

I wonder too, if these buses are making ends meet considering the excessive police brutality and massive breakdowns from poor roads. I salute the staff and the owners for their endurance. The extreme breach of justice, abuse of peoples' rights and unyielding demand for bribery is beyond comprehension.

When you want to know the conduct of the rank, you look to the conduct of the file. There is a total failure of leadership in that part of the country. The misconduct of public officers in Northern Kenya is deeply entrenched culture never seen anywhere else in the country. It is brutal, barbaric and bigotry of a kind.

While the other Kenya is fighting corruption, Northern Kenya is fraught with institutional extortion, more so the security arm.

Local and national leaders wake up and stand up against this vice. Wake up government!. Your citizen is painfully consumed a live by your own institution. Where are you human rights watchdogs and advocates? Gather courage to speak up and speak out. Wake up citizens; Kenya has changed and the culture of corruption and police brutality can be confronted boldly with no adverse consequence to you for doing so. Where are the youth and college students? Volunteer for your communities and educate them of their freedom of movement everywhere and anywhere in their country. Where is the media? It is not about national coverage alone, it is also about local coverage; shame and shape the police force and public officers. Let us do it in unison for the suppressed voices, subjugated rights, miscarriage identities and frightened minds.

Snow Storm - Twin Cities, Dec. 2010

Driving on snowed highways and streets was not fun. Can you imagine driving on 16" dip snowed roads? Don't ask how but I managed!!

Northern Kenya; a century of marginalization and still on

The perpetual social, economic and political menace in most parts of Africa is the relic of the colonial powers. The African brand of colonialism was a pervasive laceration on humanity; deep and chronic wounds that continue to fester with pungent mistrust to this day. Every region was affected in a different way. Those on Kenyan highlands were thrown out of their farms and replaced with white settlers. West Africa was converted to slave harbor. The south is even more vivid with its apartheid masters still alive. The north is mostly remembered for the power struggle for the control of Suez Canal route and the Gabon-Niger-Moroco pipeline that empties African oil into massive Paris tanks. The entire Congo-Brazzaville was the private farm of the Belgian King, Leopold-II; the African natives forced to be his personal slaves and labored to transport wood for European real estates.


These are the colonial woes on Africa, its people and natural gifts used for consumption by the Europeans. In Northern Kenya, the colonial story takes a divergent path.

Before independence:

Northern Kenya was not truly colonized. Economically, the region was of no interest to the British. Their tactical presence in the region was one of tripolar mission. First, it was a buffer zone to interrupt Ethiopian imperial expansionist from advancing towards Kenyan hinterland and other regions placed on big British tabs. Second, it was a land-bridge to connect British settlements in East Africa and port of Berbera on the Gulf of Aden. Third, it was a suppression strategy on ‘naturally hostile’ Somali pastoralist. The later was not perceived threat because they had bad experiences with Sayid Abdullah Hassan and bruising battles with Aulihan in Northern Kenya.

Sir Charles Elliot and his cronies slapped the region with the 1902 outlying district ordinance that would isolate the Northerners for the rest of the 20th century. This has essentially turned northern Kenya into a large prison where exit and entrance was by a special pass. The stock and produce ordinance of 1933 led to further insult on the people of Northern Kenya. The ordinances gave British establishment immense powers to arrest and seize property.

After independence:

In addition to extending the colonial policies, the Kenyan government practiced outright discrimination, human right violations and strangled resources to its Northern region. A few of these examples are; the emergency rule, the indemnity act, the pink card, the wagalla massacre, Bulla Kartasi massacre, Merti/isiolo killings, denial of right to birth certificates and the list goes on. These injustices were all well orchestrated and practically designed by the government that is otherwise assumed to protect its people.

Those are the external woes of Northern Kenya. The 20th century closed its doors living dark memories and large scares on the psyche and body of Northern citizens. Despite this history, the people refuse to lurk in their dark memories. Instead, they acquired the will and inspiration to advance and progress. A Nigerian author whose name cannot be recollected aptly stated “We had the best chance to do things right 25 years ago but now is the next best chance”.

Unfortunately, internal archetypical Somali problems remain to impede progress. Negative ethnicity, a terminology cleverly crafted by Koigi Wa Wamwere is a perfect embodiment of Somali internal troubles. A curse as referred to M. Sambul, social cancer, societal venom, ghostly ambience, what ever best describes it, ethnicity holds the Somali society on the shackles. Even amongst the most learned, it has its magical manifestation. Rationally, we can conclude that an effort to exorcise ethnicity from Somali setting is worthless. Solutions can be found in a paradigm shift – a shift from negative ethnicity to positive ethnicity. The question is how do we flip the ethnicity coin from negative to positive?

Another impediment is poor leadership. Leadership that can tower over the internal squabbles steadfastly holding on the driver’s seat of peace and prosperity is NOT a far cry for the Somalis of the Northern Kenya as is for the rest of Somali people. The test is to select leaders on the basis of merit and quality with no absolute regard to ethnic background. This approach will bring the northern region to economic and political maturity at par with the rest of the world. However, seeking leadership will remain a far cry only if the ethnicity coin will fail to flip or shift to the positive paradigm. Other setbacks, we can overcome.