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By Bradley Allf, Features Writer UNC Institute for Global Health & Infectious Diseases
In 1996, Angie Rhodes, DDS, spent her second summer of dental school providing health care and education to children living in an orphanage in Miacatlán, Mexico, as part of a program called the UNC Mexico Project. This summer her lifelong patient Roxie Braxton, now a third year dental student at UNC, went on the same trip.
Rhodes was thrilled when she learned that Braxton was going on the Mexico Project trip. “I knew that she would have an amazing experience and treasure her time there just as I still do,” says Rhodes. “The love and excitement hasn’t changed in 20 years!”
The UNC Mexico Project, which started in 1987, has a long history of service in Miacatlán. The project is a partnership between the UNC School of Dentistry and an international organization called “Nuestros Pequeños Hermanos” (NPH) that provides homes for orphaned and abandoned children in Latin America.
NPH was started back in 1954 by a priest named William Wasson who adopted a child convicted of stealing from his church in Mexico, rather than press charges. Over the course of that year, Wasson ended up adopting 31 more disadvantaged children and the program grew from there. NPH is now a multinational humanitarian organization, which has provided homes for thousands of children.
UNC has sent dental students to the NPH home in Miacatlán since 1987. These students provide dental care and education to hundreds of the children that live and study in the home. The project itself is three weeks long and takes place each summer around August. This year five students attended, as well as Carolina Vera Resendiz, DDS, Clinical Assistant Professor in the UNC School of Dentistry’s Department of Prosthodontics and an advisor for the Project.
The students assist the community’s only local dentist Leticia Gomez, DDS, with fillings, sealants and cleanings for the kids as well as dental education. Braxton says one of her favorite parts of the trip was teaching some of the younger kids about oral hygiene.
“We were showing them how to floss; they were only 3 so it was hard for them to wrap the string around their fingers,” says Braxton. “But they were just so interactive in wanting to participate, and that connection you make with the kids—it’s so gratifying.”
All the dental students have clinical experience, but for many of them the trip provided a bigger exposure to dental pediatrics. This can bring with it certain challenges. “Sometimes you have to be a bit more persuasive,” says Sarah Park, another student who went on the trip.
Park had a moderate amount of Spanish training going into the trip, which she says was helpful. But fortunately there were also bilingual volunteers on hand to help translate for the students without a strong Spanish background.
In addition to the two weeks of living and working at NPH, the students had a “culture week,” where they were able to explore Mexico City, tour the Chapultepec Castle and expand their palates with food like toasted grasshopper. They were also shown around the National Autonomous University of Mexico’s state-of-the-art dental facilities. There, they had the opportunity to hear from dentists working in the region and get a broader perspective on how dental care is provided in a country with such a wide spectrum of healthcare access.
Park says her experience in Mexico certainly impacted how she thinks about practicing dentistry. “When you’re a provider you have the power to improve someone’s health and educate them and help them help themselves. [The trip] was a good reminder of that,” she says. Park’s experience also solidified her commitment to humanitarian outreach, and she wants to stay involved in the Project going forward.
Braxton says she thought the impact of the trip really hit home during the meals with the kids. “They really warm your heart and remind you why you’re in the field,” she says. Braxton also hopes to stay involved with UNC Mexico Project in the future.
“And who knows, maybe one day down the road one of my patients will go on the UNC Mexico Project service trip!” she says.
By Elizabeth Poindexter, Communications Director of UNC’s Department of Allied Health Sciences
Nikhil Tomar, a doctoral student in occupational science in the Department of Allied Health Sciences, has worked for years to understand and reduce stigma surrounding mental health concerns around UNC’s campus, the Chapel Hill community and the world.
Through collaborations with the UNC School of Social Work, he has also conducted research at the intersection of mental illness and the criminal justice system in the state of North Carolina. This past summer, he participated in a Movement for Global Mental Health research project, being conducted via a collaboration between Public Health Foundation of India and King’s College London’s India Institute. As part of his dissertation, he hopes to expand upon research gathered during the summer and understand stigma toward mental illness in India.
Tomar, a Royster Fellow at UNC’s Graduate School, became interested in mental health after realizing the impact of negative and ill-informed perceptions about mental health on life experiences of individuals with mental illness. Tomar connected mental health issues with his studies in occupational science, which studies the science of everyday living, including productive physical and social activity.
“Removing stigma from a community can help people not feel embarrassed when accessing services or being diagnosed, which can have a significant impact on their future mental health. Research evidence suggests that stigma can have a more detrimental effect on individuals with mental illness than the symptomatology of the illness itself,” Tomar said.
Starting Local with Club Nova
Research indicates that mortality rates are much higher among people with a mental illness when compared to the population at large. Additionally, people living with mental illness face an increased risk of social discrimination and chronic physical medical conditions.
Club Nova is trying to reduce these numbers. Since the spring of 2015, Tomar has volunteered with Carrboro-based nonprofit. Club Nova uses an international psychiatric recovery model called the clubhouse model, where people with mental illness work together to sustain the clubhouse.
“Nikhil came in to a brand new setting and was completely open. He went out of his way to build authentic relationships with members and staff and he blended right in with our way of working and was eager to absorb everything around him in a very positive way,” said Club Nova Executive Director Karen Kincaid Dunn. “Nikhil is committed to approaching the world from a place of non-judgment and it shows in his relationships with everyone he comes across. If we had a world of Nikhil’s, we would be truly stigma-free.”
On any given day, clubhouse members work in their area of interest or expertise to maintain the clubhouse – such as cooking daily meals, gardening, managing Club Nova’s thrift store, creating budgets and paying bills. The Clubhouse also helps members return to work or school, and live the life of their choice in the community.
“It has been an enriching experience for my own thinking about stigma,” Tomar said. “I thought to myself, ‘there is a need for more volunteers here. How can I, given my background as a student and on campus, assist them?’”
Specifically, Tomar, through a summer fellowship, assisted in streamlining the volunteer process at and strengthened ties between University resources and the Clubhouse.
“Nikhil came in at first with only the intention to observe and learn. He is tremendously devoted to learning a system before he attempts to work with it, which is rare. He was then able to identify a need—more structure around our volunteer program—and jumped right in,” said Kimberly Anderson, Club Nova Public Relations & Development Coordinator. “We now have many more volunteers working with us doing meaningful things and it enriches our program on all sides.”
As Club Nova enters a capital campaign, they hope to expand into a new facility to support the estimated 8,000 people in Orange County who live with serious mental illness.
Tackling Stigma on Campus
Tomar is also co-founder of Stigma Free Carolina, a campus organization aimed at reducing stigma toward mental health concerns and treatment on college campus. According to Stigma Free Carolina, more than 19 percent of UNC students felt receiving mental health treatment was a sign of personal failure. More than half of students surveyed agreed that most people would think less of someone who has received mental health treatment. Stigma Free Carolina also connects students to resources, both on and off campus, for those who need them.
While Tomar will likely finish his PhD work in 2017 or 2018, he hopes that other students will be motivated to volunteer at Stigma Free Carolina and at Club Nova.
“Students, from any walk of life, can learn so much by being at the clubhouse,” he said.
By Jamie Williams, Editor of UNC School of Medicine’s Vital Signs
By formal training, Anthony Charles, MD, MPH, is a trauma surgeon. By experience, he’s a diplomat.
Charles leads the Malawian Surgical Initiative, a partnership between the UNC Department of Surgery, Kamuzu Central Hospital in Lilongwe, Malawi, and the Malawi College of Medicine in Blantyre, Malawi.
On Dec. 5, 2015, the first class of surgeons graduated from the five-year training program. And on that day, the number of trained surgeons in a country of 15 million people grew by six – to a total of 20. The goal is that they stay in their home country to serve their fellow citizens.
Leading the initiative requires Charles – also an active trauma surgeon – to navigate the challenges that come from coordinating a program from another continent and closely collaborating with a foreign government.
“This program is entirely built on trust, which has contributed to its success, but also makes it fragile,” Charles said. “We’ve done a lot of good, which I think has bought us some grace and goodwill, but all it takes is one person going down there and saying the wrong thing, and it can just come crashing down.”
For eight years now, Charles has kept that from happening.
“He is the glue,” said Bruce Cairns, MD, the John Stackhouse Distinguished Professor of Surgery at the UNC School of Medicine and director of North Carolina Jaycee Burn Center. “The reason the program is successful is because of his efforts. In Malawi, our involvement is a socio-political issue as much as a health care issue. Each linkage we make there has to be through an individual; a committee won’t work. And what we have with Anthony is someone who has the unique capacity to connect all of the dots.”
An International Perspective
Charles was born in Germany to Nigerian parents, who met while his father was studying medicine in Heidelberg and his mother working as a nurse at a military base. When Charles was 3, the family moved back to Nigeria, where his father began a successful career as a pediatrician, educator and administrator.
His father became medical director of Guinness’ philanthropic health outreach efforts in Nigeria. Guinness Beer is a national favorite in Nigeria. In fact, the first Guinness brewery outside of the United Kingdom was actually built in Nigeria’s largest city – Lagos. One of the perks of working with the beer giant was the opportunity for Charles’ father to send his children to boarding school in Ireland.
So, from the ages of 9 through 18, Charles lived and studied in Ireland, before returning to Nigeria to attend medical school at the University of Lagos. Residency training took him to London where he met his wife, a native of Los Angeles. When her time was up in London, Charles went with her to LA, completing his general surgery residency at Martin Luther King Medical Center, an inner-city hospital with an abundance of trauma cases.
After a trauma and critical care fellowship at the University of Michigan, Charles arrived at UNC in 2006. Central to his progress in academic medicine, he said was the decision to pursue his master’s degree at UNC Gillings School of Global Public Health.
Through his public health studies, Charles became aware of the infectious diseases work UNC was leading in Malawi. He traveled to Africa to see it for himself and learn how he might become involved.
UNC Project-Malawi was founded in 1990 as a partnership with the Malawi Ministry of Health with a focus on providing technical assistance in the design of clinical management guidelines aimed at stemming the country’s rate of HIV. By the time Charles visited in 2007, UNC’s presence there had grown to hundreds of people including physicians and researchers, medical specialists, medical and clinical officers, nurses, laboratory and pharmacy technicians, data officers, administrators, and logistical support staff.
Through the great successes of UNC Project-Malawi, Malawians with HIV and other infectious diseases had access to effective treatments. But access to trauma care was much more limited.
“In Malawi, injuries account for more deaths than tuberculosis, AIDS, and malaria combined,” Charles said.
However, in a country of 15 million people, there were only 14 trained surgeons. Charles said 10 percent of trauma patients were dying in the hospital and untold others were seeing their future economic prospects disappear because of the burdens of their medical conditions.
“Say you’re a carpenter and you ride your bike to work; if you break your ankle you can’t work and your family’s income is gone,” Charles said. “If we can fix the ankle, then that person is back to work, and we help that family and the country as a whole. At the time, Malawi didn’t have the capacity to help these people.”
Charles saw an opportunity to expand upon the solid foundation of UNC’s infectious diseases work with a surgical training program. But, from the start, he was adamant on training Malawian surgeons in their home country.
“When we set out to do this, we never had the intention of bringing American-style care to Malawi – that would be impossible. But, what we wanted to do was foster Malawian care provided by Malawian surgeons,” Charles said.
Convincing the Government
In order to get the program up and running, Charles set out to convince the Malawian government of both its economic and social value. Traditionally, the government had paid for surgical trainees to go to South Africa or Europe to receive their training. Some returned home, many did not.
“There are more Malawian surgeons in Glasgow than in Malawi,” Charles said.
The government was spending on average more than $60,000 per year funding training of their surgeons in other countries, said Charles. If those surgeons never returned to Malawi to practice, none of that investment was recouped.
It costs $15,000 per year to train a surgeon through the Malawian Surgical Initiative.
Funded through public, private and corporate philanthropy, the Initiative covers half of the expenses for students, including a stipend, books and other learning materials, and funding for travel to academic conferences. The Malawian government covers the rest.
The curriculum was developed by Charles and others at UNC and is taught by visiting faculty and residents from UNC in collaboration with faculty from Norway’s University of Bergen. The program is fully accredited by the College of Surgeons of Eastern, Central and Southern Africa.
He’s also honed his diplomatic touch.
“One of the skills that I’ve acquired over the years is the ability to convince the government officials to do what will be most advantageous for the program without making it seem like I am making demands,” Charles said. “The fact that I am an African is not lost on them, but I’m still a foreigner and there is still some skepticism, so I just have to ensure what I’m suggesting will work and they will look good in the end.”
The fluid nature of the nation’s civil service means Charles always has to plan for contingencies. What if a new health minister doesn’t like the program? What if he favors the old model of just sending surgeons abroad for training rather than supporting the necessary infrastructure required for in-country training? What if strife within the government threatens the funding?
“There’s an African saying: ‘When two elephants fight, it is the grass that suffers,’ and so my job has always been to make sure that the program doesn’t suffer. I always have to be thinking ahead,” Charles said.
It takes more than just a surgeon to perform a surgical procedure, and the Malawian Surgical Initiative provides training and education for Malawians interested in a wide range of health careers. From the start, they have offered nursing training. In addition, there are plans underway to introduce a partnership through UNC’s Department of Anesthesiology to provide Malawians training in that discipline as well.
“We recognized early on that just training surgeons wouldn’t be enough,” Charles said. “We have very active educational programs for non-physicians who are interested in surgical care and a large part of that is assisting with procedures, but we also are able to make sure they have the resources to go into the community and provide some education to their communities.”
The hospital can then be an economic driver, providing good, sustainable jobs to people while also helping improve the health of the nation.
Charles also emphasized the training of women. Women, he said, have always dominated the nursing roles. But, they are also training female surgeons. In Malawi, much like the United States, surgeons have always been overwhelmingly male. But Charles said the training of more female surgeons will help foster the sustainability of the program.
“We’ve seen in Malawi that men are more likely to take the increased training and salary potential and move elsewhere,” Charles said. “In our experience, the women have stronger community roots, making them much more likely to stay.”
From the start, the Malawian Surgical Initiative has provided training opportunities for UNC’s medical students and residents. Charles said the experience in Malawi can “fundamentally change” the world outlook of students who participate.
“Each time I take a new medical student it blows their mind that amidst such immense poverty there is such great pride,” Charles said. “Going down there, realizing you aren’t going to save the world through your mere presence has a way of changing the way you think about solutions, it’s incredible.”
Humility is the key.
“The one lesson I try to emphasize the most to our students is simple: respect everyone,” Charles said. “No matter what you’re used to and how much of a hurry you may be in to get things done, we will do it at the Malawian’s pace. You really have to take a step back and realize whose country you are in, and whose people you are helping to treat.”
What the students learn there is how to creatively solve problems in an environment that does not have the unlimited resources of the operating rooms that they are used to. They learn to work with teams and to consider the true efficacy of the procedures and tests that they order for patients.
By working alongside the Malawian physicians and treating Malawian patients, Charles said UNC’s students gain a perspective that will be beneficial throughout their careers.
“In this immersive experience, the students are seeing people that don’t look like them, don’t speak their language and are remarkably less fortunate. The ability to thrive in that environment is incredibly beneficial,” Charles said. “Those lessons are pertinent here in Chapel Hill as we see patients from all different backgrounds, and, as a public hospital, provide care for them all.”
“Surgery is intensely personal; and the reality that each individual matters equally is inescapable in an operating room,” Cairns said.
Caring for Burns
The North Carolina Jaycee Burn Center has been a partner in the Malawian Surgical Initiative from the beginning, and in 2014, that partnership culminated in the formal establishment of a dedicated burn unit at Kamuzu Central Hospital.
“Burn is a disease of poverty,” Charles said. “We know that 90 percent of the world’s burns occur in undeveloped countries where much of the cooking is done on open flame, or a family’s economic circumstance dictates that they don’t have the resources for sufficient childcare and you’ve got children running around unsupervised. Seventy percent of the burn victims in Malawi are under the age of 10.”
The burn unit in Malawi is funded largely through a partnership with Johnson & Johnson. Charles said the company was interested by the model they used to train nurses, and offered further training for Malawian nurses at a Johnson & Johnson facility in Johannesburg.
Charles said it has been an incredible partnership.
“It’s been gratifying that they have shown such support of our work, and we’ve seen that their philanthropy is completely divorced from their business interests. They are there to do good, not sell products,” Charles said.
The Malawian resident physicians provide care to patients, as do visiting physicians and residents from UNC. UNC surgery resident, Joanna Grudziak, MD, is currently in Malawi for one year to work in the unit.
In order to properly treat burns, nutrition is key. So, Charles is helping develop a nutrition program. When a person suffers a burn, Charles said, the body uses up a great deal of calories in its attempts to heal. The patient’s diet must be modified and closely monitored.
“We believe that the burn unit is the ideal environment for a nutrition program to achieve optimal results and reduce burn mortality as 60 percent of our patients are malnourished,” Charles said.
Now that the first class of trainees has graduated, Charles has focused on ensuring that they are fully prepared for their future. He worries that many will be thrust into administrative roles for which they are not ready. He’s working with the government to make sure that they receive leadership training. He is also working with the government on solutions for providing adequate compensation for their work.
“Botswana is only a short flight away, and these surgeons could easily double or triple their salaries there, which we have to fix,” Charles said.
There is still work to be done to improve the program, but one measure of success already achieved is the drastic reduction of surgical mortality at Kamuzu Central Hospital.
“We have more Malawian doctors and more nurses now. Increasing health care personnel saves lives and we have seen great success there,” Charles said.
The ultimate success, though, will come when Charles’ regular trips to Malawi cease.
“The crowning achievement will be when we aren’t there anymore and the training program is running itself with Malawians leading it,” Charles said. “We are getting there, and I hope that happens in the next decade.”
Until then, Charles will remain as a teacher, a leader, a steady hand, and a voice of reason. He’ll continue to build deliberately step-by-step.
“If you build the system around trauma, you can deliver the whole of medicine, and that’s where we’re heading,” Charles said. “I truly believe the greatest gift you can give any society is the capacity to care for its own people.”
Angela Vick-Lewis never thought she was at risk for contracting HIV. Free HIV testing was offered during her church’s New Year’s Eve party in 2006, and she thought nothing of taking the quick test.
“My son and I both took the test and we both came back positive,” said the 55-year-old Durham resident. “I couldn’t believe it. We were referred for further testing. I prayed he would be negative and that only I would be positive.”
Vick-Lewis’ prayers were answered. Additional tests revealed a false positive result for her teenage son, but another positive result for her. She has been living with HIV for nine years and has used the diagnosis as a springboard to join research studies and educate the community. She will be one of three women living with HIV on a patient panel discussing access to HIV care during the University of North Carolina at Chapel Hill’s 18th World AIDS Day Symposium on Thursday, Dec. 1, from 8:30 a.m. to 3 p.m. in room 1131 of the Bioinformatics Building on campus. Click here to register and here for a list of presenters.
“Educating the community is so important because people have many misconceptions about HIV,” said Vick-Lewis, who has been a part of the Women’s Interagency HIV Study (WIHS) at UNC for the past three years. “I had a friend ask me if you can get HIV from sharing a cigarette with someone. I am glad I disclosed my status to him and was able to be a resource for him to answer these questions.”
In the United States, 382 out of every 100,000 Americans are living with HIV, according to the Centers for Disease Control and Prevention (CDC). In North Carolina, 327 out of every 100,000 residents are living with HIV. The numbers vary by where people live in the state. In Durham County, this number doubles with 656 people out of every 100,000 living with the virus. Educating the Durham community about HIV has been the mission of Allison Mathews, PhD, founder of 2Beat HIV and a researcher within the UNC Institute of Global Health & Infectious Diseases (IGHID).
“We try to empower people to know that they are the experts on what they need in their communities,” Mathews said. “If we want to find a cure, we need ideas and solutions from community members just as much as we need scientific advances in HIV research.”
World AIDS Day, which began in 1988, is an opportunity for the global community to unite in the fight against HIV, increase international awareness, combat stigma and improve education. This year’s symposium at Carolina features presentations by UNC-Chapel Hill faculty members as well as researchers from the North Carolina Division of Public Health, the University of Alabama and the University of Arizona.
In addition to the patient panel about access to care, targeting the reservoirs in the body where HIV hides and the epidemiology of the virus in North Carolina will be discussed. The symposium is organized by the UNC Center for AIDS Research (CFAR) and the UNC IGHID.
The Society for Healthcare Epidemiology of America, or SHEA, has elected David Weber, MD, MPH, Professor of Medicine, Pediatrics and Epidemiology at the University of North Carolina Chapel Hill to its Board.
Since its founding in 1980, SHEA has advocated for safe healthcare by promoting the prevention of healthcare-associated infections and antibiotic resistance, and by advancing the fields of healthcare epidemiology and antibiotic stewardship.
“I am both honored and excited to be joining the SHEA Board,” said Weber. “SHEA serves a critical role in bringing professionals interested in infection prevention and antibiotic stewardship together to improve the health of patients via training, research and public advocacy.”
Election to a board with this mission is in line with Weber’s life’s work. He serves as Medical Director of UNC Hospitals’ Departments of Hospital Epidemiology and Occupational Health Service, and as Associate Chief Medical Officer of UNC Health Care. These roles charge him with keeping staff healthy and keeping patients from developing an infection while they are in UNC hospitals’ care. He also serves as an Associate Editor of Infection Control and Hospital Epidemiology.
Under his guidance, healthcare-acquired infections at UNC hospitals have been reduced by 70-90 percent over the past decade.
“We’ve done this in a variety of ways,” Weber said. “Hand washing is key and I’m proud to say we have more than 90 percent compliance among clinicians and staff.”
Chen Zhongwei, the retired Director of Oral Health at Guangdong General Hospital in China, was attacked this spring and killed by a patient whom he treated more than two decades earlier. The former patient, who claimed that he should receive compensation for a discolored tooth, followed the dentist home where he stabbed him over 30 times. This tragic story is the latest of a number of episodes in which Chinese patients kill health professionals.
Responding to the endemic mistrust between patients and physicians in China, Joseph D. Tucker, M.D., Ph.D., assistant professor in the University of North Carolina at Chapel Hill School of Medicine and director of UNC Project-China, organized an initiative to rebuild patient-physician trust. The research team used in-depth interviews and policy analysis to better understand patient-physician trust in the Chinese context, speaking with patients, physicians, and health administrators. The team found the need for reform of several areas, including health systems, legal, ethical, and medical education. For example, requiring medical humanities training within medical education could help increase capacity for physicians to more effectively communicate with their patients and begin to restore trust. The results and suggested action items to rebuild trust were published in The Lancet.
“Trust is not a simple construct and rebuilding it will take time, energy, and resources,” Tucker said. “But as we noted in The Lancet, the lingering mistrust in China should be seen as opportunity to do better. This is not about pointing fingers, but rather about figuring out how to move forward.”
In addition to The Lancet publication, his research laid the foundation for a Shanghai conference on patient-physician trust. Tucker along with colleagues from Harvard University, Stanford University and the University of Otago in New Zealand organized the two-day conference at the Harvard Center Shanghai to develop actionable recommendations for rebuilding patient-physician trust in China. The team included leading public health officials, philosophers, lawyers, medical doctors, private sector leaders, and medical ethicists. This multi-disciplinary group created a list of recommendations to help rebuild patient-physician trust in China.
As part of the patient-physician trust initiative, the next step involves using a participatory campaign to crowdsource messaging to rebuild patient-physician trust. The team is also working on a thematic issue on rebuilding patient-physician trust with a major international bioethics journal.
Faculty from the UNC School of Medicine and Eshelman School of Pharmacy pledge to continue keeping North Carolinians living with HIV healthy in a new video produced by the UNC Center for AIDS Research or CFAR.
“We want to make sure everyone living with HIV feels like a worthwhile citizen of North Carolina,” says Claire Farel, MD, MPH, Medical Director of UNC’s Infectious Diseases Clinic and Clinical Assistant Professor of Medicine in the Division of Infectious Diseases at the UNC School of Medicine.
This means improving access to clinical care and treatment. David Rosen, MD, PhD, MSPH, Research Assistant Professor of Medicine in the Division of Infectious Diseases, talks about how individual and public health are interconnected.
“We want people living with HIV as healthy as possible not only for their own health, but because it also reduces the likelihood of transmission to others,” Rosen says.
In addition to clinical care, the group reflects on UNC’s commitment to researching better treatment and prevention options.
“Is there a drug out there that could prevent HIV and be taken only once a week rather than every single day?” asks MacKenzie Cottrell, PharmD, Research Assistant Professor in the Division of Pharmacotherapy and Experimental Therapeutics in the UNC Eshelman School of Pharmacy.
The purpose of the UNC CFAR is to provide infrastructure to support investigation of the HIV/AIDS epidemic using clinical research, behavioral research, research into HIV biology and pathogenesis at the molecular level, and educational outreach. A special thanks to Bruce Curran and Jeff Raskin for producing this video.