COVID-19 hospitalisation outcomes in Africa, and Canadian health equity in a pandemic

Bruce Biccard and Dean Gopalan discuss their work looking at the poor outcomes for COVID-19 hospital patients across Africa, the first study of its kind, and Kwame McKenzie talks about how Canada has dealt with COVID-19 and what lessons have been learned about health equity.

Bruce and Dean's study on COVID-19 outcomes for African hospital patients can be read at:
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00441-4/fulltext

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Transcript

This transcript was automatically generated using speech recognition technology and may differ from the original audio. In citing or otherwise referring to the contents of this podcast, please ensure that you are quoting the recorded audio rather than this transcript.

Jessamy: Hello and welcome to The Lancet Voice. I'm Jessamy Baganal. 

Gavin: And I'm Gavin Cleaver. Coming up later on the podcast, Jessamy and I speak with Professor Kwame McKenzie, who's the CEO of the Wellesley Institute in Canada, about the Canadian COVID 19 response, lessons learned from the pandemic, and how to ensure health equity after COVID 19.

First, a new study in The Lancet found that mortality rates among adults in Africa admitted to critical care were considerably higher than in other regions. A lack of intensive care resources, underuse of available resources, and poor access were some of the reasons found. It's the first COVID outcomes data reported from Africa, and it included hospitals in ten countries.

Jessamy and I spoke to the two lead authors to find out more. So Jessamy and I are very pleased to be joined today by Professor Bruce Bickart, who's an anaesthesiologist and professor at the Groteshire Hospital and University of Cape Town. I'm Professor Dean Gopalan, who is Head of Department in Anesthesiology and Critical Care at the Nelson R.

Mandela School of Medicine at University of KwaZulu Natal. Bruce, Dean, thank you so much for joining Jessamy and I today. You're two of the lead authors on a new paper published this week in The Lancet, which looks at hospitalisation outcomes for COVID 19 patients across different countries in Africa.

Perhaps we could start by you telling us a little bit about how the study was developed, how it was brought together, what the story is behind it. What were some of the challenges of this study? And perhaps Bruce, you would like to go first. 

Bruce: Thank you, Gavin. What we were concerned about was that we knew our resources were limited.

We had seen how devastating the pandemic had been in Wuhan and then subsequently in Italy. And we were trying to see, is there something Or could we find evidence, which which might help us drive management. And so with the help and support of the Critical Care Society of Southern Africa, who helped fund this we put out basically a call to our network.

Would you participate in trying to generate data quickly so we can identify factors associated either with mortality or survival that we could basically provide some evidence for managing the. the pandemic for severity of patients in Africa. 

Gavin: Ian, what were some of the challenging aspects of putting this piece of work together?

Dean: Thanks, Gavin. Maybe I can pick up on that. So research in Africa, of course, presents numerous challenges. In a system where there's, where we're greatly under resourced as an environment, especially during a pandemic where all hands on deck are needed. It's difficult, really, to be able to recruit eligible patients across all our sites.

So that in itself presents a major challenge. You will struggle to find dedicated research. Personnel across the continent. And, that presents a big problem, especially with big projects, such as one we had in mind. Again, difficulty in fulfilling ethics and regulatory requirements. These are very variable across the continent and processes can take anything from weeks to months, depending on how quickly the wheels turn in the different.

countries across Africa. And lastly, of course funding as a general element for research across Africa presents much challenges. So these were some of the issues that we were faced with in, in putting this initiative together. 

Gavin: Moving on to the findings from your work, one really striking finding was the one in two patients sadly died without receiving oxygen.

Could you? Walk us through some of what for you were the key findings and maybe tell us a little bit about the explanation behind them and some of the background of that as well. 

Bruce: Certainly, Kevin. Yes, it was really striking that one in two patients died without receiving oxygen and it's difficult to understand why that happened.

But I think more importantly, was that only one in two patients who needed high care or critical care was actually admitted. So there's a whole cohort of patients that we're not quite sure what happened to them. And we suspect that their outcomes were associated with very high mortality. But I think the first thing it refers to is that how little critical care beds there are, that only one in two could be admitted.

The other findings were that mortality in Africa is significantly higher than in any other region in the world. That there's excess mortality of, in the region of 11 up to possibly 23 extra deaths. per 100 admissions to critical care. And that's obviously very distressing. What we saw also were that the interventions often to the patients were much lower than you would expect for the severity of illness.

And we estimated. That maybe it's in the region of 7 to 14 times lower for things like dialysis or proning or ECMO, for example. So those are also all point to the resource limitations of the environment, which ultimately must be impacting on the mortality with the high mortality we saw. And then we identified factors associated with mortality, obviously increasing age, diabetes of a disease.

Kidney disease, but obviously the big one, HIV and AIDS, which hadn't been documented before. So we weren't actually sure of the impact of that. Fortunately, we confirmed that steroids offered benefit in this environment and possibly we may have helped in identifying that patients who had a severe organ dysfunction at admission had terrible outcomes.

So very high quick surface score may in the future be a triage tool. 

Kwame: Yeah, thanks so much. It's a great study. I found it really interesting and I think it's very informative. Obviously a lot of the Patients are from South Africa and Egypt, a fairly higher income countries in regard to the rest of Africa.

Do you think they're still pretty representative, these findings of the continent? 

Dean: So that's an important point and we raise this as a concern in the paper. What we had hoped to get when we embarked on this was as broad a representation across the African continent as possible.

And this perioperative research group across Africa, this network that we'd had, we'd invited 40 countries and 26 leaders agreed, but we only ended up with 10. So yes, I think you're correct that there are concerns. in, in terms of the, uh, South Africa and Egypt being representative of the African continent as a whole.

We know they are better resourced when compared with many other countries across the continent. The other thing to think about in terms of representation across the the continent is the levels of care because most of our centers were actually tertiary healthcare facilities. And this, of course, raises concerns with not having appropriate representation across all levels of healthcare facilities because, of course, you can imagine that a patient with COVID 19 is going to be managed at all levels of care.

But I think the important thing to consider from what I've just said Is the following lower resource countries than South Africa and Egypt. These are more likely to have challenges when it comes to resources. So the expectation might be. That the outcomes in these places might be potentially worse than what we demonstrated.

And the same might well hold true if we look at the lower level facilities than tertiary care centers where resources and expertise themselves are challenges and those centers themselves may also have worse outcomes than what we demonstrated. 

Kwame: Yeah, that's an interesting way of looking at it, isn't it?

So from a sort of policy point of view that actually this is probably very much the tip of the iceberg and there, there may be much more. Problems going on elsewhere. But I suppose following on from that this finding that some of the resources were underutilized and obviously your study was not designed to understand why those things were underutilized but from a sort of interest point of view and, it's speculation, but what are some of the reasons that you think that these resources are not being utilized properly?

Bruce: I think they're fundamentally two problems here. The first is that we definitely documented that the availability of resources is limited. So the type of resources you need to treat critically ill patients are limited in Africa and that's not unsurprising. I think the severity of the limitation was extremely surprising.

The fact that you can't provide oximetry, pulse oximetry to every critical care patient. I think most people would consider that an absolute minimum. And about one out of ten sites couldn't do that. And so that's a real concern. But I think The, what really impacts then on patient outcome is that when you've got limited resources to provide therapies, they get used on patients, which means that other patients in the unit don't have access to the therapy when it's needed, even though it is available in the unit.

And I think that's where you see this double impact of having low resources, meaning that you can't provide it to other patients at the same time. And I think that's how we. Ended up with that estimation of the severe limitation of resources is because once something like dialysis is in use I read that its ability to be used by the patients is obviously impossible.

In the linked commentary to our paper there was a very interesting point made and it was about the fact that there are resources also in Africa, which are available, but unfortunately they either non functional or they're poorly maintained. And so that's a whole nother aspect. So just counting, merely counting resources as well, probably overestimates what's available.

I think a lot of reasons why the resources are actually so limited. 

Gavin: I have the stats from the comment in front of me. Dr. Bruce Karenga, who wrote the comment, said that 40 percent of medical equipment in Africa was out of service, and that 70 90 percent donated equipment was never operationalized, which is really an incredible stat when you think about it.

Bruce: Given on that point, I think one often sees of pictures of operating theaters or intensive cares in Africa, where there's these beautiful donated machines, which have become basically tables for coffee cups and teacups because they're incompatible in the environment. Yes, that's a big problem, especially in, on the donor front that needs to be addressed.

That donations are appropriate to the environment in which it's supposed to be working. 

Kwame: Just going back to another kind of interesting finding about this difference between men and women and outcomes and it was an unexpected finding that men didn't have worse outcomes than women in your study.

Obviously, again, we don't know the reasons why, but can we just flesh out what some of the reasons 

Bruce: might be? The finding that Men and women had the same outcomes was surprising to us, especially because the early data and the data had been pouring in at the beginning of the pandemic and consistently you saw the signal that men were doing worse than women.

And it's obviously we don't know the reason, but I think there are a few possibilities. The one is, I think there may be. A bias in accessing care. In other words, men are more likely to get care, and it could be for a number of reasons. It could be one where the hospitals are placed. In other words, we had a very high urban environment for our hospitals and a lot of men working in a urban environment that could have selected out men for admission.

Similarly, women are often involved. in looking after households in Africa. And that's another reason why they may not have received care that they should have received. The second thing is once in critical care, one wonders if there's a bias in receiving care. In other words, are men actually afforded more care in Africa when they're severely ill than women?

We, we don't know what the answers to these are, but they're certainly very important questions. And then the final thing is maybe there is actually no difference in sex outcomes for severely COVID infected patients. But I suppose any time we'll tell. With accumulation of, more granular data like this.

Kwame: Yeah, agreed. Just bringing it back to where we are now, in terms of vaccine distribution, it's great that we've got this study, we've got this data, this sort of snapshot of mortality and outcomes. What does it mean from your point of view for the urgency about vaccine distribution?

We've seen how quickly things can change in places like India. Looking forward what are the implications of this study? 

Dean: I'll pick up on that. I think just to be clear, we didn't explore vaccination as part of our study as vaccines were still being developed when we commenced with the study. So we can't comment on that directly related to the study, but what we can comment on and what the study does raise as an important consideration in any vaccine program plan.

is the excess mortality that we demonstrated. So we clearly showed that mortality is associated with the severity of organ dysfunction and the extent of organ support that's needed at critical care admission. What we do know is that vaccines help by reducing the number of severe cases. It's very self evident from that, that if we want to have a major impact on the high mortality of COVID 19 in Africa, there's no question that there needs to be an urgent, extensive vaccination rollout across the continent.

As you indicated, we're seeing what's happening in places like India. And Africa as a continent remains a big threat to world health from that point of view if it's not adequately and appropriately addressed. Certainly in this case. By by timeless, effective rollout of vaccine programs across the continent.

Bruce: I wholeheartedly endorse every word Dean has just said. Thank you, Dean. 

Gavin: On such a strong message, it seems like a pretty good place to end. Bruce, Dean, thank you both so Jessamy today to talk about your study. Thanks, 

Bruce: Gavin. Thanks very much.

Jessamy: Wonderful and important to hear from Bruce and Dean there on African COVID outcomes. And as they said, it's a situation that needs close attention. You can read their article for free on thelancet. com. Turning to Canada now, Professor Kwame McKenzie, CEO of the Wesley Institute, is a prominent authority on health equity.

Gavin and I spoke with him to find out a little bit more about his career journey from Ealing in West London to CEO of a major think tank in Ontario. We hear more about Canada's COVID 19 response and find out what he thinks is the future of health equity. 

Gavin: Professor Kwame McKenzie, it's a pleasure to have you joining Jessamy and I today on The Lancet Voice.

We're going to talk a little bit, of course, about Canada's COVID response, about health equity, which you have a particular interest in. But I thought perhaps we could start by talking a little bit about your career path, which is unusual. Tell us a little bit about it how you got started and how you got to where you are today, which is CEO of the Wellesley Institute Think Tank in Ontario.

Kwame: Oh my word, my career journey. I'm a black British second generation immigrant growing up in a low income area who got to university because the state system paid for university when I was young in the UK and went to med school. Very simple, my reason for going to med school it was that I didn't have a huge amount of imagination and I thought it was going to be a way of making sure somebody who was pretty good at sciences could afford themselves a decent living.

Didn't grow up rich and saw parents worried about money and never wanted to have to worry about money. Got to university and realized very quickly that one of these things was not like the other. And , I wasn't really, I didn't really fit in at university and I think probably my experience at university started me thinking a bit about social justice and, that was really it.

I became a a doctor ended up in psychiatry by one way or the other. And ended up in psychiatric research. And so I got into trying to develop more equitable services. And then, the more you try and work out how to create more equitable services, the more you end up in policy because you know The way of decreasing an incident is to try to decrease impacts of the cause of the things that are pushing the causation.

And so if you've got poverty, if you've got racial discrimination, if you've got low rates of social capital, if you've got differential access to health services. And if you've got poor housing or increased urbanization you feel like you have to do something about that. And so after all of that, I've ended up a clinician who does research.

and does social policy work, and that social policy work is on the social determinants of health, which is wider than just the sort of normal clinical lens. But in my really weird way of looking at the world, All makes sense. Yeah, that all makes sense. You can, you should be able to do a bit of this, a bit of that, a bit of the other.

Why would you put all your eggs in one basket when it's possible to have more than one basket? So that, that's where I am. So I've been a human rights commissioner. I've given advice to health ministers, housing ministers basic income study for Ontario. And at the same time I do schizophrenia research different ethnicity type researches.

And for the last year. I've been doing COVID stuff and now I'm into vaccines and, so it's crazy. And I've been very lucky to have lots of opportunities often because people have believed in me. Usually because I've been working with really great teams. And so loads of people have been spending a lot of time making me look good.

And giving me opportunities to make a difference, but, usually I'm making a small difference in a team and trying to leverage change. 

Jessamy: Thanks. That makes a lot of sense. And I it's a great journey and that you followed your interests and your passions. It's wonderful. I wonder whether you might be able to tell us a bit about your reflections because you're based in Canada about the Canadian response to COVID 19 thus far and how you think things would be managed and how you think things are going.

Kwame: I think that it's difficult to talk about a Canadian response because of the complex nature of pandemic responses in Canada. There is the federal government, the Canadian government, who have strategies and policies, have money, are not linked to the provincial. Health response. So the provincial health response is run by the 10 provinces and then the three territories and that is where most of the action happens and they have had very variable responses.

So some of them have had in wave one, saw almost no COVID, right? If you go down to Newfoundland whereas others like Quebec. And Ontario saw quite a lot of COVID and had worse responses in BC, which British Columbia, which saw a lot of COVID, but was much better at dealing with long term care, and so had much lower death rate.

When you look overall at Canada, and you look at Canada as, a high income country, Canada's done really well. reasonably well as a high income country with regards to death rates from COVID. But when you look inside Canada, a lot of the COVID is driven by just two provinces, Quebec and Ontario, with BC some ways behind for the first wave.

And now we're into the second wave, we're seeing Alberta. Increasing its rates as well. So long winded way of saying federal government's tried to do its bit mainly with guidance and then also with income supports Which have made a very big difference and the provinces have had variable responses, with some being very good at decreasing deaths by their work in long term care, and others not so much.

Now, I do a lot of work in Ontario. Ontario is about 13 to 14 million people and its response has been very variable. And especially with regards to low income and racialized people, the response has been pretty poor and with the indigenous populations. It's very difficult. One way of thinking about Ontario's response is to consider the Titanic.

And you'll probably know if you're a epidemiologist that on the Titanic 1, 500 out of 2, 000 people died. But your risk of dying was completely related to your gender, your age, and the class of the ticket that you got. Actually, if you're a woman In first class, you had 97 percent chance of surviving the sinking of the Titanic.

If you were a child in first class or second class, you had a 95 percent chance of surviving the Titanic. Whereas if you were a man in third class you had a 16 percent chance of surviving the Titanic. And the reason was that they had a one size fits all strategy. And at that time it was man the lifeboats.

Problem is That if you had a third class ticket, you were on a lower inside berth. And people on lower inside berths needed more help to get to the lifeboats, which were not available in the middle of the night when they struck the iceberg. And so this one size fits all strategy interacted with existing social inequities.

and with sort of cultural rules, women and children first to produce a differential outcomes. And that's exactly what happened in the pandemic in Ontario. We had existing social inequalities, which then interacted with a one size fits all pandemic strategy to produce what were completely predictable differences in the incidents and the impacts of the pandemic, not just due to COVID.

Also due to the public health strategies and also because of the social impacts. So all of those things went together and it was totally predictable what happened. 

Jessamy: Moving on from that then, do you think that there are new insights into how we view vulnerable groups that we've gained from COVID 19?

Or do you think that what we've seen is just totally predictable and actually it just solidifies our views of vulnerable groups and inequalities that we already had. 

Kwame: I think that's a really interesting question about that. I'll tell you, the question I always ask people is, when they talk about, say for instance, Toronto, and if you're in Toronto 50 percent of the population are racialized, 80 percent of hospitalizations from COVID racialized.

Parts of Toronto. 10 times higher rates of COVID than others, right? And the question is, what are you vulnerable to? Were they, are they vulnerable to COVID 19? Or are they vulnerable to bad social policy? Or are they vulnerable to bad health and public health policy? So what do they mean by vulnerable? And so sometimes I quite like the idea of people being marginalized.

Because the truth was That people just didn't get the protection that they could have got. The actual pandemic protections in Toronto were pretty good. Some of the population were pretty, pretty well protected and other people weren't. And the question is were they Vulnerable to Covid or were they marginalized from covid protections?

And I think that it's possible to think that there's a bit of both, that there's a vulnerability because of historic social in, in inequalities and inequities. But there's also marginalization which meant that equitable protection wasn't given to people. And so we dropped the ball. It's easier to see with, say for instance, long term care.

In COVID in Canada, 75 to 80 percent of people who died in wave one were in long term care. In COVID in Germany. 30 percent of people who died were in long term care. If Canada had the same response, COVID response as Germany would have, it would have saved about 4, 500 people in wave 1. And if Ontario had the same response as BC had, it would have saved about 2, 300 people in wave 1 of COVID.

And the difference between Canada and Germany Ontario and B. C. is how they prioritized long term care and how they prioritized protecting people in long term care, either with protocols and rules and proper investigation and monitoring or with PPE. And those things are different. So were people in long term care vulnerable and more vulnerable in Ontario, more vulnerable in Ontario than BC, more vulnerable in Canada than in Germany?

Or were they less protected and more marginalized? And I quite like the idea of marginalization and lack of protection because it becomes clear that people are making decisions. And those decisions change outcomes. And it's not that they're just, they're some sort of environmental vulnerability, which is why these things happen.

These are choices. And the thing about choices is not that it's important for the blame game. It's actually important for the equity game. Because if you can see that these are choices that are made, then it's possible to imagine other choices. That can move towards equity. 

Gavin: How will you use all of this to inform policy going forward?

Kwame: One of the ideas that I've been working on in my mind and it'd be interesting to know what you think about it, is the idea of precision medicine. And you've probably come across this idea from a biological and individual level and from a biological point of view. You run some assays, you work out what your metabolic status is.

You work out how you meta metabolize the drug. You work out and you find the right drug to suit the individual which decreases the side effects and increases the effectiveness. Of your drug, you're trying to pinpoint the drug in a precision way for an individual. And it feels like we should be talking about precision public health, or precision population health, and definitely precision pandemic strategies.

And instead of thinking about the individual. We're now starting to think about the characteristics of the population. And what do you need to do from a policy perspective, from a public health perspective, to find the sweet spot so that you are tailoring your interventions so they actually meet the needs with the lowest level of side effects.

And if we're talking about that individual level. about precision medicine, then we should really be talking about precision public health medicine and what that looks like. And to a certain extent, we should be thinking about precision social policy in the same sort of way. And maybe using the same terms will help, but I really do think that one of the things that has made a difference, a huge difference in Toronto is.

data. Data has been just vital, but not having the data, collecting the data, analyzing the data, and then publishing the data, and for people to see what's going on. When we started the start of the pandemic, everybody was talking about flattening the curve. And then soon after we started seeing the high rates of COVID in black populations in the UK and the US, we started saying, Hey, we need to know who's under that curve.

And so we went from flattening the curve to thinking about who's under the curve and to work out who's under the curve, you need data. And those data help you. Not only identify who's under the curve, but work out why they're under the curve and what you can do about it. And it can help you monitor the impacts of your interventions.

And if you don't have those, then people become, they get lost, their stories get lost in the aggregate. And if you, your stories are lost in the aggregate, then no one is coming to produce strategies for you. So the data's important, but it really has to be analysed, out there, transparent, and it allows people to call health and public health to account for disparities.

Jessamy: I think it's so interesting that you're talking about that because I also have felt for a long time that, we're able to stream 5, 000 different sort of individually miniature things that target, people on Facebook to vote a certain way, but we don't have the same sort of precision when it comes to policy and public health.

It's all about universal then. It's about universal credit, universal this, universal that, which obviously has huge holes in it for people because it's universal. It's not based on people's individual lives and individual needs. Can you realistically see us moving towards a way where that sort of policy that moves away from a universal type approach and does try to really look at the individual and look at the weaknesses in that system so people aren't falling through the holes?

We obviously have the, we have the scientific and the technological Ability to do that now because we do it in other places, big tech has been doing it for years now Do you see us moving towards that or do you think that policy is just too far behind and may not be able to get there?

Kwame: I think that's a great question. Just me and I think i'm not an either or guy if you say, do you want dessert or do you want cheese, I say both. If you say to me do we need to move away from the universal to the individual, I say, no, it's not either or, it's both and, right? We need the universal.

The universal's gonna work for a whole bunch of people. It's going to be fine. It's going to be the most efficient and effective way of doing things. And then we're going to have to look at the people for who the universal is not going to work. And we're going to have to do something else. And that's fine.

That's what equity is. One size fits all didn't work on the Titanic. The people on the lower berths needed more help. Universal worked for a whole bunch of people, but the people on the lower berths needed more help. And that's how we need to think about it. We can organize a universal strategy that works for a whole bunch of people, and then we need tailored strategies to make sure that everybody gets the same benefit.

But it's even more important in a pandemic because if you don't deal with the people who are marginalized and who don't get access to your pandemic strategy, you are leaving opportunities for mutation. If you only had Medium sized Wellington boots. Somehow I don't think that would work. Who would go to a shop that only had medium sized Wellington boots?

You'd say that's stupid. How could we say the same thing with social policy? Oh yeah, we'll just have a medium size. Don't worry, everybody will buy that. Really? No. No, I don't think so. I think it's not either or, it's both and always it will be, because that's how human beings work. 

Gavin: Hopefully we'll move towards a kind of cheese and dessert style version of public health policy, although I'm not sure cheese and dessert is the best public health advice.

When we're thinking, in a few years time, when we have hopefully moved past, or at least, COVID 19 isn't the overriding concern for people around the world, Do you think that maybe some of this kind of renewed and fresh thinking that has taken place over, over the COVID 19 pandemic will, will look more in depth at tackling inequalities?

Do you think inequality and equity will be something that's actually now far more at the forefront of public thinking? 

Kwame: I will predict something. I'll predict that we're going to get over Wave 3 and a whole bunch of people are going to be joyous and they're going to forget everything that's happened.

And they're going to forget inequities And they won't remember them till wave four and probably by the time we get to wave four and then We start thinking about the recovery I'm hoping it will solidify and people will start thinking from now onwards that we may have had a run of policy for a while where we've got much more individual and where we have been happy to make profits and money out of winners and losers.

And I think we're getting to a point where people realize that unfettered move towards inequities and inequalities is not a great idea. I think I've been amazed to see how COVAX has got together and started running. I'm amazed to see how countries are starting to make good on their vaccine donation policies.

Because they realize that they can't do it unless we're all safe, no one's safe. And I think that Enough people around a lot of high income countries have had a little taste of what happens when things go wrong to start thinking that government is important, that you can't go it alone, that small government is not a great idea if we hit any problems.

And I think a whole bunch of people will start seeing that problems such as global warming that are increasing and the next pandemic are things that we're only going to be able to deal with if we have strong government that understands the social determinants and strong government needs to be paid for, which means that we have to have a collective effort of paying our taxes to make sure that on a local basis, on a country basis, And on an international basis, because I really think that we should be funding the WHO so it can do its job properly that we need to be thinking about equity and our own security is based on understanding equity.

I actually think people are getting there. I actually think this enforced break has given some time for people to reflect and I hope that time and this experience for us all will leave a lasting legacy of thinking slightly differently. about things and maybe certainly for me, not taking so much for granted and starting to think about what's really important.

Gavin: Thank you Kwame. It's been a really interesting chat and we're just very happy that you found the time to speak with Jess, me and I today and best of luck with your future work.

Jessamy: Thanks for listening to this episode of The Lancet Voice. You can subscribe to us wherever you usually get your podcasts and we'll see you again 

next time.