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Africa: Donors Retreating on AIDS
AfricaFocus Bulletin
Nov 6, 2009 (091106)
(Reposted from sources cited below)
Editor's Note
"After almost a decade of progress in rolling out AIDS treatment we
have seen substantial improvements, both for patients and public
health. But recent funding cuts mean doctors and nurses are being
forced to turn HIV patients away from clinics as if we were back in
the 1990s before treatment was available" - Dr Tido von
Schoen-Angerer, Director of MSF's Access to Essential Medicines
Campaign.
A new report released by M�decins sans Fronti�res (MSF) / Doctors
without Borders, documents both extensive achievements in expanding
AIDS treatment in recent years, and the threat that funding
slowdowns will not only stall expanding treatment, but also force
life-threatening cutbacks for patients already on treatment.
"Meanwhile," the report notes, "a dangerous trend is underway in
the global health policy arena. Rather than looking for ways to
leverage and replicate the success of the AIDS public health
revolution to improve global health, there are increasing calls for
a diversion of foreign aid away from HIV/AIDS and towards other
health priorities. While there is clearly a need to give urgent and
additional resources to an array of global health priorities, not
least maternal and child health, cutting HIV/AIDS funding is not
the answer."
This AfricaFocus Bulletin contains excerpts from the full report,
which is available, including footnotes and tables, at
http://www.msf.org.za/punishing_success.pdf
Another AfricaFocus Bulletin sent out today contains the executive
summary of a call for U.S. support for all facets of global health,
released by a coalition of 24 U.S. groups focusing on health, in a
report released in late October. See
http://www.africafocus.org/docs09/gh0911.php for the summary, and
http://www.theglobalhealthinitiative.org for the full report and
press coverage.
For previous AfricaFocus Bulletins on health and related issues,
visit http://www.africafocus.org/healthexp.php
++++++++++++++++++++++end editor's note+++++++++++++++++++++++
Punishing success in tackling AIDS: Donors' retreat could wipe out
health gains in HIV affected countries
Full report is at http://www.msf.org.za/punishing_success.pdf
For more information, please contact:
Borrie la Grange, MSF South Africa, mobile: +27 83 287 5294
[email protected]
Baikong Mamid, MSF South Africa, mobile: +27 798 722 950 or +27 768 295 325
[email protected]
Sharonann Lynch, HIV/AIDS Policy Advisor Doctors Without
Borders/M�decins Sans Fronti�res (MSF) US mobile: +1 646 824 3066
Email: [email protected] /
Email: [email protected]
Johannesburg, 5 November 2009 - A retreat from international
funding commitments for AIDS threatens to undermine the dramatic
gains made in reducing AIDS-related illness and death in recent
years, according to a new report by M�decins Sans Fronti�res (MSF).
The MSF report highlights how expanding access to HIV treatment has
not only saved the lives of people with AIDS but has been central
to reducing overall mortality in a number of high HIV burden
countries in southern Africa in recent years. In Malawi and South
Africa, MSF observed very significant decreases in overall
mortality in areas where antiretroviral therapy (ART) coverage was
high. Increased treatment coverage has also had an impact on the
burden of other diseases, for example tuberculosis cases have been
significantly reduced in Thyolo, Malawi and Western Cape province,
South Africa.
"After almost a decade of progress in rolling out AIDS treatment we
have seen substantial improvements, both for patients and public
health. But recent funding cuts mean doctors and nurses are being
forced to turn HIV patients away from clinics as if we were back in
the 1990s before treatment was available", says Dr Tido von
Schoen-Angerer, Director of MSF's Access to Essential Medicines
Campaign.
International support to combat HIV/AIDS is faltering as reflected
in significant funding shortfalls. The Global Fund, a key financer
of AIDS programmes in poor countries is unable to respond to
countries' needs. Next week its Board of Directors will vote in
Addis Ababa whether or not to suspend all new funding proposals in
2010; and PEPFAR, the US AIDS programme is flatlining funding for
two more years.
"The Global Fund must not cover up the deficit caused by its
funders", says von Schoen-Angerer. "The proposed cancellation of
the 2010 funding round and other measures to slow the pace of
treatment scale-up are punishing the successes of the past years
and preventing countries from saving more lives."
In 2005, world leaders promised to support universal AIDS coverage
by 2010, a promise that encouraged many African governments to
launch ambitious treatment programmes.
"What about the promise made to people with AIDS? We gave them hope
and life. We have to be there for them, we all knew from the
beginning that this treatment was for life," says Olesi Ellemani
Pasulani, MSF Clinical Officer in Thyolo District Hospital, Malawi.
"Passing on the bill for treating AIDS to very poor countries would
be a colossal betrayal."
Reducing funding at this time will leave people in urgent need of
treatment to die prematurely and can lead to dangerous interruption
of treatment. In Uganda, cuts have already begun to hit home with
some facilities forced to stop treating new patients with HIV.
Other countries are backing away from their earlier treatment
coverage targets. In Free State, South Africa, past funding
problems that have now been resolved led to disruption of treatment
and a moratorium on treating new patients which resulted in an
estimated 3,000 deaths.
The report provides evidence that, particularly in high
HIV-prevalence settings, treating AIDS has a positive impact on
other important health goals, in particular maternal and child
health.
"A stronger commitment to other health priorities must happen, but
this should be in addition to, not instead of, continued, increased
commitment to HIV/AIDS", adds von Schoen-Angerer.
At present, over four million people living with HIV/AIDS in the
developing world receive antiretroviral therapy. An estimated six
million people who are in need of life-saving treatment, are still
waiting for access. MSF operates HIV/AIDS programmes in around 30
countries and provides antiretroviral treatment to more than
140,000 HIV-positive adults and children.
Punishing Success?
Early Signs of a Retreat from Commitment to HIV/AIDS Care and
Treatment
November 2009
Introduction
Over the past decade, enormous resources have been mobilised
globally to address the HIV/AIDS crisis on a large scale.
M�decins Sans Fronti�res (MSF) has seen first-hand the
achievements, as well as some of the shortcomings, of these
efforts in the course of providing care and treatment in more
than 30 countries.
The good news is that four million HIV-positive people are alive
on antiretroviral therapy (ART). The scale-up of ART in
developing countries has allowed individuals to live longer and
enjoy a better quality of life, leading to a restoration of
dignity and autonomy, and an ability to contribute to family and
societal life. In some countries, ART coverage has resulted in a
decline in overall mortality and other population-level impacts.
But there is also bad news. Today, MSF teams working to treat
HIV/AIDS are witnessing worrying signs of waning international
support to combat HIV/AIDS. In some high-burden countries,
patients are being turned away from clinics, and clinicians are
once again being forced into the unacceptable position of
rationing life-saving treatment. At the same time, more robust
and better-tolerated treatments - widely prescribed in wealthy
countries - are not reaching patients.
The most glaring sign of the decreasing political commitment to
HIV/AIDS is a major funding deficit. The Global Fund to Fight
AIDS, Tuberculosis and Malaria Board is considering a motion to
cancel the funding round (Round 10) for 2010; if accepted, no new
proposals will be considered until 2011. Similarly, the US
President's Emergency Plan for AIDS Relief (PEPFAR) plans to
"flat-fund" its programmes for the next two years, reneging on
promises made last year to support expanded treatment access.
Meanwhile, a dangerous trend is underway in the global health
policy arena. Rather than looking for ways to leverage and
replicate the success of the AIDS public health revolution to
improve global health, there are increasing calls for a diversion
of foreign aid away from HIV/AIDS and towards other health
priorities. While there is clearly a need to give urgent and
additional resources to an array of global health priorities, not
least maternal and child health, cutting HIV/AIDS funding is not
the answer.
Reducing funding at this juncture would not only undermine the
goal of reducing maternal and child mortality, but it could also
lead to the interruption of treatment for people with HIV/AIDS
already on ART, and leave those still in need of access to
treatment to die premature, avoidable deaths.
HIV/AIDS is the leading cause of mortality among women of
child-bearing age worldwide and responsible for more than 50% of
mortality in five of the countries with the highest HIV
prevalence. This killer disease is an ongoing emergency that
requires dedicated resources at the national and international
levels. A strengthened commitment to other global health
priorities must happen - but it must happen in addition to, not
instead of, a continued and increasing commitment to HIV/AIDS.
Successful Scale-Up of Treatment
MSF has provided HIV/AIDS care and ART to more than 140,000
people in approximately 30 countries. MSF treated its first
patients with ART in 2000. At that time, the epidemic had killed
16 million people and 33.6 million people were living with HIV
worldwide, the majority in poor countries. Although 95% of people
did not have access to life-saving ART, the UN adopted Millennium
Development Goals (MDGs) for health that made no mention of ART.
In 2001, then-UN Secretary General Kofi Annan called for a "war
chest" of US$7-10 billion to address the global HIV/AIDS crisis.
The promise of treatment regardless of ability to pay was
reiterated at subsequent G8 and UN General Assembly meetings. At
the G8 summit in Gleneagles, Scotland in 2005, then-UK Prime
Minister Tony Blair launched a specific commitment to achieving
"universal access" by the end of 2010.
As a result of widespread public pressure and an eventual
worldwide mobilisation of resources, HIV/AIDS care, treatment,
and prevention programmes have expanded massively. There are now
four million people alive as a result of access to ART and
thousands of new infections have been prevented. Nevertheless,
prevention efforts still lag far behind and unmet treatment needs
are dramatic.
A Continued Emergency
The crisis is not over. In the ten highest HIV prevalence
countries, AIDS is the leading cause of death: 80% of all deaths
in Botswana and two-thirds of all deaths in Lesotho, Swaziland,
and Zimbabwe are due to AIDS. Less than a quarter of HIV-positive
pregnant women have access to Prevention of Mother to Child
Transmission (PMTCT). Whereas HIV among children has been
virtually eliminated in rich countries, AIDS remains the leading
cause of under-five mortality in the six highest HIV prevalence
countries, accounting for more than 40% of under-five deaths in
these countries.
Despite scale-up successes, today at least six million
HIV-positive people clinically need to start ART but do not have
access to it. Moreover, as the World Health Organization (WHO)
revises standards in line with the scientific consensus that
people living with HIV/AIDS should initiate treatment earlier,
this could increase needs to 18-22 million. Most people living
with HIV/ AIDS in need of treatment will die within three years
if they do not have access.
...
Spotlight on South Africa
South Africa accounts for 17% of global HIV infections. There are
more people living with HIV in South Africa than in any country
in the world-5.5 million people-and more people on ART than
anywhere else- 700,000. However, an additional 1.5 million people
are estimated to currently require ART but lack access.
[see full report for more details]
International funding stalls as needs grow
UNAIDS estimated that the total resources needed for a global
AIDS response was US$22.1 billion in 2008. The resource gap in
2008 was reported to be US$6.5 billion. But despite the gap
between needs and resources, the overall trend until recently had
been positive - increased resources over time with corresponding
increases in access to prevention, treatment and care.
The Global Fund to Fight AIDS, Tuberculosis and Malaria and the
US government's HIV/AIDS programme, PEPFAR, are the two most
significant supporters of AIDS programmes in developing
countries. While there is widely recognized room for improvement
in programmes financed or managed by both, their positive impact
has been undeniable. Donors with the most significant
contributions to the global AIDS response have been the United
States, the United Kingdom, the Netherlands, France, Germany,
Norway and Sweden.
But both political commitment and funding allocations are waning.
This could have catastrophic implications on people who depend on
this aid to access HIV prevention, treatment and care.
The Global Fund: Universal Access Ambitions in Jeopardy
Since its inception in 2001, the Global Fund to Fight AIDS,
Tuberculosis and Malaria reports that it has committed US$15
billion worth of grants in 140 countries, and saved an estimated
3.5 million lives. Today, the Global Fund, which depends on
contributions from donor countries for the majority of its
revenue, is responsible for disbursing almost a quarter (23%) of
HIV/AIDS international donor aid.
But the Global Fund has been unable to obtain donor commitments
to fill a growing funding gap, which directly affects countries'
capacity to scale-up and sustain HIV/AIDS treatment. In order to
cope with a lower level of funding, the Global Fund has
implemented tough measures such as imposing a 10% cut in grants
already approved, and delaying by six months the 2009 closing
date for proposals.
In countries like Malawi, a least-developed country where
HIV/AIDS is a leading cause of illness and death, the 10% cut was
withdrawn from funds intended for ARVs. Some countries report
being told to "cap" their applications to the Global Fund due to
limited resources. Others are pre-empting tighter conditions by
downsizing their ambitions and their proposals, particularly for
ART.
This pressure, created by funding shortfalls, is a reversal of
progress: until now the Global Fund actively encouraged ambitious
proposals from countries to scale up access to life-saving
treatment. In 2008, Round 8 approved grants for HIV, TB, and
malaria were 2.5 times more than any previous round of funding.
This year, the total amount of Round 9 HIV grants recommended for
funding was 35% less than Round 8.
In March 2009 the Global Fund announced it was facing an alarming
funding gap of US$4 billion based on budget needs through 2010.
In response, a new set of demand reduction measures were proposed
including suspending and possibly eliminating the Rolling
Continuation Channel, a mechanism to extend funding for
"well-performing" grants. More recently, the Secretariat has
proposed having no funding round in 2010. The Board of Directors
will decide on these measures in November 2009. ...
More than HIV/AIDS treatment is at stake. Progress in the
diagnosis and treatment of TB and malaria also relies on support
from the Global Fund. For example, the internationally agreed
scale up of diagnosis and treatment of multidrug-resistant and
extensively drug-resistant tuberculosis will greatly rely on
increased funding from the Global Fund.
...
Spotlight on Malawi
Malawi is a densely populated, mostly rural country with a
population of over 13 million people. Malawi has a GDP per capita
of US$800 and ranks 160 out of 182 on the Human Development
Index. The government estimates between 800,000 and one million
Malawians are HIV positive, including at least 100,000 children
under 15 years of age.55 The national HIV prevalence is 12%.
Despite the barriers, Malawi rose to meet the challenge of the
international community to scale up ART. According to government
statistics, there were more than 164,000 people alive on ART by
the end of June 2009 with 18,000 people initiated on treatment
between April and June 2009. Since the scale-up of ART, the
country has seen a significant reduction in HIV/AIDS-related
deaths between 2003 and 2008.
The vast majority of financial support for Malawi's ART programme
and the country's response to HIV/AIDS has come from the Global
Fund. Starting with its first round of funding in 2002, the
Global Fund has disbursed over US$465 million to the country.
MSF works with the Ministry of Health in two districts in Malawi,
Chiradzulu and Thyolo, to provide comprehensive HIV/AIDS services
as part of primary care in 26 health centres and three hospitals.
Since 2003, over 38,000 people have been put on ART. In Thyolo,
universal access (80% of need) was reached and has been
maintained, at a cost of US$3.20 per inhabitant.
The three-year Malawi HIV/AIDS plan lays out an ambitious
strategy to reach universal access to prevention, care, and
treatment by 2013. The cost of the three-year plan is US$800
million. Based on all funding commitments to date, a shortfall of
just under 50% (US$423 million) is anticipated. The Global Fund
provides the best opportunity to fill the funding gap and for the
country to provide lifesaving treatment for every Malawian in
need. However, with the Global Fund in crisis, Malawi's scale-up
to universal access is in jeopardy.
"How can you go back to rationing access to care?"
...
Olesi Ellemani Pasulani, an MSF clinical officer at the Thyolo
District Hospital, shares his experience and observations from
the last five years.
"I can remember what the situation was like before we had ART in
2003. We could only offer people voluntary HIV testing and
counselling. We could only promote the use of condoms and
distribute them, we could treat other sexually transmitted
diseases. ... There were very few people that came forward to be
tested for HIV, because there was not much we could do without ART.
It was like a death sentence to test HIV positive," Olesi says.
Health care workers were left disheartened because they could
only deliver home-based care, simply being able to offer
treatment for chronic illnesses and providing end of life care to
patients. Olesi explains, "You could just take care of them, and
wait for the day that they would die. ... That era was really hard
for health-care workers and it de-motivated you completely."
Thanks to an MSF and Ministry of Health developed model of care,
the ART scale-up in the Thyolo district in 2003 turned around
thousands of lives and entire communities by providing universal
access to treatment across the district. By the end of 2008 the
number of people on ART had increased even further and now in
2009 universal access is maintained.
"Now people living with HIV/AIDS have courage, there is light at
the end of the tunnel for them. There is hope among people in the
villages. You can see the difference that you as healthcare
worker make in someone's life thanks to ART. We would see a
patient that was bed-ridden earlier, and they would start ART.
When you meet them again six or seven months later in the market
or on the street, they are completely changed. They have joy."
The threat of the early retreat of HIV/AIDS funding and the dire
impact it would have on patients' lives across the most affected
areas of sub-Saharan Africa is something that worries Olesi and
his colleagues.
"It is important to continue with ART and increase it even more.
How can you go back to rationing access to care? It is a right to
life. If treatment is threatened it will mean we go back to a
situation worse than before ART. It will also damage the
relationship of trust that communities have built with healthcare
workers over the years," he says.
PEPFAR: Flat-Funding and the Rationing of Treatment
The US government's AIDS programme, PEPFAR, has had a
considerable effect on the scaling up of AIDS care and treatment
in resource-limited settings since its inception in 2003. PEPFAR
has supported HIV/AIDS and other health programmes in 31
countries. PEPFAR now supports more than two million people on
treatment with a commitment to scale up treatment to at least
three million by 2013, with some advocating for a more aggressive
US commitment to scale up treatment to six million by 2013 and
seven million by 2014, given the tremendous need. PEPFAR also
reports having supplied more than two billion condoms and
supported PMTCT for 16 million pregnancies between 2004 and 2008.
The 2008 reauthorization of PEPFAR included a strong commitment
for continued treatment access - requiring the majority of
bilateral AIDS funds to be spent on treatment programmes - and
many countries in Africa have built ART programmes around the
promise of continued PEPFAR support.
In May 2009, US President Obama announced the Global Health
Initiative (GHI) as a US$63 billion, six-year "new, comprehensive
global health strategy." Yet it is unclear if any of this money
is "new" money: it includes PEPFAR as well as other pre-existing
government programmes. In the announcement of the GHI, President
Obama stated a commitment to PEPFAR, yet advanced a budget that
underfunded international spending for AIDS.
After steady increases over each of the last five years, US
government bilateral HIV/AIDS funding has flatlined in 2009.69
The proportion of PEPFAR's budget dedicated to treatment has
decreased.
...
Spotlight on Uganda
Uganda provides an example of what will happen in other countries
if current trends continue and the international commitment to
treatment access is undermined.
...
Uganda had been the darling of the PEPFAR programme from its
inception. As one of PEPFAR's early "Focus Countries," Uganda
received US$929 million between 2003 and 2008, at consistently
increasing levels to enable treatment scale-up.
Now, however, the situation is different. So, too, are the
options for patients. Less than one-half of those eligible for
ART in Uganda are receiving it. The Ugandan government's revised
AIDS treatment guidelines attempt to align clinical care for
HIV-positive patients with WHO recommendations. But its
implementation, including an increase in the eligibility criteria
and a transition to an improved priority first-line regimen, are
in peril because of a funding crisis.
PEPFAR is the principal lifeline for much of Uganda's treatment
scale-up but this support is under threat. The US government is
scheduled to cap funds to Uganda at least through 2011.
The primary message from the US government to treatment providers
and the Ugandan government regarding the recent policy changes
has been clear: funding will continue at the current rate but
will not increase. Yet some implementers have been told that they
must cease enrolment immediately, others that they must initiate
new patients with caution, and still others that they can only
initiate new patients on treatment if there are "efficiencies"
found, or "attrition" - the death or loss of patients already
receiving treatment.
...
National Governments: Insufficient Investment in National AIDS
Response
Due to the global financial crisis, government budgets are tight.
Some governments have already slashed budgets for HIV/AIDS.
National governments have downsized ART coverage goals in
Swaziland, Botswana, and Tanzania. Individuals also have a more
constrained ability to pay for health care including
transportation, user fees, and lab, drug, and hospitalisation
costs. Some governments are exploring new "cost recovery" and
"cost sharing" strategies even though these strategies have been
shown to dramatically reduce access to care and worsen survival
rates.
Such cutbacks come amid a backdrop of insufficient domestic
contributions to health. More than half of African countries
underspend on health according to the minimum requirement (US$34
per capita) recommended by the WHO. Only eight African countries
have made good on the 2001 commitment to allocate 15% of their
national budgets to health. Even then, few African governments
could mobilise sufficient resources to cover the costs of
HIV/AIDS care and treatment; international aid would still be
necessary.
Other Global Health Actors
The contributions of other global health actors are often less
far-reaching than those of the Global Fund and PEPFAR, but can
play an important role in supporting life-long ART.
[includes information on European Union member countries, World
Bank, and UNITAID - see full report]
Conclusion: addressing the funding crisis
Global health remains underfunded. MSF has repeatedly called for
increased global support for a number of pressing health needs
such as childhood and maternal malnutrition, vaccinations,
tuberculosis, and neglected tropical diseases. However, such
efforts should not come at the expense of HIV/AIDS funding and
programming: this will undermine opportunities for synergies
between HIV/AIDS and other, often linked, health needs.
Funding for HIV/AIDS treatment is not keeping up with need, and
appears to be shrinking. Funding shortfalls punish the early
success of the last decade of ART scale-up, and threaten to have
a devastating impact on people living with HIV/AIDS as well as
efforts to prevent new infections. As global health actors
retreat from providing direct support for AIDS treatment, more
demand is placed on the Global Fund, which is itself critically
underfunded.
In order to expand and sustain HIV/AIDS care and treatment
worldwide MSF recommends:
Sustained and increased funding for HIV/AIDS from the
international donor community and national governments - and a
continued commitment to universal access to AIDS care and
treatment
- Global Fund: The Global Fund Board and Secretariat should
clearly articulate their funding needs, rather than obfuscating
their funding crisis by reducing demand. It is not too late to
prevent a downward spiral of lowering expectations and shrinking
programmes. The Global Fund should ensure a funding round for
2010 and avoid administrative changes that hide the funding
shortfall. Ultimately, it is donor governments that have the
power to change the current reality. Furthermore, the Global
Fund, underfunded itself, cannot provide an exit strategy for
other actors.
- PEFPAR: This US programme has been central to encouraging
large-scale HIV/AIDS treatment scaleup. As such, the US
government has a responsibility to help countries avoid treatment
interruptions and continue to enrol new patients. This means
honouring commitments made repeatedly by the US and other G8
countries to support universal access. Implementers on the ground
are all too aware that countries cannot do it alone, and talk of
self-sufficiency is premature in many contexts.
- National governments: National governments must not abandon or
delay their commitment to universal access to HIV/AIDS treatment.
In addition to adequate funding for national health budgets,
addressing mismanagement of funds is required if governments
expect to continue receiving adequate funds.
- The international community: In addition to fulfilling
commitments on financing for health, donor and national
government should support mechanisms that allow raising enough
money for global health on a sustained basis. Small taxes on
untapped global economic flows, such as currency transactions,
are currently under discussion internationally.87 Such innovative
strategies are needed as additional sources of revenue to help
address the increasing discrepancy between global problems and
national resources.
Improved treatment in line with scientific evidence and
recognised international standards of care
Not investing today in improved treatment and protocols will cost
lives, increase a double standard in HIV care and lead to
increased costs later. There is a clear risk that donors will not
support or try to delay the implementation of proven and
recommended medical strategies for the sake of short-term
savings. Therefore, MSF recommends:
- Supporting earlier initiation of ART (at a CD4 cell threshold
of 350), which can reduce the incidence of TB and other deadly
opportunistic infections and improve survival rates, reducing the
need for costly and complex acute care.88
- Implementing a more robust tenofovir-based first- line regimen,
which will allow patients to stay on their first regimen as long
as possible and with fewer side effects, and delay the need for
more costly second-line regimens.89
- Providing access to viral load testing to support adherence and
detect treatment failure, thereby preventing resistance and
needless switching to expensive second-line treatment.90
- Supporting innovation that can lead to further improvement and
simplification of HIV treatment in resource-poor settings such as
point-of-care viral load testing.
Measures to ensure that prices of drugs and diagnostics remain
within reach of poor countries
The international community should support policies that will
enable funds to stretch as far as possible to meet needs and
contain costs in the short-and long- term by ensuring a
competitive supply for drugs.
- The Global Fund and PEPFAR, among others, should continue to
embrace and encourage the use of generic drug regimens.
- In accordance with the Doha Declaration on TRIPS and Public
Health, governments can authorise governmental use or compulsory
licenses to ensure generic production of patented products �
Companies and governments should support the patent pool for
antiretroviral medicines that is currently being designed by
UNITAID.92 This mechanism brings together patents held by
different owners and makes them available to others for generic
production and further development.
AfricaFocus Bulletin is an independent electronic publication
providing reposted commentary and analysis on African issues,
with a particular focus on U.S. and international policies.
AfricaFocus Bulletin is edited by William Minter.
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