The Global Forum for Health Research Forum 2009: Innovating for the Health of All took place in Havana, Cuba from 16-20 November. This is the fifth in a series of posts from the conference. Only one or two more after this one.

My reason for attending Forum 2009 was to participate in a session title “Innovation for Remote Populations”. This post is a about that session. What follows is taken from my recent report to the Global Forum for Health Research – edited only slightly.

Innovation for Remote Populations

Thurs-19-Nov-2009, 14:00-15:45, Global Café, Palacio de Convenciones, La Habana, Cuba

Coordinators/Facilitators:

• Patricia Mechael, mHealth and Telemedicine Advisor, Millennium Villages Project, Earth Institute, Columbia University, USA & Egypt (organizer & facilitator)
• Tim Hurson, Facilitators Without Borders (facilitator)
• Charles Gardner, Global Forum for Health Research (focal point)

Speakers (alphabetical order):

• Simon Adebola, NEPAD Council Global Health Commission, Geneva
• Najeeb al-Shorbaji, Director, Knowledge Management and Sharing, WHO
• Caren Serra Bavaresco, Student, Epidemiology, Universidade Federal do Rio Grande do Sul, Brazil
• Karl Brown, Associate Director, Rockefeller Foundation
• Arul Chib, Assistant Professor, Wee Kim Wee School of Communication, and Assistant Director, Singapore Internet Research Center, Nanyang Technological University
• Dziedzom Komi de Souza, Ph.D. Student and Research Assistant, Parasitology, Noguchi Memorial Institute for Medical Research, Ghana
• Bastiaan Hoefman, co-Founder, Text2Change
• Bernardita Labarca, Project Coordinator, Zoltner Consulting Group, Chile
• Claire O’Neill, Chairperson, Cell-Life-South Africa
• Ravi Ram, Head, Monitoring & Evaluation, African Medical Research and Research Foundation (AMREF), Nairobi Kenya
• Marco Salmen, OHR-GMCP Initiative for HIV/AIDS, Global Micro-Clinic Project, United States
• Jaspal S. Sandhu, Design Researcher, College of Engineering, University of California, Berkeley, USA
• Joel Selanikio, co-Founder and Director, Datadyne.org, USA
• Garance Upham, General Secretary, Direction, Safe Observer International, France

Additional participants – from the audience:

• Elmer Zelaya – Fundación Chica/Nicaragua
• Timothy Dye – SUNY Upstate Medical School/USA
• Jane Kengeya – WHO
• Oyewale Tomori – Redeemer’s University/Nigeria
• Lishandu/Zambia (full name/affiliation not available)
• Vargas/USA (full name/affiliation not available)

Summary:

1. Diverse users and uses: The speakers presented a variety of mHealth/eHealth applications involving a wide variety of users, including both the health workforce and community members, e.g. educating teenagers about HIV/AIDS in South Africa (O’Neill), Internet access in western Kenya to improve uptake of HIV VCT (Salmen), mobile emergency response systems in Aceh (Chib), electronic IMCI in Tanzania (Brown), text-based health education and health service promotion in Uganda (Hoefman), training for health workers as a downloadable game package for phones in Kenya (Ram), telemedicine to improve the skills of health workers at primary levels in Brazil (Bavaresco), delivery of health information to communities in Chile (Labarca), a general set of tools for mobile data collection being used worldwide (Selanikio), and handheld computers to support rural healthcare delivery in Mongolia (Sandhu).
2. mHealth/eHealth is about enabling access: A common theme across diverse applications was that information and communication technologies are being used to enable access to health information and services in places where access is difficult because of remoteness and/or cost.
3. Coordination among the various players: Coordination among donors and projects is necessary to avoid unnecessary duplication of effort and to share what works. This is the role of the mHealth Alliance, supported by Rockefeller Foundation among others (Brown). While there were questions from the program side as to what data donors want (Chib), there was a simultaneous sentiment that donors need “stepwise” guidance (al-Shorbaji).
4. De-emphasizing technology: The mHealth Alliance has recently been discussing development of an “mHealth Toolkit”, to provide a common technical architecture and platform for those planning to implement mHealth programs (Brown). The existence of free technology platforms – in this case DataDyne’s tool – enables programs to focus on developing health content (Labarca). It is important to have a generalizable tool, as DataDyne has done, that can be used by anyone; if individual governments must approve technology “you’ve lost the battle” (Selanikio). Programs must focus on understanding people and applications more than technology; in response to a question from Dye about the use of ethnography in this field, three examples were given: ethnography of teen chat rooms in South Africa (O’Neill), multi-year ethnographic fieldwork as the basis for the program in western Kenya (Salmen), and design ethnography of the information management practices of rural health workers in Mongolia (Sandhu).
5. Defining good evaluation: There are challenges to seeing change in population health outcomes (Chib). It is difficult to measure behavior change (Hoefman) and to evaluate systems that provide health content to people (Labarca). Ethnography should be considered more seriously as a complementary evaluation strategy in mHealth (Sandhu). In evaluation, the metrics should match the intervention – mHealth is another intervention; in addition, we want to see the unintended effects of technology (Ram).
6. New modalities of engaging people: Mobile phones enable fundamentally new ways of engaging with people. As opposed to mass communication that is often used in social marketing, phones allow for interpersonal communication that can be tailored and cost-effective (O’Neill). There are two modalities, moving messages out to people and demand-driven services, where people demand the information that they need (Ram). Salmen lent his support to the importance of demand-driven services and argued that phones will bring more equity. This is all supporting the shift to citizen-centered healthcare (Mechael).
7. Cautions moving forward: In natural disasters, the cellular network is the first to go (Zelaya). An open question: Who owns the data? (al-Shorbaji). Nobody is thinking about “real sustainability” (Adebola). Reliable phone networks are a challenge (Lishandu). We should be careful that we don’t become too dependent on one tool (al-Shorbaji).
8. Need to think more creatively: We should be bolder with approaches; if we are, poor countries “could leapfrog” in health and development terms (Upham). Many of the applications discussed focused on SMS and telephony capabilities; we should think about leveraging more advanced capabilities of mobile phones (Kengeya).
9. Who should design technology? There is an assumption that Africans cannot develop software, but that is not true (Adebola). DataDyne software was already developed by Africans (Selanikio). Africans should develop software, but they shouldn’t redesign what has already been built (Brown).

Conclusions/Recommendations:

1. There is a need for increased knowledge-sharing about mHealth/eHealth within the global health community. This should definitely include policymakers. As Prof. Tomori elegantly stated, while we are thinking about how to reach remote populations, we should think about “hard-to-reach” African leaders.
2. While there was discussion of both eHealth and mHealth, the discussion focused primarily on the latter.
3. There is a need for a continuing dialogue about mHealth. It is unrealistic to expect policy recommendations to come out of this meeting given the state of the field (many open issues) and the limited engagement at the meeting.
4. Major mHealth topics to be discussed at future meetings: definitions; standards, including how to conduct evaluation; and successes and failures from the field.
5. The value of the meeting was threefold: (1) it helped extend the network of those working in mHealth; (2) it provided those outside the field with an understanding of the opportunities and challenges of using mobile phones to improve population health; and (3) it placed a much-needed emphasis on prioritizing people and applications over technology.
6. Mechael suggested reviving the Mobile Metrics and Evaluation Group as a means of maintaining an active mHealth community discussion outside of official meetings.

Other observations:

1. The fishbowl format was successful in eliciting relevant commentary from a large group of speakers as well as from the audience. Time was an issue, though, as several invited speakers only spoke once and several audience members had comments or questions that they were unable to share.
2. One key issue that was not explored – as I stated at the end of the session – was the link between social entrepreneurship and mHealth. This is especially relevant to issues of demand, incentivization, and sustainability.
3. There is a need for an ongoing discussion of these issues at Forum 2010 and beyond – while the conversation will continue in other settings, the Global Forum for Health Research should continue to be involved because of its systems focus, its emphasis on actionable research, and the unique mix of parties (policymakers, donors, implementers) it brings together.

In my work in the field, I am no longer surprised to see test stockouts, essential medicines stockouts, supply stockouts, broken or missing diagnostic machines, or patients who are afraid of healthcare workers. It is a complete tragedy, and as I work to help, I think of all the people who are sick or die because of failures of the healthcare system, who cannot tell anyone their stories. For those who do not work in the health system, or haven’t had an experience of health system failure, transparency and data on implementation is practically invisible – so there’s no public awareness of the issues.

So I was thrilled to see recent developments in accountability – the Stop the Stockouts campaign, and the creation of the Budget and Expenditure Monitoring Forum in South Africa.

Power to the People: Stop the Stockouts

Stop the Stock-outs , a multi-country Africa campaign, is using text messages sent by activists and members of the public to expose stock-outs of essential medicines at public health facilities and put pressure on governments to address the issue. It was launched in Kenya, Uganda, Malawi and Zambia by Health Action International (HAI) Africa. During Pill Check week in June, facilities were surveyed, and a map of stockouts was created. The image below incorporates July 2009 data. It was found that many government health facilities were routinely running out of, or just not stocking essential medicines to treat common diseases such as malaria, pneumonia, diarrhoea, HIV and tuberculosis (TB).

“We were finding availability levels in rural, lower-level health facilities of 40 or 50 percent for essential medicines,” said Christa Cepuch, a pharmacist at HAI Africa. Read more from IRIN here

Show me the Money: HIV Policy AND the Budget and Expenditure Monitoring Forum in South Africa

With a new government in South Africa as of May, there have been some very positive signs. Read the rest of this entry »

Credit: PATH

As reported recently on Xconomy.com, scientists at PATH—a Seattle-based nonprofit organization working to improve global health and well-being—have found a cheap and simple way to tackle the challenges associated with protecting hepatitis B vaccine effectiveness when the vaccine gets too hot or too cold. Given how important this development seems, I contacted PATH to ask them some additional questions about this important breakthrough which they have kindly taken a lot of time to answer (many thanks to Amy for working with me on this). The e-interview consisted of the following 8 questions:

1. What was the primary breakthrough?

2. How did you get this done?

3. Why was no one else able to do this before?

4. What are the barriers to applying this to other vaccines? AND how does this change the costs of delivering vaccines in general (does the cost structure change in any way)?

5. What was the approximate cost to achieve this?

6. On the surface this appears to be a major breakthrough, is that how PATH scientists are viewing this?

7. Have you done projections on the increased number of vaccinations that can be done with this new technology?

8. Is this something that can be used in OECD markets?

Temperature regulation is one of the biggest challenges to vaccine use worldwide. According to PATH, keeping some vaccines at stable temperatures requires the use of a vaccine cold chain — a global distribution network of refrigeration equipment and procedures for maintaining vaccine quality during transport and storage. Cold chain storage and exposure to extreme temperatures presents a critical obstacle to delivering needed vaccines to some of the most at-risk regions around the globe. Other research teams in addition to PATH’s are currently using various innovations to address the problem. A group of researchers at the University of Colorado at Boulder, for example, is developing a powdered, inhalable version of a measles vaccination that is ready for human testing. With regards to PATH’s work, the full e-interview is below:

E-INTERVIEW WITH PATH

What was the primary breakthrough?
One of the biggest challenges to vaccine use is temperature regulation. World Health Organization guidelines recommend that nearly all vaccines be stored at 2°C to 8°C. These temperature requirements necessitate use of a vaccine cold chain—a global distribution network of refrigeration equipment and procedures for maintaining vaccine quality during transport and storage.

In many parts of the world, the need to keep vaccines cold during transport and storage requires allocation of scarce resources to cover costs for refrigeration equipment and special handling procedures. A growing body of research indicates that cold chain storage facilities are insufficient to handle the increasing number of vaccines that are being introduced in immunization programs. In addition, vaccines are frequently damaged when they are accidentally or inadvertently frozen or exposed to heat—which, in turn, greatly affects vaccine effectiveness. Improving both the heat- and freeze-stability of a vaccine can help with these issues. Heat- and freeze-stable vaccines are more resistant to damage when temperatures rise and fall due to power outages, faulty refrigeration equipment, or handling errors. Heat-stable vaccines could potentially be moved to storage at higher temperatures (with appropriate controls) to provide space for less heat-stable vaccines.

The heat-stable hepatitis B vaccine recently developed by PATH and partners could be kept in alternate storage facilities (such as air-conditioned rooms) and under alternative transport conditions (such as insulated packaging without ice packs) for potentially its entire shelf life without compromising the effectiveness of the vaccine. The added heat stability can also facilitate outreach to remote areas and enable better heath outcomes when health care providers, for example, travel to remote areas to deliver the necessary birth dose of hepatitis B vaccine to hard-to-reach populations.

Altogether, the heat- and freeze-stabilization of common vaccines, like hepatitis B vaccine, has the potential to improve immunization effectiveness and efficiency—to help to extend immunization coverage by simplifying the logistics and reducing the costs associated with transport and storage of vaccines in regions of the world where the cold chain is insufficient, impractical, or otherwise constrained.

How did you get this done?
PATH and partners tested many formulation approaches and perfected a particularly promising one that combines a freeze-protection method developed last year by PATH with a heat stabilization method previously developed by Arecor. The approach, once tested and refined, includes the addition of common stabilizers to hepatitis B vaccine formulations.  The stabilizers used include propylene glycol—a compound that is found in many consumer products, foods and medicines, and protects the vaccine from cold—and an amino acid called histidine, which contributes to the vaccine’s heat-stabilization.

According to research findings recently published in a July issue of Vaccine (volume 27, issue 34), this freeze- and heat-stable formulation was found to be well tolerated in animal models without any significant local or systemic side effects.  Tests of the new formulation also showed it to be heat-stable for 12 months at 37°C in addition to proving freeze-stable at ?20°C. In partnership with Arecor and the University of Colorado Denver School of Pharmacy, PATH published more recent findings in the August issue of Human Vaccines (volume 5, issue that describe the new hepatitis B vaccine formulation exhibiting nine week heat stability at 55°C and at least six month stability at both 37°C and 45°C.

Why was no one else able to do this before?
To our knowledge, researchers have not previously sought solutions to protect vaccine from freeze-damage through formulation methods. Vaccines that are freeze-sensitive are simply labeled as such and the burden is on health care providers to keep the vaccine at appropriate temperatures. A concerted effort by PATH scientists over a number of years—with support for our project work in vaccine stabilization, funded by the Bill & Melinda Gates Foundation—allowed PATH to tackle this issue head on. The freeze-stabilization method should apply equally-well to all vaccines containing aluminum adjuvant. The heat protection method also arose out of PATH’s vaccine stabilization project and applies a technology from commercial partner, Arecor, to hepatitis B vaccine, which is an important childhood vaccine that is often distributed and used in difficult settings—thus requiring outreach to hard-to-reach areas (to deliver it to newborns in their home).

What are the barriers to applying this to other vaccines? AND how does this change the costs of delivering vaccines in general (does the cost structure change in any way)?
The costs of both additives, propylene glycol and histidine, are neglible.  Scientists at PATH say that the additives cost an extra one-tenth of one US penny per vaccine dose. However, the hepatitis B vaccine is a mature product that has been on the market for some time. To stabilize this vaccine now requires reformulation—plus all the necessary laboratory, preclinical, and clinical work to validate that the new product is still as effective as the existing product. The product must also receive regulatory approval.

Presently, the heat and freeze-stabilization technology has been transferred to one vaccine producer that is undertaking this work to achieve a superior hepatitis B vaccine. By comparison, the freeze-stabilization technology is broadly applicable to all vaccines containing aluminum adjuvant and could be added to any new vaccine incorporating this type of adjuvant. PATH has placed the freeze-stabilization technology in the public domain to encourage uptake.

What was the approximate cost to achieve this?
The development of these formulation methods and the research described in both published studies were conducted in conjunction with PATH’s broad project work in vaccine stabilization funded by the Bill & Melinda Gates Foundation.

On the surface this appears to be a major breakthrough, is that how PATH scientists are viewing this?
Yes, it represents a major breakthrough because the research shows how we can now prevent the problem from the beginning through the vaccine formulation itself.  The application of heat and freeze stabilization technologies to new vaccine products represents a sea change, of sorts, in how vaccine producers could optimize vaccine products—and, in turn, ease logistics for immunization programs as well as expand the reach and ensure the effectiveness of life-saving vaccines.

Have you done projections on the increased number of vaccinations that can be done with this new technology?
It is difficult to project because of the many additional factors that effect increases in the number of vaccinations, for example, the availability of health care workers and transportation for outreach.  That said, PATH has analyzed the projected health impacts and the cost-effectiveness of introduction of thermostable vaccines into three countries—Bangladesh, Cambodia, and Ghana.  For more information, please contact us by email (info@path.org).

Is this something that can be used in OECD markets?
Yes, the heat and freeze stabilization technologies have the potential to optimize vaccine products for OECD markets, as well as vaccine products used by immunization programs in emerging and resource-poor settings.  The challenges associated with maintaining vaccine temperature requirements during storage and transport are not limited to the developing world.  No matter the country, vaccine damage caused by heat or freezing is not a simple problem—it is hard to detect.  You can’t always tell whether or not a vaccine has been rendered ineffective simply by looking at it.  The U.S. Centers for Disease Control and Prevention estimates that poor refrigeration wastes hundreds of thousands of doses of vaccine every year, costing the U.S. health care system millions of dollars and, when noticed, requiring children and others who need vaccination to be reimmunized.

As promised earlier, here is a brief account about the design+water workshop I conducted in Mexico in June.

Two months ago, I was in La Paz, Mexico at NGO Fundación Cántaro Azul, helping them build organizational capacity in human-centered design (HCD).  Cántaro Azul works to improve access to safe water and sanitation for disadvantaged communities, not only in Baja California Sur, but in other parts of Mexico, and abroad. Their interest in HCD is two-fold: to improve existing initiatives and to innovate new approaches.

I recently completed the workshop final report for the organization. In the hopes that the work may be helpful to others, I’m posting the synopsis of the report here, along with some workshop photos. If you’re interested in accessing the report, please contact me directly.

Design thinking workshop final report: Safe water options with rural community stores in BCS 

Fundación Cántaro Azul • La Paz, Baja California Sur, México 

Jaspal S. Sandhu, Ph.D. • July 2009 

This document describes the outcomes of a week-long design thinking workshop held at Fundación Cántaro Azul (FCA) in La Paz in June 2009. The workshop aimed to build design thinking capacity at the organization while working on a problem of actual importance to FCA. The most important practical outcomes of this workshop were two complementary models for providing a clean, affordable drinking water choice for rural people in Baja California Sur via community stores. The primary audience for this document is FCA. It is intended to help them with ongoing activities focused on the community store model and in incorporating this approach in their various activities. The workshop was designed and facilitated by Jaspal Sandhu, the report author. Workshop funding was provided by the Blum Center for Developing Economies at the University of California, Berkeley.

Shown below: Field research during Day 2 and Day 3 of the workshop. (1) Using an auto-servicio system in La Paz (top left); (2) interviewing a user at a rural, government-run purificadora in San Antonio (top right); (3) debriefing after the San Antonio research (bottom left); (4) and obtaining water samples to test from a home in Rosario (bottom right).

As many of you may know, the tiffin delivery/dabbawala system in India has achieved remarkable rates of success in setting up a complex delivery system. Their ability to deliver millions of meals a year without making mistakes makes me think about how this system can be transferred to healthcare and for what purpose… something to think about. As Dr. V took inspiration (WSJ, PDF) from a highly standardized and high volume system, I am wondering the same thing for a system already in place in a low resource setting. Food for thought, well worth checking out:

From The Economist (link):
“Using an elaborate system of colour-coded boxes to convey over 170,000 meals to their destinations each day, the 5,000-strong dabbawala collective has built up an extraordinary reputation for the speed and accuracy of its deliveries. Word of their legendary efficiency and almost flawless logistics is now spreading through the rarefied world of management consulting. Impressed by the dabbawalas’ “six-sigma” certified error rate—reportedly on the order of one mistake per 6m deliveries—management gurus and bosses are queuing up to find out how they do it.” Full story link here.

Hat tip Intangible Economy.

‘The Biggest Challenge Is There Is No Organized Supply Chain’

This headline in Wharton’s newsletter intrigued me, only time for a quick posting, but this is certainly food for thought. Wal Mart is expanding operations in India and there are two quotes of note that we should think about in the context of culture; delivery and distribution of medical/health goods to those in need; and in the context of refrigeration of medication and/or vaccinations:

===========

“The biggest challenge is that there is no organized supply chain in India. We’ve even been surprised by some of the leading manufacturers in India like Unilever, Procter & Gamble, and some other big names, who are actually welcoming the arrival of organized supply chains in India and Wal-Mart pioneering that effort. Because of the lack of that supply chain today, there is no forecasting, there is no understanding of how demand is. It’s largely a push based system. So, I think, getting that transparency across the supply chain will be very unique.”

“The other thing is, there is no refrigerated cold chain for fresh produce in India, so therefore a lot gets wasted. By McKinsey’s own work, which the consulting firm has done, almost 40% of fresh produce in India gets wasted from farmland to the time it reaches the consumer.”

“India is very unique. In fact, I have lived in China, so maybe I can say it with a little bit more liberty that the only thing common between India and China is the one billion people. If you really operate in the two countries, I think, there are very different consumers, very different kinds of legislation, very different levels of economic development, social infrastructure, and governmental management of the economy.”

 
Read the full interview here.

Nov 14, 2006
Scojo Foundation Wins Fast Company Social Capitalist Award

Fast Company and Monitor Group Recognize Innovative Non-Profits for Applying Business Savvy to the World’s Toughest Social Problems

“New York, NY (November 14, 2006) — Scojo Foundation, a non-profit social enterprise that works to improve the economic condition of families in the developing world by broadening access to affordable reading glasses, is honored to be among the 43 winners of the 2007 Social Capitalist Award…

Employing market-based solutions to address this crucial public health issue, Scojo Foundation trains microfranchisees, or “Vision Entrepreneurs,” to run profitable businesses conducting vision screenings within their communities, selling affordable reading glasses, and referring those requiring advanced eye care to reputable clinics.” The full press release can be found on the Scojo Foundation website.

From Fast Company: The amazing organizations that received the Fast Company/Monitor Group Social Capitalist Awards have found a better way to do good: They’re using the disciplines of the corporate world to tackle daunting social problems. In our third exclusive ranking, we used a similarly hard-nosed approach to find the 25 best social entrepreneurs.

Paul Farmer gave the second of two keynote addresses at today’s opening of the APHA (American Public Health Association) Annual Meeting – the first was from Helene Gayle, now President and CEO of CARE International. In reporting on his address, I have quoted him as directly as possible, and where appropriate.

The theme of this year’s conference is “Public Health and Human Rights”, and as it is in one of Paul Farmer’s backyards (Boston), he was a well-suited speaker. The overall message was an extension of his 1999 article “Pathologies of power: rethinking health and human rights” (American Journal of Public Health, Vol 89, Issue 10 1486-1496). In short, he argued “prevailing orthodoxies” in public health center around the “crude” concepts of sustainability and cost-effectiveness, while the focus should be on social and economic rights. “[Sustainability and cost-effectiveness] are tools we need, not religion.”

The more practical message was that we need to address more immediate, material concerns, such as food, clean water, drugs, and medical supplies – much of which can be considered “wrap around services”.

“There should be a right to sutures. There should be a right to sterile drapes. There should be a right to anesthesia … We will need gloves, sutures, drapes, and hot, clean water. This is uncharted territory for human rights groups. We here are ready to talk about gender inequality, but to few of us are ready to buy generators, sutures, or [operating room] lamps … [This] may not seem sexy to people commenting on health and human rights.”

I was delighted to hear his talk touch on such “unglamorous” issues as supply chain and procurement.

He is still very committed to his ideology of providing equivalent technology to poor people. While this is certainly the most effective and ethical approach in many cases – as he has demonstrated to the rest of the world – it is unclear that this is always in the best interests of poor people. I argue not from the point of “cost-effectiveness”, but rather of “effectiveness”. Take for example his advocacy for clean water and infant formula in Rwanda. A colleague who is an expert on breastfeeding reported that people at this year’s International AIDS Conference were highly critical of this approach because of the increased potential for infant deaths from diarrheal diseases. Significant, comparative research over the last few years has shown that while formula is effective for PMTCT (prevention of mother to child transmission) of HIV, breastfeeding results in fewer overall infant deaths. One key is the lack of access to clean water, which results in diarrheal disease, while another is the protective nature of the breastmilk itself. Farmer’s response, no doubt, would be that Partners in Health will provide all the clean water necessary. Achieving this for small communities will be difficult, but not impossible – achieving it at a large scale will take considerable time. In the short-term, breastfeeding seems to be a much safer bet.

Several nursing colleagues and I went to dinner in Chinatown, where we discussed Farmer’s talk. The consensus was that Farmer often makes it seem as if nothing positive is being done in the sphere of international health.

Despite some concerns about his ideology, he provided a strong, persuasive, and needed message. His quote from a young Kenyan doctor, lamenting about working conditions and supplies, sums it up best: “I did not go to medical school to become a mortuary attendant.”