“Being born in a certain place conditions you”. Health, right to the city, crisis and participation in a relocated neighborhood

Abstract

The present paper analyzes, in the context of a settlements’ relocation, the participation and tactics developed by the Barrio Nuevo inhabitants and doctors of a Health Centre in La Plata (Argentina), to face the crisis that is taking place in the country from the application of austerity policies. Our assumption is that community participation and in health issues (understood in a holistic sense) makes it possible to identify and intervene in social conditions, such as the right to the city, to produce changes in the health situation of the territory. For this, we will investigate the crisis, the current public policies and the modes of participation. Specifically, we will develop the experience of a Health Situation Analysis (ASIS) held in the territory and we will analyze the relationship between the right to health and the right to the city.The methodology used is ethnography. We carried out participant observations, in-depth interviews, a health workshop and participated in the ASIS.We conclude that there is a dialectical relationship between the right to the city and to health and this is a collective construction. All community participation strengthens health interventions. This is essential in crisis contexts to fight for violated rights.

Key words
Health; Crisis; Participation; Right to the City; ASIS

Resumen

Este artículo analiza, en el marco de una relocalización de asentamientos, la participación y las tácticas de los/as habitantes de Barrio Nuevo y médicos/as de un Centro de Salud de La Plata (Argentina) ante la crisis acontecida a partir de la aplicación de políticas de austeridad.El supuesto del que partimos es que la participación comunitaria y en el campo de la salud (entendida en un sentido holístico) posibilita identificar e incidir en los condicionantes sociales, como el derecho a la ciudad, para favorecer transformaciones de la situación de salud del territorio. Para ello, indagaremos la crisis, las políticas actuales y los modos de participación. En particular, desarrollaremos la experiencia de un Análisis de Situación de Salud (ASIS) en el barrio y analizaremos la relación entre derecho a la salud y derecho a la ciudad.Se empleó una metodología etnográfica. Se realizaron observaciones participantes, entrevistas en profundidad, un taller de salud y se participó en el ASIS.Concluimos que hay una relación dialéctica entre derecho a la ciudad y a la salud y ésta es una construcción colectiva. Toda participación barrial fortalece las intervenciones en salud. Ello es indispensable en contextos de crisis para luchar por derechos vulnerados.

Palabras clave
Salud; Crisis; Participación; Derecho a la ciudad; ASIS

Introduction

The present paper, as part of a post-doctoral research, has the purpose of analyzing the tactics¹ of the Barrio Nuevo inhabitants and of the doctors of a Primary Health Care Center (CAPS) within a framework of a relocation facing the crisis in Argentina. Our assumption is that community participation and participation in the health field² (understood in a broad sense) allows to identify and influence the social constraints, such as fair access to habitat and the right to the city, in order to favor transformations in the health conditions of the territory. For this, we will describe the crisis, the current public policies and the ways of participation built – understood as tactics- to modify the health condition of the place. Specifically, we will develop the experience of a Health Situation Analysis (ASIS). Along that same line, we wonder: How is the crisis experienced in the health center (CAPS)? What tactics are adopted by the parties to intervene?

It is worth mentioning that Barrio Nuevo is the result of a relocation of settlements placed on the bank of a stream called El Gato, and this is why most of its inhabitants do not know each other. After the flood in 2013 – one of the most serious floods affecting the city –, the Provincial Housing Institute (IVBA) started a relocation to undertake hydraulic works. The moving process took place between 2015 and 2018 and it implied moving families to temporary houses first (made of durlock) and then to permanent houses (made of brick). As to the services, there is only gas in some permanent houses; the IVBA guarantees that water is potable, although many neighbors disagree; and the power connection is temporary, supplied by the builders. With the purpose of describing the sociodemographic features of the territory, we reveal in advance the results of the preliminary report of the ASIS³, which states that 70% of the population live in permanent houses and 29% in temporary ones. In this report it is explained that “in 57% of the survey homes there are less than 2 people per room, while in 39% there are 2 to 3 people. In the 4% left, there is critical overcrowding”. In connection to income, taking the reference values provided by The National Institute of Statistics and Censuses (INDEC), it is confirmed that 49% of the inhabitants live below the indigence line and 42% below the poverty line. 70.85% have access to public health system.

Few blocks away from the neighborhood, there is the abovementioned CAPS, which has in house staff and medical residents. In 2018, a health center – with a narrower range of health services – was opened in one of the permanent houses. The doctors of the CAPS worked here for some weeks while their center was being repaired.

It is important to emphasize that the Argentinian health system is made of the public, the private and the social security sector. According to the doctors of CAPS, it is a mixed but not integrated system: there is not a good organization. They explain that the public system is divided in Nation (in charge of a health philosophy), Provinces (in charge of regional implementation) and Districts (local implementation).

Here we focus on the first level of attention, formed by the centers which prevent diseases, treat frequent pathologies and typically make a direct connection with the territory. An example of this are the CAPS, which favor the access of communities to health services.

Methodology

We employ an ethnographic qualitative methodology⁴. As a continuation of the doctoral dissertation⁵, whose field work was made between 2013-2017, we made for this paper between 2018 -2019: 1 field notes, 4 in-depth interviews to women neighbors, 2 ad hoc group interviews to the doctors of the CAPS, participant observations of the events; we also participated in an ASIS, in a health workshop and in meetings to evaluate the results of the survey conducted.

In ethnography, thick description⁶ and part of the viewpoint of the individuals involved in the practices have a central role. This is why the selection of the corpus was made on the basis of the observation of women predominance in the role of health care. The women neighbors told us that they took care of their family´s health and participated in the making of the ASIS. We realize, however, that interviews with men might produce other results, which we plan to analyze in future papers. Among the doctors, there were both men and women. The names of the participants are not revealed for the sake of their privacy.

Crisis in Argentina

A woman arrives at the health center. They have just told her that the following day she will have to travel by ambulance to the Garraham Hospital (60 kilometers away) so that her baby with cancer can undergo some tests. There isn´t a car available and her only option is the train. Finally, the husband of a nurse takes her to the place and solves the problem by building up a “network”, as doctors of the CAPS state.

Field notes from October 3^rd 2018.

Barreto⁷ argues that the current austerity policies cause concern due to the damages done: he points out that as from 2015, with all the government changes, neoliberal policies were adopted, which provoked a crisis – understood as a social political process- and had an impact on the health field. According to a report provided by the Center of Social and Legal Studies⁸, in 2018 there was an exchange crisis in Argentina that devalued more than 100% the national currency against the US dollar. The government requested a loan from the International Monetary Fund and committed to make a reduction in public expenditure, and this, according to the report, affects health. In connection to the history of the country, as agreed by Chaloum and Varas⁹, foreign debt becomes larger and public investment in health is reduced. Therefore, the provinces are forced to face the situation but unfortunately, the sharing does not cover transfer costs and that affects the area.

Austerity policies jeopardize access to human rights, such as health and habitat. According to reports of the Sanitary Sovereignty Foundation¹⁰, in Argentina the health budget was reduced; the government dissolved the Ministry of Health and turned it into a Department. Now some of the consequences are: doctors’ salaries are reduced, there is a lack of supplies and professionals in public hospitals, there are dismissals in public health and infrastructure problems. About all this, doctors claim that “when it was a Ministry, the national Government gave the plans to the different Districts, apart from epidemiological surveillance, from considering catastrophes, from organizing collaboration with international entities and management. Today, all this has been left to the market and is shifting to a private system”.

We point out that, beyond what is outlined here, there is no official information about the impact of the crisis in the area of health in La Plata. According to the interviews, the CAPS are essential spaces within the system and they are affected by the reduction. Following official data¹¹, there are 46 in La Plata. Doctors think that “the crisis is more clearly seen in the first level because it is level where you have more access to the community. The complexity of the cases we treat is related to the current social complexity”. In connection to the health centers in La Plata, they explain:

This is a district that has never prioritized health for having relied on the provincial system. As La Plata is the capital of the province, there are a lot of hospitals; therefore, when people cannot solve their problem in the health center, they go to the hospital. This is the reason why there has never been a serious sanitary policy for the first level, says a Doctor.

Doctors described the CAPS situation: they mentioned the lack of professionals (they needed an obstetrician and a psychologist) and they defined the building conditions as “deplorable” and “precarious”. These deficiencies were clearly demonstrated with the lack of gas in winter, the electrification of walls and the risks that both situations implied. Moreover, they did not received medication to keep the treatments:

When you call the pharmacy or the dispensary of the Health Department, they tell you that there aren´t many things and that they probably won´t be sending any for a while, says another Doctor.

As a consequence of not getting any answers, doctors come up with “handmade” solutions by creating “networks”: they get in touch with other hospital or colleague.

They also confirm the appearance of diseases that should be eradicated by now: “Syphilis is an old disease that with a more or less serious sanitary policy can be eradicated. The same occurs with tuberculosis. Diseases from the 20^th century: the cure exists and is cheap. These are in general diseases of poverty”, they argue. This is connected with the Di Virgilio’s¹² suggestion which considers that the social character of health- disease is understood in the specific ways of getting sick and dying of the communities: “It should be possible to identify differentiated epidemiological profiles according to the position of the agents in the social structure”. Spinelli² adds that the causes of the epidemiological problems affecting the groups are social inequality and aspects related to what we call here right to the city: access to water, housing, work, etc. This concept refers to the right to build cities according to our needs and wishes¹³ and it includes the right to habitat – that is why the neighborhood is so important-, to live in a healthy environment, to have a proper house, to health and participation. Thus, its importance as a determining factor of health.

Due to the above and to the attempt of transferring a female doctor to another CAPS or firing her if she refused to leave, in 2018 a “Hug to the Health Center” was organized and it consisted of a meeting in front of the health unit of health workers, neighbors, community and union leaders. As a result of this meeting, local authorities promised to keep the doctor and guarantee supplies and infrastructure requests. The assessment was the following:

We were surprised by the support of the community; they were a lot; also, their words were moving. We can change people´s lives, working more or less well and with very little, guaranteeing a basic right such as health – Doctor.

We went with the whole neighborhood to support the guys. It was very touching – Neighbor.

Thielmann¹⁴ explains that the crisis affects health due to its negative impact on everyday life, on working and social conditions, insecurity, poverty. Therefore, in connection to the neighborhood and from the basis of interviews, informal conversations and participant observations in the meal center, we confirm that the crisis is observed in the fact that many people have lost their jobs recently, the number of families going to the meal center has increased – a meal center where resources were scarce to supply the community (for this reason, a non-profit association was created to demand resources from the State) –, as well as the use of drugs among young people (the neighbors state: “There are a lot of drug dealers over here and the police does nothing. Before we moved here, there weren’t so many”; “There is a lot of drug here, in the other neighborhood there wasn’t”): all of this is related to the constraints that we will see below. Apart from the abovementioned techniques, this last fact is confirmed in the ASIS preliminary report, where it is stated that for the inhabitants the main problem is drug use.

Discussion

Considerations on health

We suggest moving away from the simplistic vision that emphasizes the health- disease binomial. We start from a rights perspective, which focuses on processes, getting away from the idea that compares health with the state of complete well-being. The health-disease-attention-care process is understood from a sociocultural and dialectical dimension. Then, health refers to a collective, historical construction, constituted by scientific, popular knowledge, social norms and practices.

Ávila-Agüero¹⁵ says that “different determinants or factors contribute to health, which have to be considered as part of the concept of health” and that they are related to family aspects as well as environmental, economic, sanitary and cultural, among others. These are (adjustable) elements that condition the health of individuals. Here, we prefer to talk about constraints because determinants account for a linear cause-effect relationship with which we do not agree and whose use is risky in social sciences since it makes it possible to fall into biological views that we dismiss.

Along that line, the UN Committee on Economic, Social and Cultural Rights indicates that the right to health is connected with and depends upon the exercise of other human rights¹⁶. It implies attention to health and its constraints: access to appropriate housing, potable water, healthy environment, etc. Therefore, the habitat and the right to the city are major constraints: health difficulties transcend the biological; they are political, social and economic matters; and these two aspects play a fundamental role. Just as Junge¹⁷ suggests: “health is part of the vital experience of people and life is not restricted to physiological factors; in consequence, health cannot be reduced to a biomedical approach”.

Ávila-Agüero¹⁵ points out the need of creating the conditions for the individuals to develop their self-care. According to her, access to information is not enough and she calls attention to the links between health, habitat and public policies. She considers that the majority of health problems are due to socioeconomic conditions but in this field, solutions centered on the treatment of diseases predominate, without intervening on the “causes of the causes”.

Social constraints are related to the contexts in which the individuals live. Some of them are: housing, diet, participation, education, work, spare time. They are connected with the public policies in the area and that has – not deterministic- consequences for health. This is the reason why relocation is so important in the health of the families of Barrio Nuevo. The emphasis on the constraints is essential to our analysis, where we will investigate the tactics employed in order to face the crisis.

The relation between the health center and the neighborhood

A doctor sees a four-year-old boy climbing the train tracks. He comes closer, shouts at him and the boy goes down. A woman from the neighborhood talks to the child while another resident removes thorns from his bare feet. The boy, who barely talks, asks for something to eat. They give him cookies, although they think he might have celiac disease. Government institutions know the situation but due to the lack of funding – or will – they do not intervene.

In Argentina, the definition of State emphasizes multiplicity. With the neglect of the government and the crisis, it has never been so clear that the State is all of us.

Field notes from July 16^th 2019.

The Health Center is just a few blocks away from Barrio Nuevo and its program area comprises this and other neighborhoods with similar socioeconomic characteristics.

As to the epidemiological data of the population, the doctors interviewed suggest considering them from a population base in which, according to the ASIS, a child population predominates. They observe low weight, short size and neurodevelopmental disorders: “The majority of their causes are social or parenting issues”, they affirm. They also add that many of the current biological diseases, such as respiratory cases, are related to family dynamics and life issues: “There is a social determination of health: being born in a specific place conditions you”, they say. Other common diseases are parasitosis and scabies; and finally, they explain that there are situations they consider to be part of health and that take place in the neighborhood: gender-based violence and violence against children.

For their training, the residents at the CAPS do community work, moving away from the “hegemonic medical model”¹⁸, and they develop the “migrant post”, which means “getting out of the office to share with the community in different places”.

In this way, they started going to the neighborhood in October 2016 since they were having unknown patients in their office. At that time, there were few permanent houses in Barrio Nuevo and most families lived in temporary houses; it was a context of “complete absence of the State”, they say. Their first contact was through the meal center:

We started to be in charge of the breakfast/tea time so that we could start working on some issues with the children: a mapping was made, also games and different activities. Some of us in the meantime looked after patients and gave appointments – Doctor.

Moreover, workshops on women health were organized and also events with other people who participated in the neighborhood for its integration. They also constituted an internal training space for the approach of community work since they wanted to avoid a healthcare activity like the one they did within the CAPS and instead, favor a practice putting into play a concept of integral health.

Then, in order not to impose their own prejudice or what they considered to be the population priorities, they decided to organize an ASIS, making emphasis on the need of participation of the neighbors in order to avoid that neoliberal governments “take all your rights away from you”. As a result, they organized meetings where they worked on the idea of health and considered together the survey.

Such interventions constitute tactics to fully address the neighborhood health with the purpose of bringing about transformations to it in a context of political, social and economic crisis. We talk about tactics as “land of the weak”¹⁹ in the sense that these people acknowledge the rules of the game and the limits established by the hegemony but also find cracks which allow them to act and adopt tactics as a kind of resistance for the purpose of emancipation, democratic strengthening and equity²⁰.

Analysis of health situation in Barrio Nuevo

Neighbor: I´d like a new health center because many people here need one.

-And what did they say?

Neighbor: Garro (La Plata Mayor) said that they were working on it so that it could start functioning as a health center and not as a stand because a stand has nothing to do with a health center. The stand is less than a center. I hope that with the help of the survey this can finally be done.

The survey the neighbor makes reference to is the ASIS, in which she places expectations so that it becomes a tool of struggle for the opening of a new CAPS. This is carried out within the framework of community work undertaken by the residents and in a context of crisis deepening. According to Pría Barros et al.²¹, this is a significant activity in the Primary Health Care, whose purpose is to “identify the socio-psychological, economic, historical, geographical, cultural and environmental characteristics that have an impact on the health of the population, as well as the health problems presented by individuals, their families, groups and the community as a whole, in order to perform actions that contribute to a solution”. That is to say, knowledge is needed to intervene, so that the production of local knowledge becomes a tool which contributes to the organization and the struggle to access resources and rights.

To make an ASIS it is essential to start from a holistic conception of health. Thus, we emphasize the influence of living conditions in health. Di Virgilio¹² asks himself about the consequences of the neighborhood environment in the health-disease processes and he argues that it has an effect due to the influence of lifestyles, the coexistence with violence situations, the risks connected with epidemic outbreaks, etc. Chiara²² also adds that “the unequal life conditions, the environmental risk factors, the mobility, the access to services and the relations between services and establishments are some of the problems that show the relevance of the territorial dimension in health policy”. In other words: it is essential to know the access (or not) to the right to the city to investigate the health situation of the neighborhood.

As we pointed out in the section “Methodology”, it is important to remember that we participated in the ASIS at the time of conducting the surveys. The survey itself was carried out between October and December 2018 and 284 homes were surveyed out of a total of 393. The rest were not consulted since no family member was found. An attempt was made to survey the whole population and not only the one going to the health care in order to make visible problems often ignored by the health field.

The ASIS was performed together with inhabitants of Barrio Nuevo and the residents were in charge of it. During the diagnosis and survey stage, the work was coordinated with the Network Department of the School of Medical Sciences, the Health Department of the National University of La Plata and the District Health Department. The aim was to have a clear idea of the characteristics of the place and to identify its social constraints to make a diagnosis and a plan of action so as to change the community health situation.

In October, two meetings were held at the meal center, where the work of the CAPS was presented as well as the history of the neighborhood told by two neighbors. Also, the place was inspected, theoretical knowledge was shared and brochures were distributed so that the whole community was informed of the survey. Then, six sessions were organized to survey with the mentioned groups and two with residents only. Finally, a meeting was arranged with experts in the survey technique to think about data systematization and to train us in georeferencing in view of the information processing which is carried out in 2019.

According to Pría Barros et al.²¹, when the ASIS is first performed in a community, it is essential to investigate cultural, historical and geographical matters. Thus, the confidential survey had the following main points, several of which were proposed by the neighbors: personal information (nationality, gender, level of education, occupation, income, health insurance), origin before relocation, self-perception in connection with health, place of assistance in case of a health problem, performance of recreational activities, participation in organizations, participation in neighborhood events, problems and positive aspects of the place.

Another issue to highlight is that the family was taken as the unit of analysis. This will allow to identify those who are at risk, with some disease or healthy for the purpose of prevention, promotion, etc. As reported by Pría Barros et al.²¹, this is very significant because it is the first link to share habits that are good for health.

After the systematization and analysis, an action plan will be prepared based on the problems that both neighbors and doctors consider to be the most urgent. That is to say, emphasis is made on participation and on the need to go beyond the diseases of those attending the CAPS and address the constraints, especially in crisis contexts. For example, during the survey, we reconstructed the following stories which give an account on the crisis and the life conditions: an adult was a member of a cooperative but in order to guarantee his family´s food, he did extra work, such as mowing the lawn (violation of the right to food); a pregnant woman and housewife cancelled the cable because she could not afford it (violation of the right to leisure); a family did not have gas because they could not pay for it (violation of the right to access adequate services); many children assisted the meal center but during repeated visits in 2008, we noticed the presence of old people (violation of the right to food sovereignty): all this describes constraints that affect – and harm – the inhabitants’ health and thanks to the field work started in 2003, we state that they have been strengthened in crisis contexts, such as the current one, since they cause distress and cannot guarantee the satisfaction of basic needs. Following the same line, Merlín²³ says: “Neoliberalism makes people sick because distress manifests itself in the body”.

Barreto⁷ points out the urgency of studying the consequences of the current austerity policies – with emphasis on the constraints – in order to extend existing research and include the Latin American perspective. For this purpose, we consider it will be necessary in our case to systematize and study the data provided by the ASIS together with other techniques, such as the semi-structured interview, to deepen the analysis and include approaches on the constraints in the action plan.

In conclusion, for the abovementioned subjects, the ASIS provides information about the needs of the population in order to collectively plan interventions from the health field, all of which is essential when resources are scarce and problems are exacerbated by the crisis. From an integral perspective, community practices that favor the social fabric are healthy. Therefore, neighborhood organization is encouraged and accompanied by the health center.

Other participations

Every relocation entails crisis and losses because it implies the abandonment of the community and the home²⁴. For this reason, participations become more relevant as they contribute to the strengthening of health and its constraints. For instance, without the networks we will mention, the participatory performance of the ASIS would have been more difficult. Kees Bahl²⁵ suggests that neighborhood participation and integration are essential to overcome health problems and its constraints and he understands that the absence of a common neighborhood history involves loneliness, which is for him problematic in reference to care – and we add that it is also problematic in relation to uprooting, a highly possible consequence of relocation. Therefore, participation affects health in broad terms.

We would like to stop to look at these aspects in more detail since in 2008, after an armed conflict with a bordering neighborhood, the neighbors got together with the aim of achieving neighborhood unity and supporting children and young people. Together with external contributors (doctors, university and state referents, etc.), some events were organized, such as food fairs and football tournaments, Children’s Day celebration, etc., which favor the sense of belonging to the neighborhood and the establishment of social relations.

The neighborhood used to be perceived as an unsafe place with a completely disjointed social fabric, but these interventions contributed to providing it with other meanings and to strengthening bonds, all of which are connected with health since, according to the neighbors: “health is living in a safe place” and it is about creating places for distraction. We notice that participation helps in the creation of safe spaces and thus, the neighborhood can be inhabited in other ways: with less fear, with organization, solidarity. For Mozo²⁶, we have to encourage interventions that involve “prescribing sociability”, which is practicing “Preventive Medicine”, practicing “demedicalized medicine”, influencing health by understanding it from its constraints.

Conclusions

- What do you think about the relocation?

Male Doctor: - Having your own house is a right, and with all the problems these people have had, now they have accessed a right.

Female Doctor: at the same time, other rights were violated, such as the right to choose.

Male Doctor: It also depends on who you talk to because there are a thousand neighborhoods inside the neighborhood. Many people came here after being relocated in a very disorganized way, from one day to the next, causing them deep distress; others were in the street and the next day they had a house.

Male Doctor: There are also people who built their house and had it demolished and that is…

Female Doctor: …their story.

We consider that from this case study, knowledge is acquired to transcend it and analyze health and its approaches in Argentina. Along these lines, we have tried to highlight the importance of thinking about the access to the right to health in an inseparable way from its social constraints, and thus, from the right to the city, since there is not an extensive literature on this topic. Therefore, we can establish the dialectical relation between these concepts and state that there is not access to health without the right to the city as there is not complete exercise of this right without access to health. In fact, those of us who work with this perspective understand that health is an inseparable part of the right to the city and hence, it is important to think about health from the relocation. Ávila-Agüero¹⁵ says: “It is unbelievable that we assist patients in hospitals and we make them recover their health just to see them return to the same unhealthy conditions of precariousness, poor diet and poverty that made them sick in the first place” and in this sense, the relocation implied improvements in the housing situation of many families.

Thompson Fullilove²⁷ argues that in relocations people suffer from what is called “root shock”, a term coming from gardening, which describes what a plant goes through when it is pulled up from the ground: it enters a state of shock and can die. With this metaphor, the author explains that both home and neighborhood provide a sense of settlement and relocation causes trauma and shock, which are here discussed in terms of health from the community work. In this regard, Kees Bahl²⁵ points out that there are problems and health facilitators in the territory, for example: “the fact that the neighborhood is becoming integrated involves the development of bonds and support for difficult situations (…) and creating a different way of inhabiting the city is, ultimately, part of the right to health”.

Participation plays a significant role not only in the right to the city but also in the right to health. In this connection, we are allowed to move away from a concept of health in which the professionals´ perspective prevails and instead, emphasize knowledge, perceptions and feelings of the individuals. It is important to leave the hegemonic medical model that highlights expert knowledge and strive for a conception of health that contains the excluded viewpoints: following Róvere²⁸, the essential task in health is inclusion. Neoliberalism sees health as something individual and here, we understand that it is a collective construction, which transcends what occurs in the office, and that any form of community intervention facilitates or strengthens interventions in health. Participation becomes even more relevant in crisis contexts because it allows to rethink and strengthen the community and collectively fight for rights violated by public policies, as was the case of the “Hug to the Health Center” and the ASIS. We also believe that it is essential in good socio-economic contexts as it helps to continue establishing social ties and take care of achieved rights, all of which are part of health. But in times of crisis, participation is more significant because economic adjustment cuts social rights and tends to de-collectivize society.

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Publication Dates

• Publication in this collection
  25 Nov 2019
• Date of issue
  Dec 2019

History

• Received
  24 Jan 2019
• Accepted
  12 July 2019
• Published
  27 Sept 2019