Wednesday, 10 July 2013

More the Merrier? - World Population Day

Instead of controlling the environment for the benefit of the population, maybe we should control the population to ensure the survival of our environment. - Sir David Attenborough

Golden words, these, especially as the world population exceeded an astounding 7 Billion in 2012. The United Nations recently issued a report that anticipates world population to reach 9.6 billion people by 2050.

The World Population Day is observed as an annual event that marks the date when the world's population reached 5 billion (11 July 1987).

Population Explosion has huge implications on areas like overall sustainability, access to infrastructure & basic health services. The theme for the 2013 World Population Day is specifically to raise awareness on the issue of adolescent pregnancy and the essential role played by reproductive health to create an equitable world where every young person’s dreams are fulfilled.

It is estimated that around 16 million girls under the age of 18 give birth each year while another 3.2 million undergo unsafe abortions. This is largely the consequence of discrimination, rights violations, inadequate education or sexual coercion.

Some of the other areas that are resulting in increase in Population include:

Some of the ill effects of this exponential growth in Population especially in developing countries like India are extremely significant. With a total population of 1.21 billion as per the latest Census, the pressure on resources is immense. Here are only some of the pain areas:
The recently released 2013 Failed States Index (FSI) throws up some alarming statistics on World Population. The population of the 20 countries that had the worst scores in the 2013 Failed States Index currently total 813 million. According to the UN Projections, these numbers will more than double over the next 37 years & the constitution of these countries in the world population will increase from 11% now to 18% in 2050.

In many of these countries, forty percent or more of the population is below the age of 15, and hence will soon enter the reproductive stage. The list was topped by Somalia & includes countries like Sudan, Yemen etc.
Efforts are clearly required to keep the growth in check. Primary among them, especially in the Indian context being:
  • Spread of Education
  • Women’s Literacy & Employment
  •  Family Planning Facilities.

With sustained efforts, population growth rate is a variable that can be de accelerated.
The UN has set 2015 as the target year for achieving universal access to family planning and reproductive health services. There is a long way to go, however,on that front.
In the mean time, here is an info graphic, courtesy A graphic view of the world, had the world been inhabited by just 100 people, throws up some  interesting statistics. The first that catches the eye, is that of 100 people 17 would be unable to read this info graphic on account of illiteracy.

Friday, 5 July 2013

Remaining Healthy in Monsoons

The rain gods have been more than generous this year and as is the norm, have brought their fair share of problems for the average or should we say mango people with them. Endless traffic jams, water logged roads and bottomless potholes are just one end of the story. There are the more worrying problems of water and air borne diseases which thrive in the monsoon season.

Stagnant water, dampness and muck are ideal breeding grounds for diseases and children are particularly vulnerable to catching them. Diseases most commonly prevalent in the monsoon season include 
Malaria is the most common disease in the monsoon season and is one of the deadliest diseases in India with a very high mortality rate.  The Female Anopheles mosquito which is responsible for spreading malaria breeds mostly in stagnant water and hence monsoons with water logging provide ideal breeding conditions. Symptoms include fever at regular intervals, headache, nausea shivering, muscle pain and weaknesses.
  • Consult a doctor immediately if you or anyone in your family is showing any of the above symptoms as condition can deteriorate very rapidly if not treated in time.
  • Quinine-based anti-malarial drugs like Chloroquine or Primaquine are generally prescribed. Bed rest is generally advised and the patient should be kept warm at all times.
  • Consuming plenty of fluids and electrolyte when suffering from malaria helps  prevent dehyrdration from nausea and vomiting.
Prevention measures include ensuring that there is no stagnant water in and around your area. Using mosquito repellants and nets, as well as spraying DDT in open drains are some of the other measures to prevent the breeding of mosquitoes. Contact your local municipal body immediately if you have an overflowing sewer, water clogging or un-tidied dump in your area as these can be potential breeding grounds for the Female Anopheles mosquito.

If there is no proper garbage disposal facility in your area with the result that garbage is strewn on the roads and in the sewers, chances of catching any of the monsoon diseases of cholera and typhoid are extremely high. The best remedy in such cases is to form a local group to work with your local MLA to ensure placement of bins as well as regular disposal of waste from your area.  
Cholera, another deadly disease of the monsoons is caused mainly by consuming contaminated food and water as well as by poor hygienic conditions. Cholera is a highly contagious disease as flies act as carriers of the disease; hence it is very commonly prevalent in areas with poor sanitation facilities.  Symptoms include severe diarrhea with watery stools. There is plenty of fluid loss in the first few hours, leading to rapid weight loss and severe muscle cramps. Shrunken eyes are a very common symptom. Children infected with cholera will show symptoms of fever, convulsions and may even become comatose. Adults, on the other hand, experience mental apathy.
  • Although fairly easy to treat, cholera can prove fatal if left untreated.
  • Consult a doctor immediately.
  • Treatment includes putting the patient on oral rehydration therapy with antibiotics like Tetracycline to supplement rehydration.
Immunization is the best prevention for cholera. An immunization is effective for about six months and needs to be taken again after 6 months. A person vaccinated for the first time should be immunized again after 10 days. In cholera areas prone areas, care should be taken to drink boiled water and well cooked food. Cover all eatables to keep away flies.  Personal hygiene and sanitation in the surroundings will help prevent cholera.
Typhoid is another highly contagious disease caused by contaminated food and water during rainy season. Typhoid can be dangerous as very often the infection remains in the patient gall bladder of
the patient even after being cured. Prolonged fever rising high on the fifth day are the first manifestations of typhoid.  Patients very often develop a rash by the 2nd week. Headache and severe abdominal pain with bouts of constipation followed by diarrhea are other symptoms of typhoid.
  • Doctors generally prescribe antibiotics for treating typhoid once confirmed by a blood, urine or faeces test  
  • As it is a highly infectious disease, patient needs to be isolated and a lot of care needs to be taken with the patient.
  • High fluid intake to prevent dehydration is required.
  • A lot of care is required post recovery as well as there is very high likelihood of  relapse after  two weeks of apparent recovery.
Vaccination is the best prevention against Typhoid. Other tips to protect against typhoid include:
  • Washing your hands frequently to avoid infections as typhoid is highly contagious.
  • Drinking boiled water, especially recommended for areas where typhoid is widely prevalent.
  • Avoid eating raw fruits and vegetables 

Hepatitis A is generally caused by flies and sometimes by coming in direct contact with a patient suffering from Hepatitis A. Symptom is similar to common flu with high fever accompanied by headaches and vomiting as well as pain in the joints. Loss of appetite is another symptom.  Dark colored urine and light colored stools 3 to 10 days after disease onset and a general yellow tinge on the patient's body are other manifestations of this deadly disease. Treatment includes

  • Bed rest till the fever subsides is required
  • The patient should have a high-calorie diet, low in proteins, fats and oily foods
  • Ensure that you wash your hands thoroughly after contacting the any of the patient’s things including bedpan, clothes and objects of everyday use.
  • Vaccination, available at all government as well as private hospital is the most effective prevention against Hepatitis A.
  • Other ways include ensuring a home free from flies by taking simple precaution like Ensure regular garbage disposal as garbage is the breeding ground for flies. Organic garbage, like kitchen waste or anything that can lead to the growth of mold should be immediately disposed of
  • Spray insides of trash can with aerosol based spray.
  • Burning dried leaves in the garden and clove based paste on windows and doors are some other home remedies to get rid of flies. 
Common cold, as the name suggests is the common and widely prevalent disease across all age groups during the monsoon season. Fever, continuous sneezing, sore throat and coughing are the most common symptoms. 
Homemade remedies for common cold include a glass of hot turmeric milk or a gargle with hot water for sore throat relief. It is best to consult a doctor if the conditions persist after a couple of days.
Preventive measures include following general hygiene practices like

  • Wash hands regularly
  • Do not cover sneeze or cough with your hands
  • Do not touch your face
  • Drink plenty of fluids
  • Eat raw vegetable containing phytochemicals
  • Exercise regularly and ensure regular intake of fresh air
  • Avoid Smoking
  • Limit alcohol consumption
A little bit of preparation and prevention will go a long way in helping you enjoy the beauty of cloudy skies and rain drenched earth in a healthy manner. 

Wednesday, 19 June 2013

World Sickle Cell Awareness Day

Anita Sharma (name changed) is a college student living with sickle cell disease. She was diagnosed with the disease at birth & receives regular blood cell transfusions . Balancing her College Assignments with blood transfusion schedules, Anita is one among the many patients, who refuse to let Sickle Cell Disease take over their lives!

Sickle Cell Disease (SCD) is the most frequent genetic disease worldwide. World Sickle Cell Awareness Day which is observed on June 19th, every year, was created by the United Nations, to spread awareness about the disease and its management.


As per WHO estimates:
  •  Approximately 5% of the world’s population carries trait genes for hemoglobin disorders.
  •  Over 300 000 babies with severe hemoglobin disorders are born each year.

Sickle Cell Disease is seen in many parts of India, with the prevalence ranging from 9.4-22.2% in endemic areas. You can read more about its prevalence here

What exactly is Sickle Cell Disease?

Sickle cell disease is a group of disorders that primarily affect hemoglobin, the molecule in red blood cells that delivers oxygen throughout the body. People with this disorder have atypical hemoglobin molecules called hemoglobin S, which can distort red blood cells into a sickle shape.
Sickle Cell Anemia is one of the most common form of Sickle Cell Disease. While the abnormal sickle cells usually die after 10 to 20 days, the bone marrow is unable to make new red blood cells fast enough to replace the dying ones. This results in lower than normal RBCs.
Like Sickle Cell Disease,  Thalassemia is also a genetic disorder, caused by an imbalance in the two globin chains that produce the hemoglobin molecule. In both cases, the production of hemoglobin is disrupted and delivery of oxygen to the body, is affected.
As per reports,  Thalassemia has a mean prevalence of 3.3% in India . In certain communities and religions like Punjabis, Sindhis, Bengalis, Jams and Muslims, the incidence of beta-thalassemia trait ranges as high as 8-15%
The various types of Sickle Cell Disease include:

Sickle cell trait (HbAS)

  • A person has an HbS gene and normal hemoglobin A gene  (HbA).
  • Under normal circumstances, these children do not exhibit any symptoms of sickle cell disease.

Sickle cell anemia (HbSS)

This is the most common & also the most severe form of the disease. Here the child has two HbS genes, one inherited from each parent

Sickle cell with hemoglobin C disease (HbSC)

The child has one HbS gene and one defective hemoglobin C gene (HbC). Typically children affected by it, suffer from mild to moderate anemia.   

Hemoglobin S-beta-thalassemia

This disease manifests itself in two forms- sickle beta zero and sickle beta plus. The child has one HbS gene and one beta thalassemia gene. Children may experience a broad range of sickle cell symptoms

Compound heterozygotes

The child has one HbS gene and another abnormal hemoglobin gene. The symptoms vary depending on the specific genetic disorder.

How is Sickle Cell Disease Developed?

The following are the probabilities of a child being born with Sickle Cell Disease

Common Symptoms of Sickle Cell Disease

Tests for diagnosing Sickle Cell Anemia, include:


The treatment for Sickle Cell Disease is aimed at managing its symptoms. Common treatment areas, include:
  • Blood transfusions
  • Pain medicines
  • Plenty of fluids
Treatments required to manage complications may include:
  • Dialysis
  • Gall Bladder Removal
  • Eye Surgery                   
The following vaccinations are recommended to reduce the risk of infections:
  • Haemophilus influenzae vaccine (Hib)
  • Pneumococcal conjugate vaccine (PCV)
  • Pneumococcal polysaccharide vaccine (PPV)
  • Bone marrow or stem cell transplants can cure sickle cell anemia but is limited by finding well-matched stem cell donors.
Recently, A Nagpur based NGO, Sickle Society of India, has also raised the issue of including Sickle Cell Disease in the Disability Bill, with the National Human Rights Commission.
There is further good news for people suffering from Sickle Cell Disease- University of Michigan Medical School researchers have discovered that an anti-depressant wipes out the disorder in lab-tested human blood and mice. If clinical trials prove it’s safe for adult sickle cell patients to ingest tranylcypromine, the anti-depressant could be an alternative to the current treatment. 
Thanks to progress in early diagnosis and treatment, most kids born with this disorder grow up to live productive lives. WHO has made a commitment to:
  • Recognize that sickle cell disease is a major health issue.
  • Increase awareness regarding sickle cell disease, at large
  • Eliminate wrong prejudices associated with sickle cell disease.
  • Promote satisfactory access to medical services

Tuesday, 18 June 2013

Your Guide to Health Insurance in India

In a country with prohibitively high medical treatment cost & inadequate social security coverage, the need for Medical Insurance, cannot be over emphasized.
As per a recent study by the rating agency Fitch, 80 per cent of Indians pay for medical expenses from their own pockets.

The significance of Health Insurance is ever increasing on account of:
Here is a handy guide for choosing Health Insurance, that best fits your needs. The 4 primary Health Care Insurance Schemes available currently are:

For Profit Insurance Schemes

These typically involve paying a premium to an insurance company, basis their risk assessment of the consumer. Both Public & Private Sector Companies operate in this space. Of the Public Sector Players, General Insurance Corporation’s Mediclaim Policy is the most popular. The premium paid toward this policy is exempted from the taxable income of the policy holder. Some of the other policies in this space are LIC’s Jeevan Asha, Jeevan Arogya etc.
Several Private life insurance companies, have of late, plunged into the health segment, which till recently was dominated by general insurance companies. There are however, some significant differences in Health Insurance Offered by a Life Insurer versus a General Insurer:

Government Run Schemes

These primarily include the Employer State Insurance Scheme (ESI) & Central Government Health Insurance Scheme (CGHS). ESI applies to establishments employing 20 or more people & covers employees and the dependents against loss of wages due to sickness, maternity, disability and death due to employment injury. The services are provided through network of ESIS facilities & are financed by three way contributions from employers, employees and the state government. However rising costs of treatment are an impediment to the scheme.
CGHS covers employees and retirees of the central government and certain autonomous and semi autonomous and semi-government organizations. The key deterrent to the scheme is the high out of pocket expenses due to slow reimbursement and incomplete coverage for private health care .

Community Based Health Insurance

Community based schemes are typically targeted at poorer population living in communities. Such schemes are generally run by charitable trusts or non-governmental organizations (NGOs). In these schemes the members pay a fixed amount each year for specified services.

 Employer based schemes

Employers in both public and private sector offers employer based insurance schemes. These facilities are by way of lump sum payments, reimbursement of employees’ health expenditure, fixed medical allowance etc
In choosing an appropriate Health Insurance Policy, it is important to consider the primary benefits being sought by you. Health Insurance Policies can be grouped basis the following criterion:
  • Cashless Mediclaim: These Insurance Plans are beneficial as the policy holder is not required to pay any cash either at the time of admission or discharge from the Network hospital. The cashless mediclaim reimbursement is capped at the level of the insured sum.
  • Family Floater Plan: This is preferable for people looking to insure the entire family, as the premium paid is far less than the sum of individual premiums.
  • Individual Health Insurance: These are beneficial where you are looking for a single person coverage, as the policy holder can consume the entire amount by himself.
  • Group Health Insurance: A Group Insurance Policy is of interest for a large group of people say over 20 who work or stay together.  The key advantage of a Group Health Insurance Policy is that people with an adverse health condition can also get health cover due to the greater negotiating power of the group
  • Travel Health Insurance: This is advisable whenever a person is travelling outside the geographical boundary of his own health insurance plan. Travel Health Insurance is mandatory for travel to certain countries.
  •  Critical Health Insurance: Critical Health Insurance covers many terminal diseases such as Alzheimer's disease, kidney failure, major organ transplant, multiple sclerosis, Parkinson's disease etc
  •  Hospitalization: These plans are cheaper compared to full indemnity plans as they pay only for the room rent, during hospitalization.
  • Senior Citizen Health Insurance: These are especially designed for Senior Citizens as they offer a wider coverage of diseases as well as provide for reduced waiting periods. health They also empower the elderly to go for health check-ups and financial help during emergency health problems .
  • Maternity Insurance: Maternity Insurance is typically included into regular Health Policies and covers the woman for any complication that arises during her pregnancy

While in the prime of youth, premiums paid towards health Insurance, may seem wasteful, in the long run, investments in health insurance schemes, turn out to be most judicious. Health, as they say, is wealth, in true measure.

Thursday, 6 June 2013

Doctors Ratings and References - Choosing the Right Doctor for your treatment

“God Heals and the Doctor Takes the Fees” goes a popular saying. Given a choice none of us would ever like to be one of the countless people patiently waiting in the waiting room of a doctor. But in the real world that is what we end up having to do, sometimes for ourselves and sometimes for our near and dear ones. It is only when the need is actually upon us that we start Doctor hunting, frantically calling up people and randomly searching for references to a good Doctor to consult.

Choosing a Doctor suited to your specific requirement is important. In India a Doctor consultation is done more often than not based on reference of a family or friend. However this does not always work to your best advantage and you very often end up regretting the decision to consult a particular doctor. One of the foremost things in a doctor patient relationship is the trust factor. You need to be able to trust your Doctors ability and expertise as you are to a great extent entrusting your life in his / her hands. Besides having trust in the Doctors capabilities, you also need to have a comfort factor at a personal level to be able to share information openly. Hence, conducting a thorough research on credentials, feedback, practicing time and schedules etc., before choosing helps to ensure you make the right decision.

Basically, all that a patient wants to know is whether a doctor will diagnose and treat effectively, in a place that is accessible, at a price that is affordable, which may include not just the cost in terms of money, but also the cost in terms of time, and the effect on quality of life. 
  • Basic contact information which may be accessible in some cases at the doctor's own website, or also through the hospital to which they are affiliated.
  • Credentials including education, experience and certifications, generally available at ratings sites as well as directory sites
  • Cost or insurance acceptance information The best place to find this information is at your health insurance company's website.
  • Whether he/she is a "good" doctor – defined as one who has mastered both the art and skill of the medical profession, who while adopting the best medical practices, is also deeply caring about his / her patients. Rating this skill is the basis for existence of sites that rate or rank physicians. 
However, Doctor ratings has always been a sensitive subject. While some feel rating a Doctor is not a correct practice as patients do not know medicines and hence are not qualified to give a rating for a service they don’t understand. However at the other end of the spectrum are people who feel that Doctors provide a service, and like other professional service providers, their services need to be rated. In fact, they feel that the rating is even more important as patients lives are at stake.
In India, a rating site for Doctors helps for 2 primary reasons 
The problem however lies with the fact that there are no authentic Doctor ratings available in India. There are a few sites that exist but it is not clear whether these websites really help consumers find the right doctor or even whether the ratings influence how consumers act at all. More importantly there is a huge question mark over the fact whether these sites are really able to assess the quality of a doctor.

myMEDistry offers users a genuine platform to access as well as share their feedback and rating of a doctor. The best way to rate your Doctor is by reflecting your actual experience.  Whether it’s positive or negative, you can make a difference and help others choose the right doctor or physician. Objectivity, while rating helps others make informed decisions. An important factor to keep in mind is that the personal experience with the care received at the hands of the Doctor is as important as the outcome of the care. There are patients who even after successful treatment feel dissatisfied with the care given to them. On the other hand there are patients whose medical condition might not have seen a vast improvement but are extremely satisfied with the care and attention provided by the Doctor. Even the best medical treatment can sometimes not give the desired results and it is wrong the put the onus on the Doctor in such cases. We strongly advocate rating both your experience as a patient as well as it will go a long way in establishing the importance of personal care by the Doctor and help make it an important measure in its own right.   
The underlying truth is that any doctor, however capable, will have some dissatisfied patients (since most people associate the caliber and their review of doctor by the outcome) who are more than happy to give a bad rating and spread bad word around. But, in case of a genuinely good Doctor the positive reviews will far outnumber the negative ones. Also it is possible to ascertain a good deal by reading the examples given by someone who criticizes the doctor and decide whether that particular aspect is relevant or important to you.
Ultimately it is both our right and responsibility as patients and end users to ensure we provide a balance view of the experience and enable others to avail the services of a good Doctor. 

Thursday, 30 May 2013

Say No to Tobacco

Cancer cures smoking, goes a witty turn of phrase. Unfortunately, there is little else to relieve the morbidity of tobacco induced deaths. On May 31st every year, the World No Tobacco Day promoted by the World Health Organization, is observed with the objective of reducing tobacco consumption. The theme for 2013 is "Ban tobacco advertising, promotion and sponsorship".
Source: :
The effect of tobacco on the human body is widespread, with most of the conditions being debilitating. 

Tobacco use is the single most preventable cause of death globally and is responsible for killing one in 10 adults worldwide. Lung cancer is the leading cause of cancer deaths among both men and women in the United States with 90 percent of lung cancer deaths among men and approximately 80 percent of lung cancer deaths among women, caused by smoking. The statistics in India are no less shocking:
According to a survey by the World Health Organization , around 10 million cigarettes are sold worldwide every minute. It is fairly important, therefore to fight tobacco addiction early. Here are some helpful tips:
  1. Delay-  Everytime,  you have a tobacco craving, try & delay picking up that cigarette.
  2. Avoid triggers- Identify the triggers for tobacco urges & avoid them or distract yourself.
  3. Physical Activity-  Physical activity can help distract you from tobacco cravings and reduce the intensity of cravings.
  4. Relaxation techniques - Deep-breathing exercises, muscle relaxation, yoga etc can be great stress busters.
  5. Nicotine supplements- Nicotine replacement products such as patches, gums and lozenges are of help. Nicotine nasal spray , nicotine inhalers and  stop-smoking medications such as Chantix & Zyban are available on prescription.
  6. Chewing -  Chewing gum or munching on raw carrots or nuts can give something satisfying & take away the smoking urge.
  7. There is also a lot of counseling available by way of Tobacco cessation coaches who can offer advice, share helpful resources and provide necessary counseling.
  8. A number of useful apps can also help you quit the smoking habit. One such app, Livestrong My Quit Coach Lite, not just helps create a personalized plan, but also provides periodic progress charts. You can read about 5 such apps here.
Above all, it is important to keep a strong will power & remember that tobacco addiction wreaks havoc on the smoker and his family, both in terms of health and finances. While studies have shown increase of cigarette prices as the single most effective measure to reduce smoking, there is no substitute for a strong willpower.

Thursday, 23 May 2013

Health Literacy and Awareness – New Mantra to a Longer Life

Source :

It is a hard reality that medical treatment in India is fraught with risks at every step. There is a high probability that the end result might be the total opposite of what you intended or expected, you might end up much worse than what you started out with.
Medical science has advanced by leaps and bounds rendering the common man almost illiterate in terms of medical terminologies and systems. Studies have proved that approx. every 1 out of 2 individual is unable to grasp and fully comprehend the depth of medical information to be able to make informed decision regarding their own medical care. The problem therefore is one of awareness, even more manifest in a country like India where the Doctor to population ratio is in the range of 1:2000. What this implies is that there are not enough doctors to treat the population base, leading to hurried diagnosis, half explanations and fast track treatment increasing the probabilities of human errors.
All of us have heard horror stories of relatives who have had to undergo immense pain and suffering due to complications arising from wrong diagnosis, treatment gone awry etc. On the one end, medical treatment itself comes with an element of risk of unforeseen complications like infections, on the other end lie controllable errors such as wrong medicine or dosage from trained medical practitioners.
There are 2 ways we can save ourselves from being one of the victims of the lacunae in the medical system.
The first one is to focus our efforts on preventive healthcare rather than curative healthcare. The options are fairly straightforward – we can choose to either invest time, effort and money to stay healthy, or spend a huge amount later on treatment. With spiraling medical costs nowadays, the cost of treatment could easily cross our insurance coverage and eat substantially into our life savings. When one is ill, there is no choice but to think about our health. Preventive health care needs to be planned and executed ahead of time, even when illness is absent. Remember, most diseases can be prevented by practicing preventive healthcare habits. These include:
  • Immunizations
  • Hypertension screening and treatment for adults 18 and older
  • Cholesterol screening and treatment for men 35 and older and women 45 and older
  • Seeking advice and support tools to quit smoking

The other way is to actually reduce many of the risks associated with treatment by taking an active role in your health care. The guide below will help you gain an understanding of the control you can exercise on your treatment at all stages by being fully aware and vigilant of your rights as a patient.
 You can know more about means of accessing information on preventive healthcare, diagnosis, treatment etc including answers to questions like ways to go about seeking second opinion at

There are only certain basic expectations that a patient has when approaching a physician for treatment. 

  1. Reliability: the ability to carry out his duties diligently and with full commitment.
  2. Responsiveness: the desire to understand and respond to patient distress and provide the required relief / assurance
  3. Assurance: The confidence backed by data that he can do as stated
  4. Empathy: Care and attention to patient needs and suffering
  5. Tangibles: Facilities and infrastructure available to ensure proper treatment and care
Doctors in particular and the medical profession as a whole would indeed be highly enriched if it could take cognizance of the above when responding to patient needs.