Crushin’ It

Lately, I’ve been crushing life.  If by “crushing” you mean sucking enormously at managing to keep up with everything.  The last several weeks have been filled with doctor appointments, physical therapy, acupuncture, remodeling the kitchen, trying to keep the house from being swallowed by mess, and barely qualifying as a parent and Girl Scout leader.  I look around the house each day and feel physically ill by the state of it all.  My inability to keep days and activities straight in my head make me worry about what my brain will be like when I’m old and gray.  A state of panic chases me and causes me to stumble into the next day.  

Treating my fibro
I have finally managed to begin physical therapy and acupuncture.  I love water physical therapy!  It allows me to use muscles and exercise in ways that I just can’t on land.  Therapy on land is transformative.  It turns out my SI joint and pelvis were out of alignment. It’s also been really painful to lay on my side/hip. After one session, my PT was able to adjust me, and the extreme tenderness and pain that made me yelp when she touched me was gone. GONE!  I’ve also been given very doable home exercises, some of which can be done while I go about my day. At my last session, I found out I have a weak butt. Or weak butt muscles, anyway. My homework is to clench and release my butt. 

I have had a few sessions of acupuncture or, as I like to call it, Napping with Needles.  The jury is still out on how I feel about it, but I know it’s too soon to tell if it’s making any difference, for good or for ill.  I will say that my last session seemed to make all the difference in the world. I am fighting a cold and had gotten very little sleep the night before. I was so bad off that Mike had to drive me to my appointment. Within an hour or so, I felt fantastic!  That seems like a pretty big turn around for there not to be some causal link.

One aspect of acupuncture I was not aware of beforehand is that the therapist will manipulate your body and limbs in order to loosen them.  That’s fine, but it is difficult to completely relax when the therapist is a man and leaning back makes you crotch-adjacent. Having my torso twisted, side to side quickly, so that my arms shake like cooked spaghetti and my boobs shimmy like the worst burlesque show ever, reduces me to embarrassed giggles.  Getting to lay quietly in the dark with soft music for 30 minutes, though, is pretty great. I actively try to avoid falling asleep so no one hears my snoring.  I’ve also learned that it’s pretty difficult to clear my mind, as my mind is a chatterbox with an attention deficit.

The second appointment with my new rheumatologist was much improved from the first.  My new endocrinologist is awesome; she is absolutely convinced of the existence of fibro and realizes that plenty of other doctors treat fibro patients like crap.  Finally, I’ve begun seeing a nutritionist in an attempt to lower my inflammation and lose weight.  I love her!  She is all about adding the good foods and refuses to forbid foods. Rather than making food bad or off limits, she’s more focused on making foods that will help you achieve your goal a habit.  She also understands that a person’s body in chronic pain processes food much differently than a “normal” body.  I’ve found myself reaching for better food and not craving a ton of crap. 

This is such a burden.

Taxi service
I’ve been taking Rachael to a slew of doctor appointments lately.  She’s been in therapy, as suggested by the psychologist who tested her for ADHD.  I’m not sure what, if anything, it’s doing for her.  But she seems to like going, and the therapist seems to understand the difficulties of our home.  We also had Rachael evaluated by an occupational therapist for handwriting and fine motor skills, as the results of her ADHD testing suggested that those difficulties could be masquerading as an attention deficit.  Results said she’s a bit behind and could use some therapy.  Since then, her handwriting seems to have improved and she’s not having as many difficulties as she was 5-6 months ago.  I may try to have her therapy over the summer.  I feel like the harm of pulling her out of class on a weekly basis outweighs the benefit of OT at this point.  

Finally, Rachael saw a gastroenterologist a couple weeks ago.  She’s suffered with relux and tummy troubles for a long time.  While Pepcid has made it better, her pediatrician wants to make sure that any underlying cause is found and corrected, rather than just continuing to treat the symptoms.  Rachael is scheduled for a upper endoscopy at the end of June. She was a little nervous, but understood the procedure and was fine…..UNTIL THE DOCTOR SHOWED HER A STUPID CARTOON VIDEO ABOUT THE PROCEDURE!  In the video, “Scopey” said that while he was inside, he might take some tissue for a biopsy. So NOW she’s freaking out to the point of losing sleep over it. Dude will get a nastygram over this. 

Kitchen remodel
The other major thing taking up most of my time is giving the kitchen cabinets a facelift.  I always thought the 20 year old , builder’s grade oak cabinets were disgusting, but getting up close and personal with them showed me that we had been living like animals for 6 years.  The amount of filth caked on them and the number of cracks in the wood made my embarrassment for whenever we had company skyrocket retroactively. 

I’m so close to being finished. It seems like there is always some hiccup or touch up that prevents me from getting on with things. But I do have one cabinet fully completed. 

 

All that’s left is to affix the knobs, which we haven’t chosen yet. Several doors are ready to be hung, but the hardware store didn’t have enough hinges. Because, of course.  

Hopefully I’ll be back blogging regularly again soon. I actually started writing this post weeks ago. But Zoë is snuggling with me and my brain is clear for the first time since I began writing this, so I can finally tell you what’s been going on with me. 

To All Women on this Mother’s Day

If you are a woman who has given birth to a child and are raising him or her to the best of your ability…

If you are a woman who was brave beyond belief and allowed someone else to raise your child so that he or she might have their best chance…

If you are a woman whose body and mind has been ravaged by the pain of losing a child…

If you are a woman who opened your loving home and arms to embrace a child who was not born of your womb, but is, nonetheless, your child forever and ever…

If you are a grandmother, sister, aunt, cousin, or friend who has graciously accepted the awesome responsibility of raising a child…

If you are a woman who struggles daily with the knowledge that she is unable to birth a child…

If you are a woman who may want children some day, but are not quite ready…

If you are a woman whose plans do not include motherhood…

If you are a woman who is fighting to marry the person they love and be recognized as a loving and legitimate family, worthy of bringing up children…

If you are a woman who is struggling to be recognized as a woman…

To all women on this Mother’s Day:

You are amazing people in your own right. No matter the status of motherhood, you are valuable and worthy of honor. You are eshet chayil: woman of valor.
I feel privileged to share in the experience of womanhood with you. I feel as such because women are strong, courageous, intelligent, capable, fragile, imperfect, and determined.
We are women.

We are fighters who push through our failures and rejoice in our triumphs.
We are women.

We are quiet helpers and we are emphatic advocates.
We are women.

As I Lay Hurting

 

I had my first pain management doctor’s appointment today, as the new rheumatologist I saw at the beginning of the month doesn’t do pain management.  I went in hopeful.  I should have known better.  Once again, I was met with fat-shaming and incredulity.  And after he was finished beating the shit out of my body, confirming what three other doctors have already diagnosed, I was treated to feeling like a drug addict when I signed the agreement not to sell my tramadol and handed them a pee sample.

I don’t really feel like writing a long, coherent post with subject, verb, tense agreement, so here are the highlights.

  • Is there something in the Doctor’s Guide to Being an Asshole that says that when a patient complains of fibromyalgia, the doctor must poke and prod as hard as possible so that the patient gasps and screams?  It’s like if you went to the dentist, complaining of a sore tooth, and the dentist shoved a sharp instrument up through it to make sure you’re really telling the truth.  I felt like I’d been on the wrong side of Mike Tyson by the time he was finished.
  • Maybe this is my own personal quibble but, when did doctors stop giving physician referrals?  I keep having doctors tell me, “You need to go see this specialist,” but don’t give me a place to even start.  Are we just supposed to figure it out for ourselves?  At the last doctor visit was the rheumo telling me I needed to go to physical therapy, but to make sure it was somewhere that has experience treating fibro.  Today, I was told to go see a dietician for weight loss and a non-inflammation diet.  And when I asked for professional referrals, they looked at me like I’m ridiculous and bothering them.
  • Why do doctors insist on fat-shaming their patients?  I was in a fuck-ton of pain when I was 100 pounds lighter, back before there were weight gain-causing meds and the inability to exercise.  Will weight loss make me healthier?  Sure. Will it eliminate my pain?  No.

 

Image via imgarcade.com

I’d like to get these doctors to understand how it feels to live with chronic pain, especially when it comes to exercising, (yet another thing I got shit about today, as I don’t do enough aerobic exercise.)  You know what I’d like to?  I’d like to beat the shit out of them with a baseball bat, tell them to drop and give me 100, and then scream in their faces like a drill sergeant:
WHAT’S THE MATTER, PRINCESS?! DOES IT HURT?  IS IT HARD?  ARE YOU GONNA CRY?  IS LITTLE BABY PRINCESS GONNA CRY?  Do you want to stop?  You do?  GIVE ME ANOTHER 100!

I’d also like to strap them into some sort of device that creates fibro pain, (like the ones that cause douchey husbands to feel what labor feels like) and then make them go for a 10 mile run.  RUN, FORREST! RUN!

  • “Studies show that Percoset and other narcotic pain meds don’t really help fibromyalgia.”

The pain doctor actually said that to me.  I just wish my body had known that when I had to take it while I was at Disney so I could have the ability to walk.  And I’m really tired of doctors saying that studies show this and that, when it’s really just an excuse to do whatever the hell it is they feel like doing. Of course, narcotic pain meds don’t cure fibro.  But on days like yesterday when I could barely walk without crying because of how much damage he did to my body during the exam, it would have helped. Fuck the “studies”.

I really wish I understood why doctors insist on under-medicating pain patients before they’ve even exhibited signs of addiction and abuse.  Doctors don’t do that to other patients in pain.  It would be the equivalent of a doctor saying to a person with a broken leg, “What you need to feel better is a cast and crutches, but you’re going to have to just walk it off and find some other way to feel better.”  It sounds ridiculous, but that’s what doctors do to chronic pain patients all. the. time.

Once again, I feel stuck.  Being stuck with a shitty doctor is almost like being stuck in an abusive relationship- you can’t leave because, if you do, it will look like you’re the one to blame.  It will look like I left because I’m a drug-seeker, hoping to find a dealer with a medical degree. You’re an addict, Harry.

Finally, a message to all the doctors who think I don’t exercise…

You Need to Respect Her No

It should be more horrifying when we hear of a women who was raped or sexually assaulted, and the first questions out of people’s mouths are: Did she say no? What was she wearing? Was she drunk? What did she do to lead him on?  It should be more horrifying, but it’s not.  It’s a part of the rape culture in which we live.  It’s commonplace. It’s normal.  On the bright side, it does seem that most people agree that sexual assault is a problem in this country, particularly on college campuses.  What is maddening is that people cannot agree on how to prevent rape. A largely accepted idea is that the onus is on women to protect themselves from assault.  While there are some practical things women can do to defend themselves, like learning self-defense, never leaving a drink unattended, and never accepting a drink from someone else, it quickly spirals into victim-blaming. You mean she was stupid enough to walk away from her drink to pee, and then she was drugged and raped? Well, I feel bad for her but, seriously, what else did she expect?  Society then adds on more victim-blaming shit, like what I mentioned before- did she say no?, etc.  At no point does it occur to people that, rather than placing the responsibility on women to not be raped, we should be placing responsibility on men and teaching boys not to rape!  Rather than questioning whether or not she said “no” assertively enough or if she actually meant “no”, we should be teaching males to respect her no.
Raising girls with expectations

Image via Huffington Post

As a mother with two girls, I’ve wrestled with how I would prepare them to live in a world where people like those in the fraternity at Texas Tech, who created the above banner, exist.  Quite frankly it makes me hope that, some time within the next 12 years, they’ll just be able to download college courses to a chip implanted in their brains.  I’m sure that I’ll share some common sense wisdom on how to try and stay safe: never leave your drink unattended; always be aware of your surroundings; get the fuck out if your Spidey sense starts tingling; go for the groin and yank until he’s a castrato.  But there’s one thing that I never want to teach them, and that is that how they feel and saying “no” to something is meaningless.

Girls tend to be taught, whether directly or through social cues, not to assert themselves or make waves.  As women, we learn it’s much more important for the common good to stuff our negative feelings and not make a scene.  And heaven forbid that we hurt someone else’s feelings by putting ourselves first.  Unfortunately, this learned behavior can sometimes be found in scenarios leading up to sexual assault.  Women don’t always put up a fight because they don’t feel like they can.  Men don’t listen when women say no because they’ve learned that their “no” isn’t important.

Because of this, I began telling my girls to respect people’s no’s.  Whenever Rachael gets up in Zoë’s face, I remind her to back off and listen to Zoë yelling, “Nooooooooooooo!”  Whenever Mike continues to tickle the girls after they’ve said “no” or “stop”, I gently remind him that they’re saying no and that he needs to respect that.  My hope is that this will instill in them the knowledge that their feelings and their no’s have value.  I want them to know that it’s right to expect others to respect their boundaries.  I want them to never doubt that their bodies are their own, and that no one has the right to invade their personal space or touch them without their consent.  Even Mike, their pediatricians, and I request their consent before touching them in their genital area, (for medical exams or if we need to investigate physical discomfort complaints.)  I think one of the great benefits of teaching them this is that I’ve heard them say it to others; they have said it to friends who are not listening when the girls have said “no” or “stop”.  How much better would this world be if we all began telling our children to respect one another’s no’s?

 

 

 

Top image source

Another day, another asshole doctor

 

Keeping count like the Doctor

 
I finally went to see a new rheumatologist yesterday.  She was recommended to me by my primary care doctor and a friend.  I went in, hopeful that I would find this doctor to be respectful and one who would listen to my opinion and experience.  I left feeling as though I had been burned by the fire of a thousand side eyes.  On the one hand, she was quiet and let me speak.  On the other hand, hearing what I had to say is different from listening, and it’s on a completely different plane from believing.

Doctor Speak

How doctor’s look during a fibro appointment


Generally doctors don’t come right out and say exactly what they’re thinking. Well-trained in the art of throwing shade, they tend to belittle you in such a way that it sounds like they’re trying to help you.  We Spoonies are experts in doctor-speak.  We’ve heard, it’s all in your head, you hysterical (wo)man, in many dialects: “How is your stress level?”; “Do you have a history of depression?”; “Oftentimes it’s actually depression that causes pain.”  Other common conversations involve indirect, or even aggressive and direct, accusation of drug dependency. My “favorite” so far, as a woman who has gained weight because of medication, an inability to regularly exercise, a medically confirmed genetic tendency to easily gain weight, especially when medication is involved, and an availability of Girl Scout cookies, is the insinuation that I’m just a lazy, fat load who would feel better if I just exercised and lost weight.  Yesterday, as the doctor smiled derisively and subtly rolled her eyes, I was essentially called a drug-addicted fat load who just needs to get off her lazy ass and exercise.

“We want to go ahead and get you off the pain medication so that your body is no longer dependent on it.”
You’re addicted to opiod medication.

“Do you exercise?”
Do you exercise? Because you really don’t look like it.

“I can’t exercise too much, but I have two little girls, so it’s not like I’m sitting around.”
“Yeah, you really need to exercise. You could do yoga, tai chi, walking, water aerobics, you could just walk in the pool.”
Doing all the things you do as a stay at home mom aren’t good enough. And with all these options available to you, you really have no excuse not to exercise, you lazy woman.

“It’s actually been difficult for me to get into a class that works out. I was enrolled in a yoga class, but it was cancelled because of lack of enrollment. And if you go private, it’s really expensive. That’s why I’m working with someone at George Mason, in the therapeutic recreation program, to develop an exercise program for people with chronic pain. It’s frustrating for me because, before I got sick, I was doing aerobics and strength training regularly.”
“Really?”

I’m going to be stone-faced, smiling, and slightly roll my eyes because Excuses excuses blah blah blah excuses. Your exercise program is an adorable way of avoiding real exercise, so I’m going to keep nodding and giving you side eye. Wait, what? You used to exercise? You could have fooled me.

“Have you tried Topomax?  It’s like Lyrica, but it helps you lose weight by making some foods taste unpleasant.”
Let’s try this other drug because you really need to stop eating and lose some weight.

Hostile Intentions
So why are doctors so hostile toward people who live with chronic pain?  I believe it comes from prejudice, ignorant assumptions, misinformation, and lack of education.

1) Prejudice
It’s been pretty well established in research that general attitudes toward overweight persons are negative.  These attitudes do not suddenly cease to exist at the doctor’s office door.  Researchers at Johns Hopkins found that physicians were less likely to be empathetic toward and build rapport with overweight patients.

“Obese patients may be particularly vulnerable to poorer physician-patient communications, Gudzune says, because studies show that physicians may hold negative attitudes toward these patients. Some physicians have less respect for their obese patients, which may come across during patient encounters.”

Anecdotally, I, and plenty of people I have talked with over the years, have experienced such negative attitudes from doctors over the years. No matter the complaint, the recommendation is always the same: You need to lose weight. Granted, sometimes it’s perfectly within reason for the doctor to give such advice. But all too often, the doctor walks in and decides that weight is the problem, before even hearing the complaint.  I remember one visit I made several years ago because both of my knees had suddenly begun hurting.  The older, male doctor told me that they’d feel better if I just lost some weight.  Granted, I was a little overweight at the time, but not so much that my knees should have suddenly given me the level of pain I was experiencing.

2) Ignorant assumptions
Coupled with number 1, doctors make assumptions about how a person lives their life, simply by looking at their weight.  All they see is an overweight person.  They don’t care how you came to be that way, nor your daily routine.  They don’t see you hardly sitting down in a day because you’re tromping up and down stairs with baskets of laundry, cleaning up toys, doing the dishes, shopping for groceries and lugging all the heavy bags inside, walking kids to the bus stop, chasing them around playgrounds, and helping them ride their bikes, who generally has healthy snacks of fruit and Greek yogurt.  All they see is a fat person who is too lazy to join a Crossfit box and eats junk all the time.

Ignorant assumptions are not confined to lifestyles.  They are also made about individuals who take heavy duty pain meds just to function like a “normal” human being.  It is assumed that if a patient takes narcotics, particularly opioids, they will become addicted, if they are not already.  People who live in chronic pain tend to be afraid to ask for pain medication because of how doctors may view the request.  According to Social Work Today, “‘Living with chronic pain is exhausting,’ Barrett says. ‘The undertreatment of chronic pain can lead patients to appear to be engaging in drug-seeking behavior. I have had clients whose doctors have not taken their physical pain seriously.'”  The article goes on to cite a study from 2011, which found, “For patients with chronic noncancer pain, opioid prescription remains highly controversial, and even in the wake of prescription guidelines and educational efforts, primary care physicians continue to practice under misconceptions about appropriate opioid use vs. addiction, leading to patient undertreatment (Wolfert, Gilson, Dahl, & Cleary, 2010; Hooten & Bruce, 2011).” 

3) Misinformation and lack of education
I’ve combined that last two because they go hand in hand.  Plenty of doctors still do not believe in the validity of fibromyalgia.  I’d say it’s pretty difficult to effectively manage the pain of an “imaginary” medical condition.  In addition, many doctors do not have the training to administer effective pain management.  This lack of training not only includes the inability to prescribe an effective dosage, it also makes them fear that their patient will become addicted, should they receive narcotic pain medication.  According to a 2003 study published in Pain Research & Management: the Journal of the Candian Pain Society, poor pain management is something that doctors themselves acknowledge.  In a survey of 100 Canadian physicians, researchers found,

For moderate to severe chronic noncancer pain, opioids were the first-line treatment of only 32% of physicians (16% preferred codeine, 16% major opioids) because a significant number preferred either non-steroidal anti-inflammatory drugs (29%) or acetaminophen (16%). Thirty-five per cent of GPs and 23% of PCs would never use opioids for noncancer pain, even when described as severe. Chronic pain was deemed by 68% of physicians to be inadequately managed. Almost 60% thought that pain management could be enhanced by improved physician education. Identified barriers to opioid use included addiction potential (37%) and side effects (25%).”

The study goes on to conclude that, “Even among physicians experienced in chronic pain treatment, there is a reluctance to use opioids for severe nonmalignant pain. One-half of the survey participants believed that there was a need for improved physician education in pain management, including the use of opioids.”

Why this fear of addiction?  Where did it come from?  According to the same, above-referenced article from Social Work Today, it stems from a coincidental rise in prescription drug abuse at the same time doctors began prescribing opioids for non-cancerous chronic pain.

As a result of media attention on increasing rates of prescription pain medication abuse, those with chronic pain who had previously found improved functioning, psychological health, and quality of life with appropriate opioid use began to face increased difficulties receiving effective treatment.”

This leaves chronic pain patients to, effectively, sing for their supper.  Patients must prove that they really are in enough pain to require such heavy duty medication and overcome any biases and trepidation the doctor may have about prescribing it.  It also gives patients the onerous task of somehow allaying any suspicions that you are simply engaging in drug-seeking behavior to feed an addiction.  I have done this song and dance myself.  I put it off for a long time because I didn’t want to be judged as an addict.  Once I was prescribed Percoset for breakthrough pain, it took me over 3 months to go through 30 tabs, (many of them taken so I could walk at Disney.)  The new rheumatologist wasn’t buying it, though, and refused to give me a new prescription.

Now what do I do?
My first instinct is to turn tail and run hobble. Although there were some positives of the encounter, I am still left feeling dirty all over. It’s pretty clear that she doesn’t take me seriously, nor does she believe that I won’t abuse medication.  Her hostility toward me was reflected in the comment she made to me while I was having difficulty locating a word because of fibro fog: “This is why most patients write things down.”  Not one to take an insult lying down, I fired back that I couldn’t have done because it was a question about something she had brought up during the appointment.

If I were to leave and go elsewhere, again, I know that I would risk the appearance of drug-seeking behavior.  You didn’t give me the drugs I wanted, ergo, fuck you and on to the next dispenser of DEA controlled substances. I also realize that her attitude is pervasive, so leaving probably wouldn’t do any good.  I do hope that future encounters will allow her to get to know me, for me to know her, and a better doctor/patient relationship to form.  Until then, I’ll just need to stay informed, stay strong, and get my Stuart Smalley on.

Maybe we should stop projecting our own shit onto Rachel and Nadia

Do you remember the first time you ever felt betrayed by someone? Maybe your parents broke a promise or lied to you. The time you found out a friend had been talking about you behind your back. Then there’s the doctor who didn’t treat you with respect. Perhaps a teacher took advantage of their power over you and treated you like shit.

As you grow up, you find role models, idols, heroes- people you look to for guidance and strength. They are inspirations and repositories from which we pilfer our ideas and world views in order to piece together our own personalities. They are family members, friends, writers, sports stars, actors, politicians, musicians, artists, clergy, and activists. We do this, whether unwittingly or with obsession. The pedestals on which we attempt to place these people are so high, so precarious, and so distant; is it any wonder they fall? And inevitably they will fall, with a staggering crash. The rubble and settling dust now obscure your way.

Getting to the point- last week there was a huge fallout in the progressive Christian community. An upcoming women’s conference, (WX2015) featuring Rachel Held Evans and Nadia Bolz-Weber, was* being facilitated by Tony Jones, a big and divisive personality within the progressive evangelical community. People began crying foul, as Tony Jones has been accused of spiritual, physical, and emotional abuse by his ex-wife. More people piled on when both women declared that they intended to move forward with the conference as was, believing that that was the right decision based in the information they had.

My heart sank. I admired these women, and here they were, seemingly behaving in a way that was at odds with everything I knew about them. I felt betrayed by Rachel most of all, as she frequently calls out abuse and the abusers within the church. More than that, though, it was because I so identify with her journey as a doubting Christian growing up in an evangelical world. I had put my faith in two women, whom I consider to be wise, empathetic trouble-makers, and it seemed that I was wrong.

What was I supposed to do now? I was going in circles, wanting to believe Tony Jones’ ex-wife, but not giving up hope that Rachel and Nadia weren’t abandoning what was right. And what did it say about me, that I had not chosen wisely when it came to in whom I’d placed my trust?
IMG_0003
I had to. Sorrynotsorry

I talked it over with Mike and stewed over it for days. I was surprised by how much I was bothered by this.

Then I fucking woke up and realized: Of course they’re going to let you down, you dipshit! They’re people. Just because they’re smart, wise, kickass women doesn’t mean they’re not going to make mistakes. It’s entirely possible that I would make the same decision, were I in their place.
What’s more, how does anyone know for sure that their decision is the wrong one? All we see are carefully constructed responses on Twitter or blogs. We’re not privy to their conversations with God about it. We don’t know about the crackers and ginger ale consumed because this whole ordeal has their stomachs in knots. We have no idea how many times their computers almost faced defenestration because someone was an asshole to them, and how it could all go away if they could just divulge what they know to everyone.

I still don’t know who’s right and who’s wrong, but I don’t blame Rachel and Nadia for the decision they’ve made. Having read both sides of the story, I reckon the actual truth is in there somewhere. Honestly, I think the number of fucks I have to give about it are beginning to run low. I do know that we’re all human and we all make mistakes. One of those mistakes is to place people on pedestals. It’s a horrible mess to clean up once they inevitably crumble.

*Apparently, because of the events of the last week, facilitation of the WX2015 conference has been handed off to Rachael and Nadia.