AIDS and Governance Brief No.10
May 3rd, 2007HIV/AIDS, DEMOCRACY AND GOVERNANCE IN AFRICA: A RETROSPECT OF RECENT DEVELOPMENTS
GAIN ISSUES BRIEF NO. 10; May 2007
In This Edition
1. Overview
2. AIDS and Power Bookblog
3. South Africa/Mbeki
4. Circumcision
5. Global Health Roundtable
6. AIDS, Security and Conflict Initiative Update
Overview
1) An important new initiative has been established focusing on the well-being of children in nations with high rates of HIV infection. The Joint Learning Initiative on Children and AIDS (JLICA) is an interdisciplinary group convened by, among others, the Global Equity Initiative, the Bernard Leer Foundation, UNICEF and François-Xavier Bagnoud International (FXB). JLICA’s purpose is to “…protect and fulfil the rights of children affected by HIV/AIDS by mobilizing the scientific evidence base and producing actionable recommendations for policy and practice.” Working with researchers from around the world, the JLICA establishes working groups constructed around the themes of strengthening families, community action, services and human rights and social and economic policies. The establishment of JLICA came about in response to the common criticism that the needs of children are often absent from policy-making on HIV/AIDS; and that the deficit between the numbers of children affected directly and indirectly by HIV/AIDS and the input of children and children’s needs in policy-making was large and growing. JLICA is different from many AIDS initiatives in that it is established for the express and exclusive purpose of reviewing and developing the social science research base on AIDS and children, and is time-limited to report by the end of 2008.
2) Justice Africa associate Jon Harle has provided a review for this briefing of Pieter Fourie’s book ‘The Political Management of HIV and AIDS in South Africa: One Burden Too Many?’ Fourie uncovers the political history of HIV and AIDS in Africa with a rare passion and incisiveness, and accomplishes the rare feat of making a book on the politics of AIDS sound like a work of popular political analysis rather than just cold political science. It looks set to be a useful contribution to the historical sociology of HIV/AIDS and public policy responses. “Fourie’s new book is a welcome and much-needed analysis of the political commitment and public policy approach underpinning– or more accurately undermining– the South African AIDS epidemic” says Harle. “25 years since AIDS was first recognized– and 24 since the first cases in South Africa– histories of the course of, and response to, the disease are now not only possible, but vital to a fuller understanding of why public policy has failed to curb the spread of infection.” Pieter Fourie’s book goes some way to explaining and deconstructing this failure.
3) The book’s webpage is available
AIDS and Power Bookblog
4) ‘AIDS and Power: Why there is no Political Crisis- Yet’ by Justice Africa director Alex de Waal continues to be received well by policy-making, academic and general interest audiences. As part of the process to publicise the book, and to generate debates concerning the themes and arguments that it puts forward, the Social Science Research Council is hosting a Book Blog including comments and discussions from some of the world’s leading HIV/AIDS analysts.
5) To give a very short précis of responses to the book: Alan Whiteside asks whether it is best to reach for the prozac or to become a revolutionary; Tony Barnett applauds the questioning of whether analysts have appreciated the complexity of the inter-relationship of HIV/AIDS and state cohesion; John Talbott addresses why Botswanans and other African’s aren’t yet marching on government buildings; Peter Baldwin looks at deep-seated human behaviour and asks why we are surprised that AIDS hasn’t created political change; Peter Fourie is pleased to see someone make the case that AIDS is too young and fast-changing to trust definitive conclusions on the epidemic; Francoise Nduwimama wants to know why we focus so much on peoples demands, rather than leaders actions on HIV/AIDS; and Ann Swidler applauds the book for going beyond asking why programmes fail, and instead asking about whether they were the right programmes to start with.
6) AIDS and Power is still available for purchase from Zed Books
South Africa/Mbeki
7) A small political earthquake has occurred in South Africa- in activists minds- with President Thabo Mbeki casually admitting in an interview with the Financial Times that his position on denying the link between HIV and AIDS has changed; and that he now accepts that HIV does cause immune deficiency, but that other things cause immune deficiency too, and so comprehensive health strategies are needed to combat immune-deficiency, and not just HIV. This might seem like semantics, but a closer examination of Mbeki’s statements is needed. The Financial Times article quotes Mbeki as saying “[s]o your medical documents will say Acquired Immune Deficiency Syndrome that is AIDS. What that means you have got this challenge of immune deficiency. Alright what causes immune deficiency? HIV. Alright. Is that all that causes immune deficiency? The medical textbooks will say there are other things that cause immune deficiency. There is also genetic immune deficiency that is a different phenomenon. So I say alright let’s respond comprehensively to everything that causes immune deficiency. That’s where you get the story that I have denied a connection.” On July 9, 2000, at the opening session of the XIII International AIDS Conference in Durban, Mbeki told delegates “[s]ome in our common world consider the questions that I and the rest of our government have raised around the HIV/AIDS issue as akin to grave criminal and genocidal conduct…[W]hat I hear said repeatedly, stridently, is, ‘Don’t ask questions.’” CNN reported at the time that Mbeki’s speech to the conference accepted that HIV was linked to AIDS but cast doubt on whether it was the lone cause.
8) The rhetorical sleight of hand that Mbeki has engaged in is tricky. He did not come out and accept- as the scientific consensus does- that HIV is the single pathogenic cause of AIDS; he only admitted that HIV was a pathogenic cause. Previously, Mbeki had acknowledged that HIV and AIDS were related, but expressed scepticism on whether HIV was causal. Mbeki is disingenuously accusing his critics of claiming that he has consistently denied a connection between HIV and AIDS; when what he did do for many years was to profess scepticism about the science on the causal link between HIV and AIDS. Compounding this dishonesty is the fact that he is deliberately appealing to general public understanding that background immunological health is strongly correlated with HIV, that high background levels of pathogens will affect levels of HIV and cell-corruption, and that immunity can be suppressed or increased by numerous genetic, environmental, nutritional and interventional factors, in order to cloak his scepticism with the credibility of fact that HIV is not the only thing that affects immunity.
9) This represents a new, but perhaps more pernicious, development in AIDS denialism (which has always been termed ‘denialism’ to highlight a state of mind, rather than- as Mbeki suggests- just outright refutation of scientific consensus.) The argument has shifted from scepticism of the pathogenic agency of HIV to cause AIDS, to scepticism as to whether HIV is the only cause of chronic immune-deficiency. While the argument might have logical credibility (the science is, however, nowhere close), the simple response must be- ‘Why are other middle-income nations not suffering the same decline in human immune-deficiency as South Africa?’ Why, for example, does Brazil- which like South Africa is neither the poorest country, nor the richest; and has neither the world’s best public health system, nor its worst- experience deaths from HIV (or immune suppression, as Mbeki would have it) at an approximate rate of one for every hundred in South Africa (calculated from UNAIDS figures and adjusted for population size)? It is this tortuous logic that activists have a problem with.
10) In essence, Mbeki is reporting only a trend in sophistication mirrored elsewhere by those who aspire to resist the ‘orthodoxy’ of AIDS science. Not being able to credibly claim that AIDS doesn’t exist, or that it is just a name for already existing illnesses, the attention has shifted to attacking what sceptics believe is HIV/AIDS’ weakness: that the continual pathological causal chain between HIV infection and the development of AIDS has never been fully mapped by repeated observation (largely because the complex physiology of the body’s immune system can’t be adequately replicated in a laboratory, and because HIV is too delicate to survive many clinical manipulations). Seemingly sophisticated and credible groups such as the Institute of Science in Society, who claim to challenge scientific consensus on the environment and sustainability, promote the ‘multiple-pathogen’ theory of HIV/AIDS. In short, no direct proof of HIV’s cause of AIDS is taken to suggest that one or more other pathogenic agents must be present, undetected or ignored, and these work separately and responsively with HIV to create the condition known as AIDS. Often this argument is used as a Trojan-Horse to attack the pharmaceutical companies that manufacture Anti-Retrovirals; or to promote alternative therapies that have of course not been subjected to the same clinical trials. The problem here is that the longer the ‘scientific establishment’ fails to prove through repeated and independently verifiable experiment the entire mechanical process from HIV infection to immune-collapse and AIDS, the entirely unscientific argument that an inability to absolutely prove the accepted single-pathogen theory means that the multiple-pathogen theory is thereby strengthened. In some respects, this mirrors the argument for including intelligent design in evolutionary biology instruction: ‘teach the debate.’ Just because competing theories exist; it doesn’t mean that they have equal intellectual weight; and conceding to have a debate (willingly or coercively) doesn’t thereby strengthen your opponent’s argument.
Circumcision
12) The issue of male circumcision has reached something of a ‘critical mass’ in recent years and months, and is now seen as the current cause célèbre in providing a workable, mass intervention to reduce HIV/AIDS. As detailed in GAIN Brief 9, the circumcision debate was waiting on two studies from Uganda and Kenya to determine the way forward. These two well-designed and rigorous studies, in Rakai, Uganda, and Kisumu, Kenya respectively, were published in The Lancet in February 2007, reporting that offering male circumcision as a routine part of primary healthcare would provide a uniquely efficacious way to decrease new infections of HIV in men. These studies support the findings of the Orange Farm trial undertaken in South Africa in 2005, which was stopped early by an ethics board, and led at that time to WHO and UNAIDS issuing a joint statement declaring that they noted the success of Orange Farm in showing the efficacy of male circumcision, but that they would remain agnostic about advising male circumcision as a mass intervention until further studies could confirm the Orange Farm methodology and results. The Rakai and Kisumu trials were undertaken for this purpose; and it is this confirmation of previously anecdotal (or at least treated as anecdotal) data that has created such recent excitement about the efficacy of male circumcision.
13) Circumcision is used as an intervention to reduce HIV infection as safely removing the male foreskin also removes a number of those cells- Langerhans’ cells, CD4+ T cells, and macrophages- that are targeted by HIV, and that remain at or near to surface exposure (subcutaneous). Removal of the foreskin, safely, increases the protection of the individual in terms of mucosal and dermal coverage. Circumcision poses risks in that, if applied incorrectly, the intervention can cause abrasions or lesions that increase risk of transmission. Circumcision has been observed as a preventative tool for HIV since the late 1980s; but it has taken the Orange Farm, and now the Rakai and Kisumu studies to establish a social case powerful enough to go with the medical.
14) What have Orange Farm, Rakai and Kisumu shown? Firstly, they have shown that in large-scale studies- Kisumu was 2,774 participants, Rakai 4,996, both including control groups- over a significant period of time, two years, levels of new infections of HIV among young, sexually active, and mostly unmarried men, experienced massive falls compared to non-circumcised males observed to display similar sexual lifestyles, of 53% in the Kisumu study, and 51%-60% in the Rakai study depending on the statistical model used to account for non-controlled variables. Reported widely in the media that the trials were so effective that they were halted early, this is actually only half the case. The pertinent issue here is that at regular ethics board review meetings the committees overseeing these studies determined that the interventional efficacy of circumcision was so compelling, and that scientific good practice would dictate that the results of circumcision on decreasing male vulnerability to HIV infection was so evident, that this information should not be withheld ethically from control groups, and rather than continuing the trials further, circumcision should be offered immediately to all uncircumcised participants.
15) Secondly, and more importantly, the trials show that male circumcision- previously neglected as an intervention because of the perception that it was far too simple a response to the massive medical and social challenges of HIV/AIDS- could be a powerful response to HIV/AIDS from a economic point of view, as it beat almost any other intervention in terms of cost per infection averted- including drug therapy, and probably condom marketing too. The Kisumu study reported that simulation models based on the assumption of 60% increased aggregate protection among men could prevent 3.7 million new infections and 2.7 million deaths. Furthermore, the Orange Farm study suggested that in South Africa, male circumcision would save $2.4m for every 1000 circumcisions, over twenty years. The potential socio-economic benefits in nations where HIV/AIDS is threatening productive capacity are quite rightly seen as enormous, and it is this that has persuaded UNAIDS/WHO to sanction male circumcision as an intervention, despite any potential objections to the treatment.
16) What are the objections? First, the medical. The Orange farm, Kisumu and Rakai studies all offered circumcision in well-funded and properly controlled and monitored clinics using an international best-practice technique with good instrumentation, under local anaesthesia, and with participants given post-operative care and advice on wound-management. Advising a surgical intervention to prevent infection poses risks to the individual from infection- a risk in its own right, as well as increasing pathways for HIV transmission if the infection remains chronic and the wound remains open- especially if standards of hygiene, technique and post-operative care are not as rigorous as those used in the studies. Anasthesia, even local, carries risks of illness and disablement in a small number of people. These risks will increase with mass uptake; adding to mortality and morbidity rates and potentially alienating men from the procedure. Selling circumcision as a cost-effective intervention in resource-poor settings may be undermined if the ‘hidden costs’ of clinical upgrades and better training for healthcare workers are not included in the package of future funding for circumcision.
17) The social objections are practical and moral; but amount to the same thing. On the practical side, there is a danger that circumcision may be seen as more of a foolproof intervention than it actually is. Circumcision will not protect absolutely against HIV infection; all it will do (if successful) is decrease the number of new infections. Drug-therapy and condom promotion campaigns will still be needed (and will still need expansion). This is resolutely not about making certain people entirely safe, but about decreasing HIV infection rates so that not only are less people infected, but that HIV is given fewer opportunities to reproduce and develop drug-resistance. Circumcision is a long-term strategy in the same way as condoms and drug therapy are. It is designed ultimately not just to protect individuals, but to undermine HIV’s viral fitness. On the moral side, just as with condoms, circumcision can be criticised for promoting sexual promiscuity. There is a very real threat that circumcision, if rolled-out too quickly, and if a commensurate level of public information does not accompany programmatic success, may have the unintended consequence of reinforcing the impression that men are now safe from HIV if circumcised, that women are safe if their partner is circumcised, and that good sexual health practices can be abandoned. Social marketing strategies will need to be developed to deal with this unintended consequence of circumcision’s success.
18) Successful implementation of circumcision programmes will have three social benefits beyond infections averted. Firstly, the cost-benefit of circumcision is such that even given the large variation in infections-averted between 100% coverage and realistic estimates of coverage levels, the amount of good that can be done at reasonable cost is still substantial. Secondly, it has the potential to re-orient long-term solutions for HIV/AIDS away from treatment, and back onto prevention, and in a way that condoms have never been able to do. Drug-therapy only depresses new infections somewhat, and does not decrease risky sexual behaviour. Condoms, as studies consistently show, are only efficacious if widely used and often. Partial use does not typically lead to partial reduction. Good condom adherence is needed by a large portion of the at-risk population for long periods of time; something which faces political and social opposition. Circumcision could be a way to overcome problems of both adherence and sexual risk (although of course it only reduces risk rather than eliminates it- which is why circumcision campaigns will still need extensive, and expensive, education campaigns.)
19) This is not yet absolute proof of programmatic success. The agnosticism of WHO/UNAIDS will continue until at least the publication of the results of a fourth study, again in Rakai district, Uganda, which enrolled uninfected female partners as well as male volunteers, and has released preliminary data suggesting that male circumcision may actual raise vulnerability for the female partners of circumcised men, as reported in the New Scientist. This trial was undertaken by Johns Hopkins Bloomberg School of Public Health, and will report in July 2007. The use of circumcision is likely to come under intense scrutiny in the next few months as such a potent cost-effective intervention is picked over by public health officials, UN agencies and national governments. A potential charge that this intervention will only act as a net benefit to men- and may actually be a net burden on women’s health- will complicate the politics surrounding interventional use, spread and public acceptance.
Global Health Roundtable
20) A very interesting public roundtable discussion between prominent international health experts and activists has been hosted by the American Council on Foreign Relations and published in the journal Foreign Affairs and online. The discussion was initiated by Council Fellow Laurie Garrett- author of ‘The Coming Plague’ and ‘Betrayal of Trust’- who argues in the article ‘The Challenge of Global Health’ that the problem experienced until very recently of not enough money being invested in global health has been replaced by the equally invidious problem of the rapid expansion in international health funding since 2000 being focused too exclusively on high profile diseases, and too infrequently on the sort of health-system strengthening that will create long-term improvements in development and health.
21) Garrett argues that global public health is at a cross-roads, and that a very short window of opportunity to progress the healthcare of the poorest is both rapidly closing, and being unfortunately ignored in policy-making circles. The opportunity, in short, is to choose between promoting the status quo in public health by funding specific disease reduction programmes (stovepiping) so that many more millions don’t die from the major diseases of poverty (principally HIV/AIDS, tuberculosis and malaria) in addition to those that already do; or by funding health-system strengthening programmes and general infrastructural improvements, and in particular make up for the four million doctors and nurses that Africa is reckoned to be missing- a total that increases every year. The fundamental mistake of stovepiping money such as through the Global Fund and PEPFAR into specific disease programmes that treat public health as a purely medical concern, coupled with a chronic lack of international leadership and governance on public health typified by the angst caused by the death of WHO Director-General Lee Jong-Wook in 2006, and the failure to attract a successor to Richard Feacham at the Global Fund, means that international public health is reaching something of a crisis, Garrett contends. General health system atrophy and the marginalisation of other health programmes (such as maternal health, paediatric respiratory diseases, and intestinal infections) means that these health programmes also fail to prevent at least as many deaths as the headline diseases of AIDS, TB and malaria.
22) Garrett argues that stovepiping for HIV/AIDS (which may represent up to 10% of national GDP in some African nations) may create the triple problems of ‘Dutch Disease’. Firstly, externally derived funds so exceed domestic production and investment that a local health system collapses under the strain. Secondly, inflation undoes economically any social good that large amounts of foreign investment create. Finally, the loss of national control of action on HIV/AIDS undermines local ‘ownership’- or accountability- of national efforts to combat the epidemic. The first major response to Garrett in the roundtable comes from Paul Farmer of Harvard Medical School, and founder of the NGO Partners in Health. As well as having a serious disagreement about more medical personnel automatically improving public health- his point on AIDS being that doctors are rarely efficient distributors of ARVs- Farmer believes that well-trained community health workers, in Partners for Health’s experience in resource-poor settings, are much better equipped to manage HIV/AIDS primary care which is as much social work as medicine. Farmer argues that stovepiping doesn’t need to create extra stresses within health systems given proper management. Stovepiping can actually strengthen health systems because effective mechanisms will be needed to disburse funding for HIV/AIDS, and this will promote general public health strengthening as logical steps necessary in order to create success in disease-specific programmes. He gives two examples: in many areas AIDS programmes won’t work unless they also treat TB; and that paediatric HIV cannot be tackled without addressing maternal health. Therefore, well-run programmes will not achieve the results they aim for unless they approach healthcare holistically. Where attempted, Farmer argues, HIV programmes in aggregate add to, rather than detract from, background public health strengthening.
23) Adding to the debate, Columbia Professor and ‘Celebrity Economist’ Jeffrey Sachs makes a typically strident argument that any problems that arise from mis-targted funding are dwarfed by the problem of there not being enough money to start with. “[Garrett’s] article is filled with misguided aid-bashing and disdain for targeted disease-control programs” argues Sachs. “We don’t have to choose between AIDS control and maternal mortality. And we don’t have to choose between topping up health worker salaries and breaking the donor bank…Those of us on the front lines of this fight do not recognize her black-and-white contrasts between vertical disease-control programs and public-health-system strengthening…Garrett’s attack on disease-control programs is passé, a straw man.”
24) Sachs points out that the 2001 Commission on Macroeconomics and Health (of which he was a member) argued that a one-time commitment of $30bn, then 1% of OECD GDP, would help to build the sustainable health systems that would arrest the four-million health worker deficit. He has also been arguing for years (see this year’s Reith Lectures for example) that commitments for public health even at present levels seem like a lot of money, but when dividing billions of dollars by billions of people- because the money is spread very thinly by a multitude of implementers- few results will be achieved. Instead what is needed is an end to the ‘aid-bashing’ and the injection of large amounts of well-targeted, often one-off, funding in order to create the economies of scale necessary to kick-start sustainable health improvements. Most fervently, Sachs argues that “[u]ntil Africa’s economies pull Africa out of extreme poverty- something that will be powerfully assisted by disease control- foreign aid is not a whim, a matter of dole, or a matter of avoidable dependency. It is the difference between life and death.”
25) In their response, Roger Bate and Kathryn Boateng of the American Enterprise Institute take issue with Garrett’s implied suggestion that the WHO, rather than national governments, should have the responsibility for improving global public health; arguing that the WHO has a very useful role in advising and co-ordinating governments, but lacks the capacity or legitimacy to lead international health campaigns. This seems somewhat disingenuous. For such an under-resourced body the very slow and hard-won successes of smallpox eradication, and the near-eradication of polio (unfortunately this has been sabotaged somewhat by complex social and epidemiological problems in its final stages) are real accomplishments. It has hardly been helped by the anti-multilateral and anti-UN rhetoric associated with such institutions as the American Enterprise Institute that describes the UN as ‘normative imperialism’, that is an international philosophy that “…desperately needed an organizing principle for society that could provide the altruistic sentiments lost in [the] rejection of traditional Christianity.” Bate and Boateng also dispute that the ‘brain drain’ is as much of a net drain on African health systems as Garrett suggests. Foreign-trained doctors in western health services may actually remit more money back home than they would make as doctors in their own systems; expanding national economies and providing more tax revenue than they would otherwise produce. One area of common ground they find with other participants is in a rejection of the idea that a ‘Marshall Plan’ for global health is a good idea either rhetorically or substantively. As they point out, the Marshall Plan provided direct investment to economies for infrastructural reconstruction (and for political reasons too); public health in many of the poorest locations needs building from scratch.
26) Justice Africa director, and director of the SSRC Programme on HIV/AIDS and Social Transformation, Alex de Waal, contributed to the debate by agreeing with Garrett that stove-piping may undermine national priorities and sustainability, but argues that Sachs is right on the wider point of the cost-effectiveness of tackling particular diseases- if sufficient funds can be targeted in appropriate quantities and circumstances- in order to create health system improvement by relieving the excess burden of the major diseases of poverty. De Waal also points out a major problem; namely that these arguments are made on the assumption that numerical indicators of improvements or declines in public health can be investigated in terms of their core relationship to poverty. If that were true then one side in this argument- between focused interventions and systemic strengthening- would have all the evidence, and the other would have none. Ultimately both the Garrett and the Farmer/Sachs approaches to this problem have their merits; but neither has a monopoly on the evidence here. One point that all might agree on is that the evidence has never kept pace with the funds available; nor especially the rhetoric involved.
27) Where does this leave HIV/AIDS? As Garrett points out in the original essay, the whole idea of co-ordinated efforts to improve international public health- and to confront international health problems collectively- was inspired by at first the enormous activism, and then the rapid commitments of funding, that came in response to HIV/AIDS. And as Bate and Boateng note in their response, global health leadership by the WHO (and by implication UNAIDS) was meant to cheerlead, co-ordinate and advise on health development, rather than act as a global programme implementation body cutting out the middle-men of governments and communities. Perceived crises in international public health suffer from diffuse and under-powered co-ordinating mechanisms, a lack of leadership, and a critical lack of legitimacy (a lack albeit not helped by an accountability deficit to users and national governments). All this, therefore bodes ill for HIV/AIDS. If the lack of accountability and legitimacy of international bodies such as WHO and UNAIDS is creating a deficit, year after year, of promises broken and targets not met, how will the massive health gains of the first three-quarters of the twentieth century in the rich nations- with significant gains in poor countries too- be defended, let alone be built upon in the twenty-first? And is HIV/AIDS not the gravest warning sign of all, given that health systems have been perceived to have atrophied, globally, since the late 1970s; a period coincidental with the development of the HIV/AIDS epidemic?
AIDS, Security and Conflict Initiative Update
28) The AIDS, Security and Conflict Initiative was established in 2005 as a joint venture of international partners led by the Social Science Research Council and the Netherlands Institute of International Relations ‘Clingendael’. ASCI is a joint research initiative addressing the interactions of HIV/AIDS, security and conflict, ordered around four ‘themes’ of uniformed services including peacekeepers and police; humanitarian crises and post-conflict transition; fragile and ‘crisis’ states; and cross-cutting issues of gender, data collection and measurement, and media representation. Recent Justice Africa and GAIN work falling within the ASCI remit focuses upon police services- and this has seen the commissioning of new work in South Africa, Benin, Sierra Leone and Sudan. A large amount of the background work on police services has been detailed in GAIN Brief 9. The issue is commanding attention, not least from UNAIDS, and ASCI’s expansion is putting an emphasis upon analysing the non-military security sector, such as police services, customs and immigration officials, peace-keepers and other members of the proliferating groups now categorised as the ‘security sector’.
29) Justice Africa, as an ASCI partner, will be looking to expand its research work on the police in the second half of 2007; and this will particularly focus on research that would fall under ASCI’s cross-cutting theme of gender. Any individuals or groups interested in this research, who would like to discuss the possibility of securing a small grant to conduct research under a broad theme of HIV/AIDS, gender and policing in 2007/2008 can contact Alastair Roderick in London:
