May 31, 2021

Communication in pandemic times

 Communicating Science in Times of Crisis. The COVID-19 Pandemic


Part 1 Conceptualizing Communication Science and COVID-19 1

1. Managing Science Communication in a Pandemic 3

H. Dan O’Hair and Mary John O’Hair

2. Comprehending Covidiocy Communication: Dismisinformation, Conspiracy Theory, and Fake News 15

Brian H. Spitzberg

3. How Existential Anxiety Shapes Communication in Coping with the Coronavirus Pandemic: A Terror Management Theory Perspective 54

Claude H. Miller and Haijing Ma

Part 2 Promoting Health and Well-being 81

4. Communication and COVID-19: Challenges in Evidence-based Healthcare Design 83

Kevin Real, Kirk Hamilton, Terri Zborowsky, and Debbie Gregory

5. Identity and Information Overload: Examining the Impact of Health Messaging in Times of Crisis 110

Jessica Wendorf Muhamad and Patrick Merle

6. Social Media, Risk Perceptions Related to COVID-19, and Health Outcomes 128

Kevn B. Wright

7. Overcoming Obstacles to Collective Action by Communicating Compassion in Science 150

Erin B. Hester, Bobi Ivanov, and Kimberly A. Parker

8. Communicating the Science of COVID-19 to Children: Meet the Helpers 172

Jennifer Cook, Timothy L. Sellnow, Deanna D. Sellnow, Adam J. Parrish, and Rodrigo Soares

9. The Use of Telehealth in Behavioral Health and Educational Contexts During COVID-19 and Beyond 189

Alyssa Clements-Hickman, Jade Hollan, Christine Drew, Vanessa Hinton, and Robert J. Reese

Part 3 Advancing Models of Information and Media 215

10. Toward a New Model of Public Relations Crisis and Risk Communication Following Pandemics 217

Zifei Fay Chen, Zongchao Cathy Li, Yi Grace Ji, Don W. Stacks, and Bora Yook

11. Perspective Change in a Time of Crisis: The Emotion and Critical Reflection Model 242

Helen Lillie, Manusheela Pokharel, Mark J. Bergstrom, and Jakob D. Jensen

12. Social Media Surveillance and (Dis)Misinformation in the COVID-19 Pandemic 262

Brian H. Spitzberg, Ming-Hsiang Tsou, and Mark Gawron

13. Science Communication and Inoculation: Mitigating the Effects of the Coronavirus Outbreak 302

Bobi Ivanov and Kimberly A. Parker

Part 4 Examining Policy and Leadership 321

14. Communicating with Policymakers in a Pandemic 323

Michael T. Childress and Michael W. Clark

15. Equally Unpleasant Choices: Observations on School Leadership in a Time of Crisis 338

Justin M. Bathon and Lu S. Young

16. Controlling the Narrative: Mixed Messages and Presidential Credibility 358

Robert S. Littlefield

17. Communicating Death and Dying in the COVID-19 Pandemic 375

William Nowling and Matthew W. Seeger

May 28, 2021

Medical practice variation in oncology

 Atlas de variaciones en cirugía oncológica.

Why there is still so much variation in medical practice?

Some details inside this atlas.

Aliza Nisenbaum

May 27, 2021

The Silent Evolution in EU Health Law and Policy

 EU Health Law & Policy. The Expansion of EU Power in Public Health and Health Care

This book describes the expansion of EU power in health care and public health and analyses the implications of this expansion on EU health values and rights. The main conclusion of the book is that the EU is de facto balancing fundamental rights and values relating to health, implicitly taking on obligations for safeguarding fundamental rights in the field of health and affecting individuals’ rights sometimes without an explicit legal competence to do so. 


May 21, 2021

Biases and noise, two kinds of error

Noise, a flaw in human judgement

A new book by  Daniel Kahneman, Olivier Sibony, and Cass R. Sunstein

A general property of noise is that you can recognize and measure it while knowing nothing about the target or bias. The general property of noise is essential for our purposes in this book, because many of our conclusions are drawn from judgments whose true answer is unknown or even unknowable. When physicians offer different diagnoses for the same patient, we can study their disagreement without knowing what ails the patient. When film executives estimate the market for a movie, we can study the variability of their answers without knowing how much the film eventually made or even if it was produced at all. We don’t need to know who is right to measure how much the judgments of the same case vary. All we have to do to measure noise is look at the back of the target.

To understand error in judgment, we must understand both bias and noise. Sometimes, as we will see, noise is the more important problem. But in public conversations about human error and in organizations all over the world, noise is rarely recognized. Bias is the star of the show. Noise is a bit player, usually offstage. The topic of bias has been discussed in thousands of scientific articles and dozens of popular books, few of which even mention the issue of noise. This book is our attempt to redress the balance.


May 20, 2021

Anthropocene, green arithmetic and capitalocene

 Anthropocene or Capitalocene? Nature, History, and the Crisis of Capitalism

Formulated by Paul Crutzen and Eugene Stoermer in 2000, the Anthropocene concept proceeds from an eminently reasonable position: the biosphere and geological time has been fundamentally transformed by human activity. A new conceptualization of geological time—one that includes “mankind” as a “major geological force”—is necessary. This was a surely a courageous proposal. For to propose humanity as a geological agent is to transgress one of modernity’s fundamental intellectual boundaries. Scholars call this the “Two Cultures,” of the “natural” and “human” sciences (Snow 1957). At its best, the Anthropocene concept entwines human history and natural history—even if the “why” and the “how” remain unclear, and hotly debated. 

 Green Arithmetic. It is a curious term, but I can think none better to describe the basic procedure of environmental studies over the past few decades: Society plus Nature = History. Today it is Humanity, or Society, or Capitalism plus Nature = Catastrophe. I do not wish to disparage this model. It has been a powerful one. It has provided the philosophical basis for studies that have delivered a wealth of knowledge about environmental change. These studies, in turn, have allowed a deeper understanding of the what of the biosphere’s unfolding “state shift.” But they have not facilitated—indeed they have stymied—our understanding of how the present crisis will unfold in a world-system that is a world-ecology, joining power, nature, and accumulation in a dialectical and unstable unity.

 The Capitalocene. As I think the contributions to this volume clarify, the Capitalocene does not stand for capitalism as an economic and social system. It is not a radical inflection of Green Arithmetic. Rather, the Capitalocene signifies capitalism as a way of organizing nature—as a multispecies, situated, capitalist world-ecology. I will try to use the word sparingly. There have been many other wordplays—Anthrobscene (Parikka 2014), econocene (Norgaard 2013), technocene (Hornborg 2015), misanthropocene (Patel 2013), and perhaps most delightfully, manthropocene (Raworth 2014). All are useful. But none captures the basic historical pattern modern of world history as the “Age of Capital”—and the era of capitalism as a world-ecology of power, capital, and nature.

May 19, 2021

Models for population health

 Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream

The Roundtable on Population Health Improvement of the National Academies of Sciences, Engineering, and Medicine hosted a public workshop on September 19, 2019 titled Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream. The term upstream refers to the higher levels of action to improve health. Medical services act downstream (i.e., at the patient level) in improving population health, while such activities as screening and referring to social and human services (e.g., for housing, food assistance) are situated midstream, and the work of changing laws, policies, and regulations (e.g., toward affordable housing, expanding healthy food access) to improve the community conditions for health represents upstream action.

The workshop explored the growing attention on population health, from health care delivery and health insurance organizations to the social determinants of health and their individual-level manifestation as health-related social needs, such as patients' needs. The workshop showcased collaborative population health improvement efforts, each of which included one or more health systems. This publication summarizes the presentations and discussions from the workshop.

May 18, 2021

A quantum leap on microfluidics for in vitro diagnostics

 On the Wireless Microwave Sensing of Bacterial Membrane Potential in Microfluidic-Actuated Platforms

You may remember my posts on Theranos, the company that wanted to solve in vitro diagnostics (IVD) with a drop of blood. The underlying technology was microfluidics, however at that stage was inmature, and finally Theranos was a massive fraud and Elizabeth Holmes is right now on trial.

Now you can read an interesting article in Sensors journal that tries to combine microfluidics and wireless technologies for detecting bacteria. Microfluidics is defined as the manipulation of a fluid in micrometer-sized structures or channels. In such microchannels, the behavior of a liquid is significantly different than at the macroscale. Surface effects and viscosity start to dominate and flows such as laminar flows are more predictable.

If this procedure finally works in practice, it would represent a quantum leap on In Vitro Diagnostics. Time will tell us if this is so.

May 17, 2021

Outperforming CRISPR?

 High-throughput functional variant screens via in vivo production of single-stranded DNA

A new technoique overcomes existing limitations of CRISPR

Unlike existing techniques depending on CRISPR-Cas–directed genomic breaks for genome editing, this strategy instead uses single-stranded DNA produced by a retron element for recombineering. This enables libraries of millions of elements to be constructed and offers relaxed design constraints which permit natural DNA or random variation to be used as inputs.

A group of researchers created what they call the "Retron Library Recombineering" (RLR) technique, which could allow scientists to run millions of genetic experiments at the same time. This tool, described in a recent paper in PNAS, employs retrons, which are bacterial DNA segments that undergo reverse transcription to generate single-stranded DNA fragments (ssDNA). RLR produces up to millions of mutations concurrently in bacterial cells and "barcodes" mutant cells, enabling the whole pool to be screened at once. This way large quantities of data can be quickly produced and analyzed.

May 16, 2021

Planetary health

 Safeguarding human health in the Anthropocene epoch: report of The Rockefeller Foundation–Lancet Commission on planetary health

The Anthropocene is functionally and stratigraphically distinct from the Holocene

The Conservation Revolution. Radical Ideas for Saving Nature beyond the Anthropocene

Two key articles and a book on the topic of planetary health.

Our more grounded goal was to distil the main issues at stake in these complex debates, which we argue revolve around two main axes: the human–nature dichotomy and the ecological merits or perils of contemporary capitalism. Both issues are not straightforward, and there can be no straightforward, black-and-white arguments for or against them. Indeed, there is a distinct danger in presenting them this way, as it does not correspond to empirical reality and the nuances of the debate. We therefore need to do justice to the potentially radical natures of these alternative proposals by discussing them in more depth to show in greater detail how and why they are radical and important, yet contain several untenable contradictions.


May 14, 2021

Reforming NHS (once again)

 LSE–Lancet Commission on the future of the NHS: re-laying the foundations for an equitable and efficient health and care service after COVID-19

Any reforms starts with a good diagnosis, therefore it's good to check how inequality indicators differ across countries.

And these are the recommendations:

Recommendation 1: increase investment in the NHS, social care, and public health

Recommendation 2: improve resource management across health and care at national, local, and treatment levels

Recommendation 3: develop a sustainable, skilled, and inclusive health and care workforce to meet changing health and care needs

Recommendation 4: strengthen prevention of disease and disability and preparedness to protect against threats to health

Recommendation 5: improve diagnosis, in circumstances where evidence exists to support early diagnosis, for improved outcomes and reduced inequalities

Recommendation 6: develop the culture, capacity, and capabilities of the NHS and social care to become a national learning health and care system

Recommendation 7: improve integration between health, social care, and public health and across different providers, including the third sector


May 13, 2021

Health behaviors and behavior change (2)

 Reset. An Introduction to Behavior Centered Design

A new book to read.

The BCD behavior challenge model consists of three basic problems (with two tasks for each):

• Create Surprise.

• Get exposure.

• Grab attention.

• Cause Revaluation.

• Alter rewards.

• Modify value.

• Enable Performance.

• Disrupt setting.

• Action selection.

May 12, 2021

Health behaviors and behavior change

 Behavioral Economics and Public Health

Health behaviors and practices constitute the foundation of good physical and mental health. The leading contributors to the global burden of disease include tobacco smoking, low-quality diets, alcohol abuse, physical inactivity, and obesity. Accordingly, encouraging people to adopt—and maintain—healthy behaviors is a major objective of public health. 

Today I recommend this book and this is what you'll find inside:

Chapter 1: An Introduction to Behavioral Economics and Public Health. Christina A. Roberto and Ichiro Kawachi

Chapter 2: Intertemporal Choices for Health. Justin S. White and William H. Dow

Chapter 3: Maintenance of Healthy Behaviors: Forming and Changing Habits. Dennis Rünger and Wendy Wood

Chapter 4: Emotions and Health Decision-Making: Extending the Appraisal Tendency Framework to Improve Health and Health Care. Rebecca Ferrer, William Klein, Jennifer Lerner, Valerie Reyna, and Dacher Keltner

Chapter 5: Social Norms, Beliefs, and Health. Brent McFerran

Chapter 6: Communicating for action: the importance of memorability and actionability. Jason Riis and Rebecca K. Ratner

Chapter 7:Nudging Individuals Toward Healthier Food Choices with the 4Ps Framework for Behavior Change. Zoë Chance, Ravi Dhar, Michelle Hatzis, and Kim Huskey

Chapter 8: Incentivizing Health Behaviors. Kristina Lewis and Jason Block

Chapter 9: Slim By Design: Moving from Can't to CAN.Brian Wansink

Chapter 10: Applying Behavioural Economics in a Health Policy Context: Dispatches from the front lines. Michael Sanders and Michael Hallsworth

Chapter 11: From Choice Architecture to Policy Infrastructure: Multi-Level Theory and the Political Economy of Health Behaviors. Frederick J. Zimmerman

May 11, 2021

The profits of opioid addiction epidemic (2)


The winner takes it all. And the winner is: the Sackler family. They are not alone, they needed accomplices. CDC says:

In 2019, an average of 38 people died each day from overdoses involving prescription opioids, totaling more than 14,000 deaths.1  While prescription opioids were involved in over 28% of all opioid overdose deaths in 2019, there was a nearly 7% decrease in prescription opioid-involved death rates from 2018 to 2019.

 From 1999–2019, nearly 500,000 people died from an overdose involving any opioid, including prescription and illicit opioids.

This rise in opioid overdose deaths can be outlined in three distinct waves.

The first wave began with increased prescribing of opioids in the 1990s, with overdose deaths involving prescription opioids (natural and semi-synthetic opioids and methadone) increasing since at least 19993.

The second wave began in 2010, with rapid increases in overdose deaths involving heroin4.

The third wave began in 2013, with significant increases in overdose deaths involving synthetic opioids, particularly those involving illicitly manufactured fentanyl5,6,7. The market for illicitly manufactured fentanyl continues to change, and it can be found in combination with heroin, counterfeit pills, and cocaine.

And regarding synthetic opioids, you'll find many details inside this book: "The empire of pain" that explains the largest man-made epidemic nowadays.

 My intention was to tell a different kind of story, however, a saga about three generations of a family dynasty and the ways in which it changed the world, a story about ambition, philanthropy, crime and impunity, the corruption of institutions, power, and greed. As such, there are aspects of the public health crisis that this book gives scant attention to, from the science of addiction to the best strategies for treatment and abatement to the struggles of people living with an opioid use disorder. The issue of pain and appropriate pain management is enormously complex, and while this book is highly critical of the mass marketing of opioids for moderate pain, it does not explore at any length the harder question, which is currently a matter of heated debate, about the long-term therapeutic value of opioids for severe chronic pain. 

Beyond that, somebody should remember that the regulator was and is on vacation...

Highly recommended. 

May 10, 2021


 Which Way Will Biden Go on Health Care?

David Cutler says in JAMA:

The biggest choice for the Biden administration and Congressional Democrats is whether to continue with the Affordable Care Act (ACA) or start the transition to a single-payer system. Continuing with the ACA would involve making the recently enhanced subsidies in the ACA’s marketplaces permanent, enacting a public insurance option, providing stronger incentives for Medicaid expansion in recalcitrant states, and pushing for targeted savings in drug prices and administrative costs. A transition to a single-payer system would begin by lowering the age of eligibility for Medicare to 60 years or perhaps 55 years, possibly expanding benefits in areas such as vision, hearing, and dental care, and allowing Medicare to negotiate with drug companies. These 2 approaches are not incompatible; however, it is unlikely that there will be enough money for both.

Clear message to whom it may concern.


May 7, 2021

Patents are Not the Problem (right now)!

 I agree absolutely with Alex Tabarrock and his post in Marginal revolution. He says:

Patents are not the problem. All of the vaccine manufacturers are trying to increase supply as quickly as possible. Billions of doses are being produced–more than ever before in the history of the world. Licenses are widely available. AstraZeneca have licensed their vaccine for production with manufactures around the world, including in India, Brazil, Mexico, Argentina, China and South Africa. J&J’s vaccine has been licensed for production by multiple firms in the United States as well as with firms in Spain, South Africa and France. Sputnik has been licensed for production by firms in India, China, South Korea, Brazil and pending EMA approval with firms in Germany and France. Sinopharm has been licensed in the UAE, Egypt and Bangladesh. Novavax has licensed its vaccine for production in South Korea, India, and Japan and it is desperate to find other licensees but technology transfer isn’t easy and there are limited supplies of raw materials:

Virtually overnight, [Novavax] set up a network of outside manufacturers more ambitious than one outside executive said he’s ever seen, but they struggled at times to transfer their technology there amid pandemic travel restrictions. They were kicked out of one factory by the same government that’s bankrolled their effort. Competing with larger competitors, they’ve found themselves short on raw materials as diverse as Chilean tree bark and bioreactor bags. They signed a deal with India’s Serum Institute to produce many of their COVAX doses but now face the realistic chance that even when Serum gets to full capacity — and they are behind — India’s government, dealing with the world’s worst active outbreak, won’t let the shots leave the country.

Plastic bags are a bigger bottleneck than patents. The US embargo on vaccine supplies to India was precisely that the Biden administration used the DPA to prioritize things like bioreactor bags and filters to US suppliers and that meant that India’s Serum Institute was having trouble getting its production lines ready for Novavax. CureVac, another potential mRNA vaccine, is also finding it difficult to find supplies due to US restrictions (which means supplies are short everywhere). As Derek Lowe said:

Abolishing patents will not provide more shaker bags or more Chilean tree bark, nor provide more of the key filtration materials needed for production. These processes have a lot of potential choke points and rate-limiting steps in them, and there is no wand that will wave that complexity away.

Technology transfer has been difficult for AstraZeneca–which is one reason they have had production difficulties–and their vaccine uses relatively well understood technology. The mRNA technology is new and has never before been used to produce at scale. Pfizer and Moderna had to build factories and distribution systems from scratch. There are no mRNA factories idling on the sidelines. If there were, Moderna or Pfizer would be happy to license since they are producing in their own factories 24 hours a day, seven days a week (monopolies restrict supply, remember?). Why do you think China hasn’t yet produced an mRNA vaccine? Hint: it isn’t fear about violating IP. Moreover, even Moderna and Pfizer don’t yet fully understand their production technology, they are learning by doing every single day. Moderna has said that they won’t enforce their patents during the pandemic but no one has stepped up to produce because no one else can.

 More information in his post.

Some weeks ago a journalist asked to me the same question, and I said more or less, the same!. There is no need to start discussions about patents in WCO, only the enforcement and implementation of mandatory licenses can be helpful.

¿Qué opina sobre las patentes de las vacunas de la covid-19? ¿Considera que, en este caso, deberían contemplarse excepciones al derecho de explotación exclusiva?

Antes de hablar de patentes, conviene considerar la inversión pública en investigación. Por ejemplo, en la medida que hay una vacuna cuyo coste de investigación ha sido sufragado en un 97% por el sector público, resulta lógico que se compre a un precio equivalente al coste de fabricación, tal como sucede.  Ahora bien, también sería deseable que se obligara a licenciar el proceso a otros fabricantes. En el caso de vacunas de RNA mensajero, el nivel de inversión pública en Estados Unidos es notable y sin embargo no ha sucedido lo mismo. Por consiguiente, los gobiernos deben gestionar las contrapartidas de la inversión pública en investigación.

•  ¿Considera que sería positiva una liberación de las patentes de las vacunas contra la covid? ¿Por qué? 

En mi opinión ya existen mecanismos que permiten conseguir que las vacunas sean asequibles y son las licencias obligatorias. Tal regulación que se configuró en la reunión de la OMC en Doha en el año 2003. Desafortunadamente no se ha desarrollado suficientemente por los países. Las condiciones por las que se deberían aplicar tales licencias quedan explícitas en la Declaración. Tales condiciones hacen referencia a la definición de emergencia y crisis de salud pública. En esta pandemia se daban las condiciones para su aplicación. Visto así, el debate necesita centrarse entre patentes y licencias obligatorias atendiendo a condiciones concretas. 

•  ¿Existen mecanismos ya reglados para que, en situaciones como ésta, más allá de la patente, se garantice la llegada de las vacunas a todos los países (incluyendo los de nivel económico más bajo)?

En realidad la Alianza Mundial para vacunas e inmunización (GAVI) nació para ello. En el caso de la COVID, la OMS a través de GAVI y otras instituciones ha impulsado la iniciativa COVAX que pretende ofrecer vacunas a países en desarrollo. Aún así sabemos que el esfuerzo es insuficiente a la vista de los resultados, el 87% de las vacunas ha ido a países ricos, y en los menos desarrollados tan solo ha llegado el 0,2%.


May 4, 2021

Economics of prevention

 An Ounce of Prevention

I look at prevention through an economic lens and make three main points. First, those advocating preventive measures are often asked how much money a given measure saves. This question is misguided. Instead, preventive measures can be thought of as insurance, with a certain cost in the present that may or may not pay off in the future. Although most medical preventive measures improve expected health, they do not save money. Various lifestyle and early childhood interventions, however, may both save money and improve health. 

Second, preventive measures, including medical and lifestyle measures, are heterogeneous in their value, both across measures and within measure, across individuals. As a result, generalizations in everyday  discourse about the value of prevention can be overly broad. 

Third, health insurance coverage for medical preventive measures generally should be more extensive than coverage for the treatment of a medical condition, though full coverage of preventive services is not  necessarily optimal

Well, and Joseph Newhouse says:

At one time, it was common to hear arguments that clinical preventive services were not insurable because they were “not a random variable and hence not an ‘insurable risk’” (Zweifel and Breyer 1997). Zweifel and Breyer give the example that “it is hardly conceivable that a health insurer would ever cover  expenditure on items such as . . . atomizers that help to prevent respiratory disorders;” a similar point could be made about a flu shot or mammography. There are, however, both economic efficiency and behavioral arguments for many preventive measures.

It may be arguments, but not so much incentives in private insurance market. For example, why vaccines have been bought by governments?. That's all. A misguided article.


May 3, 2021

Creative destruction or how to save capitalism from the capitalists

The Power of Creative Destruction. Economic Upheaval and the Wealth of Nations

This book is an invitation to a journey: a journey through economic history, more specifically a journey to explore the enigmas of economic growth through the lens of creative destruction.

Creative destruction is the process by which new innovations continually emerge and render existing technologies obsolete, new firms continually arrive to compete with existing firms, and new jobs and activities arise and replace existing jobs and activities. Creative destruction is the driving force of capitalism, ensuring its perpetual renewal and reproduction, but at the same time generating risks and upheaval that must be managed and regulated.

This is precisely what this book explains. And behind the driving force of capitalism, you'll find ideas, as Deirdre McCloskey dixit

From Shumpeter:

The first idea is that innovation and the diffusion of knowledge are at the heart of the growth process.

The second idea is that innovation relies on incentives and protection of property rights

The third idea is creative destruction: new innovations render former innovationsobsolete. In other words, growth by creative destruction sets the stage for apermanent conflict between the old and the new: it is the story of all incumbent firms, all the conglomerates, that perpetually attempt to block or delay the entryof new competitors in their sectors.

Creative destruction thus creates a dilemma or a contradiction at the very heart of the growth process. On the one hand, rents are necessary to reward innovation and thereby motivate innovators; on the other hand, yesterday’s innovators must not use their rents to impede new innovations. As we mentioned above, Schumpeter’s answer to this dilemma was that capitalism was condemned to fail precisely because it was impossible to prevent incumbent firms from obstructing new innovations. Our response is that it is indeed possible to overcome this contradiction, in other words to regulate capitalism or, to take the title of Raghuram Rajan’s and Luigi Zingales’ 2004 book, to “save capitalism from the capitalists.”

PS. Shelling on the strategy of conflict.

May 2, 2021

Creative construction or how big companies innovate

 Creative Construction. The DNA of Sustained Innovation

The conventional wisdom is that only disruptive, nimble startups can innovate; once a business gets bigger and more complex, corporate arteriosclerosis sets in. Over the last three decades, I’ve researched innovation and have had extraordinary on-the-ground experience with big companies and fast-growing ones that have moved beyond the startup stage. The culmination of that work is “Creative Construction,” which yields a new perspective about how bigger companies can leverage scale for competitive advantage in innovation.

You can check in this book how innovation is misunderstood quite often, and how to create a culture, strategy and organizational system that embraces it.