Day Three in Kibera is a wrap! :)

My name is Sarah, I'm a registered nurse who works in the United
States, and I am a first time volunteer with PINCC. I am hoping to
build on the excellent blog post that Tenay wrote on Monday about our
work in the Kibera slum of Nairobi. To say this week has been "eye
opening" is a huge understatement. It is challenging to work in an
environment with limited resources, yet continue to provide a high
standard of care. PINCC does an amazing job of stretching and
utilizing the resources that they do have. We reuse anything that can
safely be reused. Also, we do not have an autoclave large enough to
sterilize the many speculums that trainees and clinicians use when
screening approximately 35 patients each day. Therefore, there is a
very specific cleaning process that occurs to make sure that we are
thoroughly cleaning speculums and not infecting anyone.

Kibera slum is a difficult location to implement a cervical cancer
screening program. Kibera is home to an estimated 750,000 people (it
is almost impossible to accurately assess the population because
people come and go frequently) crammed into an area approximately the
size of Central Park in New York City. Many in the slum are still
unaware about what cervical cancer is, and the importance of being
screened. The women who have come to the clinic this week have been
very brave. Many of them come alone. The ones who do come often appear
anxious and state they are scared for the exam and/or finding out
their results. (Those who do not know their HIV status are also able
to have a rapid test to find out). The women who have precancerous
lesions on their cervix are usually able to have them removed the same
day. Women who discover that they are HIV positive receive counseling
and are educated about options they have for medical treatment.

Dr. Virginia Hanson, a gynecologist and our medical director this
week, has been performing the LEEP procedures. A LEEP procedure
removes dysplasias (pre-cancerous lesions on the cervix.) She told us
these are the most difficult LEEP procedures she has done in her 30+
years as a physician. In the United States, these lesions would have
been removed long before they had progressed to this point. But here
in Kibera, they are extensive and have grown close to the vaginal
wall, making removal much more challenging. Fortunately she has been
able to remove them before they progress to cancer. Unfortunately at
this time there is not a physician at Tabitha Clinic who PINCC is able
to train and certify in LEEP's, but the clinic will be working on
finding a physician who can be trained on a future PINCC trip. In the
meantime, PINCC is able to train the nurses, midwives, and clinical
officers in how to do Visual Inspection with Acetic Acid (VIA), Visual
Inspection with Lugol's Iodine, and cryotherapy.

The PINCC support staff and clinicians have remarked repeatedly how
impressed we all are with the trainees this week. They are Kenyan
nurses, nurse midwives, and clinical officers (similar to the role a
physician's assistant has in the U.S.) They are eager to learn and are
catching on quickly.

Certainly, it can be disheartening to see the difficulty that the
people of Kibera have in accessing health care or even staying healthy
in such extreme living conditions. Heart wrenching as well is seeing
cases of cervical cancer, which is an almost 100% preventable cancer.
(Dr. Virginia told me today that she only saw two cases of cervical
cancer while working as a gynecologist in the United States.) But, we
still have hope for the women of Kibera. We see the trainees who are
working very hard to learn how to do these screenings and continue to
advocate for women's health after PINCC leaves. They have learned much
these past three days and will attempt to learn as much as they can in
the next day and a half. After our team leaves, they will be expected
to continue doing as many cervical cancer screenings as possible
between now and when PINCC returns for further training in six months.

Thank you for your support of PINCC and we look forward to updating
you again later this week!

Pictures from Bungoma

There But For The Grace Of God I Go.

26 August 2013

Today was the first day and the first training visit to Caroline for Kibera, located in one of the world’s largest slums. Just saying “world’s largest slum”, gives little justification and a very poor description to the sobering and solemn walk we took today to reach the clinic located deep within the heart of Kibera.

As our group of ten cautiously made our way through the dirt allies and flowing waste rivers that winded around and through rusted shack dwellings, I looked around at the faces staring back at us.

Some were children’s faces, smiling brightly, waving, and happily singing in an innocent chorus “How are you? How are you? ”  The children bounced and played over small mounds of waste in flipflops and shorts as we waved back and made our way past them in long pants and covered shoes.

Other faces watched us without expression, craning their heads around others to see the intruders walking through their community. I would smile and try to look friendly, hoping my expression carried compassion and kindness and that my heart did not betray the sadness and numbness I was feeling.

That’s when the thought, There But For The Grace Of God I Go, came to the forefront of my mind. Regardless if I believe in a higher power or not, what makes me so blessed or lucky that I am not sitting on a broken wooden stool watching my child play on the ledge of a human toilet as strangers pass by?

The emotions were as overwhelming as the stench in the air.

Once we made it to the clinic and up three flights of stairs I looked out the window onto the vast dwelling; a sea of shacks packed tightly together, and my heart sank. It would take an army and a lot of money to make a difference here.

Turning around, I began to notice the men and women in white coats, filling in the classroom with eager expressions and my hope rose.

Adah Molle Alati, an extraordinary nurse helped coordinate the trainees, the patients, as well as answer questions and organize our day. Immediately we were put to work and started taking patients medical histories, examining women for cervical cancer, and treating those women who had the precancerous cells.

Three young ladies, one a social worker and the others community health educators, helped translate and answered patients questions as they waited for their exams. I was very impressed with how these young ladies stepped up and were eager to help other women in their community.

I have worked for PINCC for two and a half years, and before I came to Kenya, I understood the needlessness of women dying from cervical cancer and all the statistics behind it, but today I learned so much more.

It is a simple realization that no one man, woman, or child is greater than another. Those of us that are fortunate can find our humanity in giving back to those of us that are not. In this, we will heal.

“The only real nation is humanity” –Paul Farmer, Mountains Beyond Mountains

Notes From Bungoma, August 17 - 22

August  2013 -- Notes from Bungoma by Nurse Roseanne Packard

Saturday, Aug. 17   Eight of our group arrived Saturday evening at the Mennonite Guest House (MGH), greeted each other and had out first meeting to plan our week at Bungoma Districtl Hospital. Some of our group were lucky enough to have had a side trip to Nairobi Regional Park Game Reserve today and spotted lots of plains animals…up close and personal.   Three more will join us at Bungoma on Sunday.

MGH is set amidst lovely gardens and rooms are very nice.

Sunday, Aug. 18 was travel day to Bungoma.   Some took a 9 hour van ride across Kenya towards the west through the beautiful hills and valleys of the Rift Valley with deep greens of the fields  contrasted with the red earth  The weather  was changeable and beautiful cumulous clouds accompanied the whole way.  Our driver, Mike Muthama, was a pleasure and answered all our numerous questions.  Others opted to a flight and only a 2 ½ hour ride. We rendezvoused at the Bungoma Countryside Hotel.  We will be here all week. We are two to a bungalow with our own bath.

The food is country style, potatoes, rice, shredded salad of some type and stew of either chicken or beef, pineapple for dessert.   It is relatively the same every night, but the conversation is lively and improves the appetite. 

Monday  Aug. 19  was D Day.  The first day is always a bit difficult as we learn our parts and place in situ for the first time.  It's sort of like the first rehearsal of a local play.  We have 4 exams rooms and one very small office.  Our clients, the women of all ages, stations and education crowd to us for information on how they will be seen.  The clients are very eager for this free service which impacts on their reproductive lives.   Over the next several hours, question after question, step by step,  both of ours and the clients' needs fell into place to get this mobile clinic in a foreign land up and running.  Carol carefully answered all our questions. We had some missteps, but they were few.

We take a tea break about 10 for a sweet samosa type bun, a sausage and tea.  Lunch comes about 2, of chopped kale, rice, potatoes and some type of stew.  Notice the similarity here.  But we sure eat it all.

The staff has showed up, doctors, nurses and clinical officer students and most are eager to learn.  Our PINCC doctor clinicians are eager to teach.  It is a good combination.  As everywhere, the staff vary in their skills and commitment, but overall it is a motivated group.  We saw 30 patients today, including LEEP. Not bad for a first day.  Our Kenyan nurse- midwife, Ruth Kitai, taught a wonderful class in the waiting area, full of lots of humor, which broke the tension  for the clients  sitting, waiting, wondering.

Tuesday, Aug. 20 and we're moving along a good clip and we saw 40 patients today.  We did 2-3 LEEPS.  We couldn't train on the cryo as there was no gas.  The problems we encounter in this multi-faceted endeavor seem small as the Kenyans are a pleasure to work with; polite, soft-spoken, amenable, flexible  with a sweet graciousness.  All the clients, doubly so…so gracious, so grateful.  We often receive blessing as they exit the exam rooms after their stressful exams.  We saw 50 clients today and found four cancers. One was quite advanced.  Our PINCC staff can find this very hard to process as we assume the client would survive in the US, or at least receive supportive palliative care.

Wednesday, Aug. 21  Our clinicians feel the medical training is going well.  All work so hard in the small, crowded rooms, hour after hour.  At 3 pm every day, our Medical Director, Dr. Virginia Hanson, leads a class for the Kenyan staff.  Towards the end of the day, about 3-4 pm depending, we start to gather up records, clean remaining instruments, and re stock rooms. Our office people keep us on track,  which is not easy as we try to be fair re the first come first served principle, but at the same time, flexible.  It ain't easy.  Others of staff work hard to keep ahead of data that needs to be entered and backed up.  The cryotherapy  is up and running and we're doing our training..   Tonight the clinicians had a meeting to evaluate the Kenyan staff and identify those who may need more support in the learning process.

We had a special treat as about 30 Community Health Workers came in from far and wide for a class today to learn about prevention of cervical cancer and then spread the word.

Tonight we went out for pizza.  We ate by candle light as due to the rains, all lights were out.   This usually happens with a hard rain. We saw 50 clients today. All agreed, the day felt much more "fluid."

Thursday, Aug. 22  In spite of our breaks  for tea at 10 and lunch  at 1: 30 or 2 , the staff gets weary in the afternoons.  We do keep going, but this is not for the lame or halt.  I never work as hard all year as I do with the few weeks at PINCC.   The staff knows we are leaving and I honestly feel they will hate to see us go.  Today volunteer Mimi Pirard, who is a professional singer, treated our clients to a lovely French ballad.  They returned the favor and sang to us.  Saw another 50 clients today.

 

 

--

Carol Cruickshank, CNM, Program Director

Prevention International: No Cervical Cancer 

http://www.pincc.org/
Cell 415-846-4083

Goodbye Cameroon, until next time!

Greetings!

Our PINCC team from the US arrived in Douala yesterday. More than half of the team boarded the plane for home or a well-deserved vacation in Paris! while Carol, Monica and myself hugged and waved them goodbye, our feet still on Cameroonian soil.

It has been an exciting, exhausting adventure, full of learning, surprises, pot-holes, ice-cream, Monkey fruit, car & moto horns, and many cervices!!

The week in Yaounde at the Bethesda Hospital ended well. The group of trainees we worked with were ready and excited to continue to use their new skills- correctly identifying the GSC (squamocolumnar junction in French) and by the end of the week were more confidently deciding whether an exam was "adequate" or "inadequate" and "positive" or "negative". One gynecologist, Fidelia, exceeded expectations and was certified in VIA on the first visit!

In Yaounde we screened 189 patients (according to Shelby's and Reid's fine statistics), did 42 Pap smears, 5 biopsies, 2 LEEPs and 4 cryos. As we went around in a circle during our closing ceremony, sharing what we learned, there were tears and laughter. Monica learned even with language barriers we can still communicate (although all French speakers out there, get excited about Cameroon!) and I learned (which served me well in Kumba) that it is often necessary & incredibly helpful to get down on one's knees to do a proper speculum exam & adequately visualize a cervix!

From Yaounde to Douala in Dr.Nkeh's van we traveled (our driver is a car doctor and has even written a manual on car maintenance for other drivers in Cameroon) so we always felt very safe in his vehicle. Although safe, we also felt cramped and hot as we made our way to the humid and rainy climate in Kumba, 2-3 hours north of Douala.

On our journey, we passed rows and rows of banana, palm and rubber trees. We went through many toll booths which consisted of a man standing in the middle of the street collecting coins from the passing vehicles. Our adventure began as we attempted to find a place to stay in Kumba. After Dr.Nkeh's car got stuck in the mud, requiring all of our female strength to push it out, we arrived at a hotel and finally were able to stretch our legs.

In Kumba we were welcomed by Stella, a nurse in Cameroon, who originally motivated PINCC's trip to Cameroon. Stella is a passionate, dedicated nurse who opened her own medical clinic- We Care- in the Kosala neighborhood of Kumba. I leaned from both Stella & Carol that Stella found PINCC on the Internet, and continued to write to Kay many, many times until Kay was finally able to make the trip to Cameroon, one year ago. Stella's dedication & commitment to her patients brought PINCC to the We Care clinic to continue to teach Stella and other nurses, nursing assistants and lab technicians (who routinely do many vaginal exams) VIA and cryotherapy. Although Stella's clinic has minimal resources, Stella is a fighter and she will continue to bring many resources to her clinic to better serve her patients.

Although we were only in Kumba for less than 3 full days we screened 137 patients, did 49 Paps, 1 biopsy, 1 LEEP and 6 cryos.

I know I, and I think it is safe to say the other PINCC volunteers from the US will leave Cameroon touched by many amazing individuals we had the opportunity to meet.

We will also be leaving with dresses, skirts, pants and shorts handmade by an incredibly skilled Cameroonian seamstress, with fabric we purchased in Yaounde! The very-fashionable seamstress, Mercy, took our measurements one day and the next day an after-work fashion show took place as we modeled our new attire, which brought delight to all!

It was exciting for me to be a part of PINCC's first trip to Cameroon- according to Carol, Cameroon was a success. After spending the last couple weeks with Carol, not only do I attempt to emulate her and channel her patience and calm in times of chaos, but I trust her word 100%.

Tomorrow, Monica will head back to the US and Carol and I plan to fly to Kenya. We hope for safe travels, good luck and we look forward to many more "wow" moments along the way!!

In peace,
Christina

Bonjour from Cameroon

Bonjour!

The PINCC team from the US- Carol, Dr.Melissa, Debra, Reid, Shelby, Dr.Amy, Dr.Katie, Dr.Christina and Monica- arrived safely, Carol holding a sign & awaiting our arrival as we passed through customs & finally exhaled.

Dr.Melissa's bag was lost en route, deciding to take a side trip to either Atlanta or Paris- but will hopefully be found & arrive tomorrow. Thank goodness Dr.Melissa's daughter, Shelby, is here for mother-daughter clothes sharing!

Daily DEET, nightly romantic mosquito nets, Carol's stock in bottled water and Carol's ban on fresh vegetables has kept us all relatively healthy:)

Daily adventures include Debra, Reid & Shelby all getting locked in the bathroom! Carol & Amy's adventure to find an "aspirador petite" and delicious adventures with Cameroonian cuisine- fried fish, meat stews, fried chicken, (we've all given up on vegetarianism) Irish potatoes! pizza! pancakes!

The Cameroonian participants are wonderful, motivated, smart & learning quickly. Today we did 41 exams and a patient even danced out of the clinic room after her VIA exam was "adequate" and "negative"!!

We are off to a good start in Cameroon, many smiles on all our faces:))

Au revoir,

Christina Hamilton

I am always doing that which I can not do, in order that I may learn how to do it. - Picasso

I am always doing that which I can not do, in order that I may learn how to do it. - Picasso

by Tina Romenesko

As we wandered through the soggy streets toward the clinic, we were all a little sad that this is our last day.  It has been challenging, and fulfilling, and wet, and long, and filled with laughter, tears, good news, bad news, and lots of hard work.  Each of us has been challenged to do, to see, to be, something that stretches our edges.  In service work, expecting the unexpected is the norm.  We only saw 30 patients today (instead of 45-50) because we needed to clean all the speculums and pack up the PINCC suitcases with equipment and supplies.  The Nicaraguan trainees also took their written tests and all agree that they have learned A LOT in the past five days.  

Today there was a cancer diagnosis, which is always a staggering reality.  This woman has four sons - the youngest is six - and she will have to go to Managua, as soon as possible, for more diagnostic tests and treatment.  She doesn't have the money for the trip and hopes she can find help affording treatment.  Many women die because they can't afford treatment.  Joyce and I were called in to bring her to a quiet space to process the bad news.  Joyce is our PINCC team grandmother that has spent the past two weeks walking through puddles and up and down cobblestones with her two walking sticks.  Despite having MS, Joyce has ridden on boats, walked the beach, and held many hands during our time in Pearl Lagoon.  A fierce warrior with the biggest heart I have ever known, she offered sage advice.  "Take it one step at a time.  Talk to your family - and remember its okay to ask for help."  I held this brave woman's hand and told her about my son that is a 21 year cancer survivor, diagnosed at age 6.  We drank apple juice, and she talked again with Dr. Sharry to ask a few more questions before taking the bus back home.

Around 2:30, Carol brought us all together, instructing us to blow up two balloons and tie them around our ankles.  Really?  Some of us were better at inflation and others at tying, and eventually we were all set for her ice breaker.  Amidst squeals and laughter, we tried to pop each others balloons, until there were only two left standing:  Jaya and the trainee, Inez.  It was a great way to release the stress of the week and come together as a group again.  Each of member of the PINCC group shared what they had learned/loved on the trip and about Nicaragua. Sally translated for those that didn't speak Spanish and the consensus was that it was a very valuable week of learning and listening.  Many of the Nicaraguan trainees wanted to share also - expressing their gratitude and looking forward to our return in November.  PINCC will return to Pearl Lagoon every six months to check on the trainees and continue educating them in these life saving techniques.  Each visit they are progressively moved forward until they are able to perform all of the available treatments independently.  This process usually takes about 3 years and there are always new trainees with each visit, so everyone progresses at their own pace.

The rain continued to fall as we headed our separate ways, filled with appreciation, and wiser for having experienced this amazing week together.

The Good, the Bad, and the Hopeful

The Good, the Bad, and the Hopeful

by Sallie Weissinger

Each morning the PINCC clinicians train the local doctors and nurses while non-medical volunteers interview the day's 45 patients, noting their medical histories and highlighting details that might be of interest to the clinicians (previous PAP or biopsy results that turned out positive, for example).  Then we log  the sheets and pass them on to the PINCC nurses and doctors and the local trainees for their breast exams, pelvic exams, and visual inspections.  

On Thursday Mary Johnson came to the clinic for a PINCC exam.  A stylish, poised, articulate divorced woman in her late thirties, Mary is a school teacher with three daughters.  When the interviewer asked when she had her last PAP test, Mary said it had been more than five years.  She said she'd been too busy teaching her students and taking care of her daughters.  The interviewer - that was me - said the best way for her to take care of her students and her daughters was to have a regular PAP test.  She said she knew that and would make sure to have her PAPs in the future.  We talked at some length about the importance of regular check-ups.  

I also asked whether she currently had a husband or partner.  She said she didn't want to be with a man because she didn't trust one to not abuse her daughters.  She said that her children were her major concern - they were pre-teens and teenagers, and she would not put them at risk.  I wished her well, she promised me again she would take care of herself, and I assumed her exam would turn out well.

Thursday night, as is often the case, the entire group got together before dinner to socialize.  Program Coordinator Carol Cruickshank, whose energy, dedication, and kindness simply never flag, asked us to share our impressions about what we had seen this week. She specifically asked us to focus on the pain we had experienced and asked us to share coping strategies.  As part of the gathering, the doctors and nurses opened up about their patients.  I learned that two of our doctors had seen Mary and that it didn't look good.  Because her cervix wasn't entirely visible, they had to do a rectal exam and felt a bulky area that was suspicious for cancer.  They ordered a biopsy, with results to come back from Managua in two months, and a PAP smear.  The PAP came back as normal, but her situation is still concerning.  Both doctors are hoping for a possible non-cancerous diagnosis - extremely bad endometriosis? post-menopausal atrophy (although Mary isn't post-menopausal)? - the outcome isn't promising, but they hold a glimmer of hope.  

How do the PINCC doctors and nurses deal with the reality of a likely devastating outcome for Mary?  Both Pamela Lotke, our medical director, and gynecologist Sharry Kreitlow say they usually are able to focus on the many patients they can help rather than on the occasional patient with certain or almost-certain cancer.  The good results far outweigh the bad.  But Pam's misted-over eyes and Sharry's serious tone of voice showed that they can't always focus only on the good side of their work.  We all were silent after they spoke, silently hoping for the unlikely: a good outcome for Mary, her children, and her students.  

Plain Talk in Pearl Lagoon

Plain Talk in Pearl Lagoon

by Sallie Weissinger

Several of the volunteers and doctors speak fluent Spanish; many more, while not fluent, speak Spanish well enough to interview patients in Nicaragua, picking up key details of their medical histories.  We thought before coming here that in the Pearl Lagoon area many of the people spoke English, but weren't prepared for the fact that their English and our English weren't the same.  Here the prevailing language is Creole, English spiced with its own Caribbean flavor.

Our patients' names sound English:  we've seen women named Brenda, Joyce, Ellen, Jenny, and Mary.  Their surnames are Fox, McCoy, Williams, and Temple, names that sound like those of friends back home.  But, in the beginning of the week, when they began talking with us during the PINCC intake process, the challenge began.  It's been even more daunting with women of indigenous Miskito origin.

As the week has progressed, we've improved in asking questions and understanding the women's answers.  And when we've faltered, we've been able to enlist local clinic staff to interpret for us.  

First, we don't ask for an address.  We ask the village and the barrio (sector).  Sometimes a woman gives a description: two miles from village X, next to the church or across the street from the hardware store.  If we want to know her phone number, we don't ask about her phone (that means landline); she will say "I no have phone." You ask for her cellular number.  Sometimes she has one, sometimes she doesn't.  

Asking about a woman's medical history has gotten easier, as we have learned, in our various ways, how to frame questions.  The hardest thing for me to ask about was total number of pregnancies, including miscarriages.  It got easier once I began asking "How much baby born alive?  How much childs alive now? How much baby born to blood (miscarriages)?" and then have summarized for understanding, asking, " Five times pregnant?  One baby die in blood?  One baby die age two?  You have three children live now?"

Another potential misunderstanding was cleared up after a patient told me she'd been pregnant four times and had five children.  I asked her to repeat her comment.  She said, "One appear at two baby." I said, "twins?" and she didn't understand.  So I said "gemelos", Spanish for twins, and she said yes.

We also want to know how they delivered their children - vaginally or by C-section.  For a vaginal delivery, they say "normal" and flush the back of their hand down their laps, between their legs.  For a C-section they simply say "cut."  (For tubal ligation, or "ligadura de trompas," they say "cut to not have baby" and then there's "cut out womb", or hysterectomy.  For the few women we've seen who have had hysterectomies, we ask the reason they had the operation.  If it was because of a cancerous tumor, we will examine them.  If it was because of fibroids or some other reason, we don't examine them because they don't run a risk of cervical or related cancer.)

There are other translations we've learned:  diabetes is "sugar problem"; they often say "sick" instead of menstrual period.  And so on....

By the end of the week, I've found myself talking my version of Creole 'Crenglish?"), asking "How much childs you have?" without putting "did" and "do" in front of my verbs.  I've been dropping the definite article "the" and the occasional preposition and talking primarily in present tense.  I wonder how I sound to the warm, welcoming people of this area.  They listen to my questions and answer them as fully as they can, at times squinting to show me I need to repeat, using different words.  They can't know that I would love to be able to replicate the musical lilt of their Jamaican-sounding (to me) accent.  To me, it's what a smile would sound like, if smiles had sounds.  

Brenda is #1

On Thursday the woman holding hand-written ticket #1 was Brenda Joyce Jimenez, of Miskito origin, who has worked as a cleaner at the Pearl Lagoon clinic for 10 years.  Her mother, Joyce Corina Jimenez, held ticket #2.  

Brenda is 28 years old and has two children; she wants one just one more child and stopped taking Depo Provera in February.  She told her interviewer that she was worried that she hasn't gotten pregnant, but her PINCC doctor assured her nothing is wrong - after years of being on the  injection for birth control, it can take up to one year for menstrual periods to resume.  

Family planning is something that was not available to Brenda's mother, 62-year old Joyce.  Mrs. Jimenez had 14 children, six of whom died before age seven, primarily of diarrhea and dehydration  The eight remaining children all live in the Pearl Lagoon area, where we are working this week.  Brenda's father died of cholera - at first she called it diarrhea and vomiting- when she was eight.  Her mother washed people's dirty clothes to keep the family alive.  Brenda's mother told me, "Some people helped me, some didn't.  I worked hard for them.  I worked for food and I worked for money."  

Brenda went to school until age 14, coming to class only when the dory stopped to pick her up.  She stopped school to help her mother, as did her siblings.  They are proud that once they were working, they were able to support their mom so she could stay at home.

Brenda's inspection was "inadequate" - meaning the nurse and doctor could not see the entire cervical area to determine if there are lesions.  She had a PAP smear done and will get the results in two days.  Her mother showed vaginal atrophy and the speculum exam was uncomfortable, so she also had a PAP test.  Brenda will get those results at the same time she gets her own.