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Health initiatives in rural areas need to be geographically tailored, culturally anchored, and locally driven, academics argue.
The group of University of Otago and University of Waikato researchers studied health providers in rural Mori and Pasifika communities during the COVID-19 vaccination rollout. They uncovered the challenges they faced but also found ways to ensure the effectiveness of any future health promotion programs.
Rural residents in Aotearoa New Zealand are known to have worse health outcomes than their urban counterparts, and were identified as an at-risk population during the pandemic. Despite this, disparities have been found between rural and urban vaccination rates.
The study, published in the Journal of Primary Health Care, aimed to gain insight into factors contributing to this disparity by exploring the experiences of those "on the ground" during the pandemic response.
Lead author Associate Professor Kati Blattner, of Otago's Department of General Practice and Rural Health and Va'a O Tautai, Center for Pacific Health, says common issues were identified.
"The rural vaccine rollout was developed without consideration of the rural context or effective engagement with rural health providers. Challenges multiplied on rural roads with geographical distance, small low-density populations, dire workforce shortages and limited infrastructure including phone and internet connectivity," she says.
Realizing misalignment with their context was hindering progress, rural health providers took ownership of the rollout, entrusting established ways of working and engaging their communities and external Mori or Pasifika networks, enabling innovative local solutions to arise.
"We found three overarching factors influencing the vaccine rollout rurally: geographical tailoring, cultural anchoring, and local control," Dr. Blattner says.
The interaction between these three factors was as important as the role played by each one.
"Rural places are not miniature citiesthe smaller and more remote the community, the more important that health services are integrated, which requires bundled rather than fragmented administrative and regulatory frameworks and resources.
"Bundling requires a move away from siloed funding for strands of activity to a whole-of-service, community-led approach.
"Successful rural vaccine rollouts should not be built on specific immunization programs, but rather on strong, resilient rural health services."
However, despite demonstrating capability for rolling out a national initiative while continuing to operate their services as usual, Dr. Blattner says no sustained investment in rural health services was forthcoming.
"We hope the voices of the health workers and their communities covered by the research are represented loudly enough that this will lead to a better understanding of their rural context and their health services for those based centrally, particularly policy makers and program funders.
"New Zealand needs sustained investment in rural health services, which are designed for rural contexts and capable of meeting the needs of diverse rural communities."
More information: Katharina Blattner et al, He Aroka Urut. Rural health provider perspectives of the COVID-19 vaccination rollout in rural Aotearoa New Zealand with a focus on Mori and Pasifika communities: a qualitative study, Journal of Primary Health Care (2024). DOI: 10.1071/HC23171
Journal information: Journal of Primary Health Care
Americans should expect yet another update of the Covid-19 vaccine this fall at about the same time as flu shots are available, the top US public health official said Monday.
Researchers are working on selecting a strain for the upcoming version, and will probably wait until May to pick one to target with vaccines, <-bsp-bb-link state="{"bbHref":"bbg://securities/0247409Z%20US%20Equity","_id":"0000018e-0b97-d64e-af9e-cfdf92000000","_type":"0000016b-944a-dc2b-ab6b-d57ba1cc0000"}">Centers for Disease Control and Prevention Director <-bsp-person state="{"_id":"0000018e-0b97-d64e-af9e-cfdf92000001","_type":"00000160-6f41-dae1-adf0-6ff519590003"}">Mandy Cohen said in an interview at Bloombergs offices in Washington.
CDC Director Mandy Cohen speaks with Bloombergs Riley Griffin in Washington.
Source: Bloomberg
Cohen took the helm at the CDC in July, just weeks after the US ended the emergency declaration that gave the agency special powers to address the ...
The Centers for Disease Control and Prevention is now recommending that those 65 years and older should receive an additional updated 2023-2024 COVID-19 vaccine dose.
The recommendation acknowledges the increased risk of severe disease from COVID-19 in older adults, along with the currently available data on vaccine effectiveness.
PreviousCDC recommendationsensured that people who are immunocompromised are already eligible for additional doses of the COVID-19 vaccine.
Data continues to show the importance of vaccination to protect those most at risk for severe outcomes of COVID-19. An additional dose of the updated COVID-19 vaccine may restore protection that has waned since a fall vaccine dose, providing increased protection to adults ages 65 years and older.
Adults 65 years and older are disproportionately impacted by COVID-19, with more than half of COVID-19 hospitalizations during October 2023 to December 2023 occurring in this age group.
CDC and ACIP will continue to monitor COVID-19 vaccine safety and effectiveness. CDC continues to recommend that everyonestay up to date on their COVID-19 vaccines, especiallypeople with weakened immune systems.
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Scientists at City of Hope, one of the largest cancer research and treatment organizations in the United States, show that a COVID-19 vaccine developed at the organization's Los Angeles campus also protects against mpox, according to research published in Communications Medicine.
The vaccine was developed in the laboratory of Don J. Diamond, Ph.D., City of Hope professor in the Department of Hematology & Hematopoietic Cell Transplantation and a member of the Hematological Malignancies Research Institute.
In research led by vaccine experts at City of Hope, a novel COVID-19 vaccine candidate (COH04S1) has been found to also elicit a robust immune response to the mpox (formerly known as monkey pox) virus. Humans and nonhuman primates who received COH04S1 generated an mpox virus (MPXV) cross-reactive antibody response similar to individuals who were vaccinated against mpox by the only Food and Drug Administration-approved smallpox/mpox vaccine on the market, JYNNEOS.
In a relevant mouse model, the authors also showed that the novel COVID-19 vaccine provides protection against the mpox virus strain that caused the recent 2022-2023 global mpox outbreak. COH04S1 could represent a new tool for vaccinating against COVID-19 and mpox with just one injection. COH04S1 is licensed to Geovax laboratories (NASDAQ: GOVX) for COVID-19 and mpox.
In 2020, researchers at City of Hope developed a fully synthetic platform of the highly attenuated modified vaccinia Ankara (MVA) vector that is virtually identical to the form used in the JYNNEOS vaccine. MVA is a strain of a type of poxvirus used to deliver genes to cells that help the body figure out how to fight a virus. The scientists established a virtually identical replica of MVA and used it to make a multiantigen COVID-19 vaccine that is now in Phase 2 clinical trials and represents the most clinically advanced MVA-based COVID-19 vaccine.
Because the vaccine uses a poxvirus replica, the team wanted to see if it also protected against mpox, and found that it does. In fact, they found that mice vaccinated with COH04S1 or just the synthetic MVA both were protected from lung infection after being exposed to a globally circulating strain of mpox, further proving that the synthetic MVA shares virtually identical properties to the natural MVA.
While mpox is not an emergency at the moment, it is reemerging in various locales worldwide (Africa and Asia) and other poxvirus strains with pandemic potential could occur in the future. The COH04S1 vaccine could protect against different poxvirus strains and has the potential to be used as a dual vaccine that can be effective against COVID-19 and mpox disease. Furthermore, because the basic vaccine design can be modified, there could be multiple applications in which vaccines are made for other infectious disease indications but always include background protection against mpox.
The researchers also believe that COH04S1 could serve as an alternative to JYNNEOS in the face of a large outbreak or vaccine shortage, as viral vector vaccine production is hard to scale up rapidly. Immunocompromised individuals are more susceptible to mpox infection symptoms. Because COH04S1 uses the synthetic MVA vector that has been safely tested in hematopoietic cell transplant recipients, it could also serve as a much-needed option for this population and other immunocompromised populations, such as people living with HIV and cancer.
The research team is actively moving forward with plans to develop COH04S1 as an alternative to JYNNEOS and are currently producing it in a cell line for vaccinations. They would also like to develop a clinical trial to do a direct comparison of COH04S1 and JYNNEOS to see if there are differences in response rates and mechanisms.
Flavia Chiuppesi, Ph.D., formerly at City of Hope, is the study's lead author. Study author Felix Wussow, Ph.D., City of Hope assistant research professor in the Department of Hematology & Hematopoietic Cell Transplantation, is an inventor and developer of the COVID-19 vaccine, as well as the synthetic vaccine platform, along with Diamond and Chiuppesi. John Zaia, M.D., the Aaron D. Miller and Edith Miller Chair in Gene Therapy at City of Hope, is the paper's second author. Diamond is the principal investigator of these studies and a paid consultant for Geovax.
More information: Flavia Chiuppesi et al, Synthetic modified vaccinia Ankara vaccines confer cross-reactive and protective immunity against mpox virus, Communications Medicine (2024). DOI: 10.1038/s43856-024-00443-9
New research reveals the adaptation of the H5N1 avian influenza virus to spread among birds and marine mammals, marking a significant threat to wildlife conservation and highlighting the viruss ability to affect multiple species across South America. The research underscores the viruss potential for human concern, driven by its rapid spread and high mortality rates among affected wildlife, including its deadly impact on marine mammals and birds across the continent.
A study from the University of California, Davis, and the National Institute of Agricultural Technology (INTA) in Argentina reveals that the highly contagious H5N1 avian influenza virus has evolved to transmit among birds and marine mammals, presenting a direct risk to wildlife conservation efforts.
The study, published in the journal Emerging Infectious Diseases, is the first genomic characterization of H5N1 in marine wildlife on the Atlantic shore of South America.
For the study, scientists collected brain samples from four sea lions, one fur seal, and a tern found dead at the most affected sea lion rookery in Argentina. All tested positive for H5N1.
Genome sequencing revealed that the virus was nearly identical in each of the samples. The samples shared the same mammal adaptation mutations that were previously detected in a few sea lions in Peru and Chile, and in a human case in Chile. Of note, the scientists found all these mutations also in the tern, the first such finding.
Elephant seals lie dead on a beach in Argentina following an outbreak of avian influenza in the region in 2023. Credit: Maxi Jonas
This confirms that while the virus may have adapted to marine mammals, it still has the ability to infect birds, said first author Agustina Rimondi, a virologist from INTA. It is a multi-species outbreak.
We know this because the virus sequence in the tern retained all mammal-adaptation mutations. Such mutations suggest a potential for transmission between marine mammals.
This virus is still a relatively low risk for humans, said senior author Marcela Uhart, a wildlife veterinarian with the UC Davis School of Veterinary Medicines One Health Institute and director of its Latin America Program within the Karen C. Drayer Wildlife Health Institute. As long as the virus continues to replicate in mammals, it may make it a higher concern for humans. Thats why its so important to conduct surveillance and provide early warning.
Uhart calls clade 2.3.4.4b the current variant of H5N1 this new monster. It emerged in 2020, while the human world was reeling from a different pandemic, COVID-19. Avian influenza began killing tens of thousands of sea birds in Europe before moving to South Africa. In 2022, it entered the U.S. and Canada, threatening poultry and wild birds. It migrated to Peru and Chile in late 2022.
Then, almost exactly a year ago, in February 2023, highly pathogenic avian influenza entered Argentina for the first time. But it was not until August 2023 when the virus was first found in sea lions at the tip of South America on the Atlantic coastline of Tierra del Fuego that the virus unleashed its fatal potential in the region. From there, it moved swiftly northward, with deadly results, first for marine mammals and later for seabirds.
A recent paper Uhart co-authored showed a large outbreak killed 70% of elephant seal pups born in the 2023 breeding season. Mortality rates reached at least 96% by early November 2023 in the surveyed areas of Pennsula Valds in Argentina.
When it first came to Argentina, we didnt know if it would affect elephant seals, Uhart said. We never imagined the magnitude of what was to come.
Since 2022, H5N1 in South America has killed at least 600,000 wild birds and 50,000 mammals, including elephant seals and sea lions in Argentina, Chile, and Peru, and thousands of albatrosses in the Malvinas/Falkland Islands.
The virus is now heading southward from South America, and scientists are deeply concerned about its potential impact on penguins and other wildlife in Antarctica.
Uhart and Ralph Vanstreels, her colleagues at UC Davis Latin America Program in the School of Veterinary Medicine, are conducting wildlife surveillance for H5N1 in Antarctica this month.
We need to keep an eye on the ability of this virus to reach species that have never been exposed to an H5N1 infection before, Rimondi said. The consequences in those species can be very severe.
The concept of One Health honors the interconnectivity among humans, domestic animals, wildlife, and the environment. Interspecies disease outbreaks are unsettling examples of such connections and require global collaboration among public, wildlife, agricultural, health, and other sectors.
We are trying to be at the forefront of documenting, recording, and providing early warning, Uhart said. Weve been in this area for 30 years. We know these species. We work with scientists who have 30 years of data on these populations, so we can know what will be important for the future. We have to give voice to these poor creatures. Nobodys taking note of how big this is.
Reference: Highly Pathogenic Avian Influenza A(H5N1) Viruses from Multispecies Outbreak, Argentina, August 2023 by Agustina Rimondi, Ralph E.T. Vanstreels, Valeria Olivera, Agustina Donini, Martina Miqueo Lauriente and Marcela M. Uhart, April 2024, Emerging Infectious Diseases. DOI: 10.3201/eid3004.231725
PAINESVILLE, Ohio (WJW) Ohio has been hit hard with the flu this season, according to data from state and federal officials.
And recently, the Painesville Water Pollution Control Plant (WPCP) has found clues in its wastewater system that further hits the point home.
WPCP announced Monday theyve found higher levels of Influenza A virus in their untreated wastewater than average. Three tests in a row showed the same results, according to the WPCP.
Detection of influenza virus in wastewater can indicate higher transmission within a community, said Maya Scullin, MPH, Epidemiologist with the Ohio Department of Health.
In an interactive map, The U.S. Centers for Disease Control and Prevention(CDC) showed that Ohio is continuing to sit at very high in its Outpatient Respiratory Illness Activity.
In the U.S., about 200,000 people are estimated to be hospitalized with the illness each year, leading health officials to continue to advocate for flu vaccines for anyone six months and older.
Northeast Ohio has especially been hit hard with flu-related hospitalizations this season, as seen in this Ohio Department of Health graphic below:
The average flu season typically continues through March. Find out how to get a vaccine righthere.
By Melissa Patrick Kentucky Health News
The Kentucky Department for Public Health still considers hospitalizations for respiratory illnesses high and says flu activity remains elevated.
Health officials say the best way to protect yourself from these viruses is to stay up to date with your vaccines.
The Centers for Disease Control and Prevention recommends that everyone 6 months old and older get the annual flu vaccine and updated COVID-19 vaccines, especially children younger than 5 or anyone at high risk for complications.
Vaccines for respiratory syncitial virus are recommended for some infants and young children, pregnant women and adults 60 and older. At some places and times, there has been a shortage of these vaccines.
This years flu vaccines have worked, substantially reducing the risk of flu-related medical visits and hospitalizations across all age groups, with some estimates higher than have been previously observed, even during well-matched seasons, said a CDC report released on Feb. 29.
Specifically, flu vaccination has reduced the risk of flu medical visits by about two-thirds and flu-related hospitalization by about half for vaccinated children and flu medical visits by half and hospitalization by about 40% for vaccinated adults.
Even though flu season usually peaks around January, it lasts until May. Health experts say that if there is any flu activity occurring, its not too late to get vaccinated.
What the numbers say
Emergency-department visits for respiratory illness in Kentucky have stayed about the same for the last two weeks, with 3,607 visits reported in the week ended Feb. 24.
Hospitalizations for respiratory disease in that week stayed about the same as the week prior, with 491 hospitalizations reported in the week ended Feb. 24.
Kentucky had 20 counties with Covid-19 hospitalizations between 10 and 19.9 hospitalizations per 100,000 people, a rate that the CDC considers medium.
Those counties are Adair, Green, Russell, Taylor, Clinton, Cumberland, Lewis, Elliott, Menifee, Morgan, Rowan, Barren, Hart, Metcalfe, Monroe, Bath, Montgomery, Floyd, Johnson and Magoffin.
Overall, there was little change in the three respiratory viruses tracked by the state health department: COVID-19, influenza and RSV, with flu continuing to drive ED visits and hospital admissions.
The state reported 3,857 laboratory confirmed cases of the flu in the week ended Feb. 24 and 2,246 laboratory confirmed cases of COVID-19. This reflected a slight drop in flu cases and a nearly 9% drop in COVID cases.
Among children, ED visits for respiratory disease increased 12% in children four and younger, to 671, compared to the prior week, and hospitalizations for children 5 to 17 increased 50%, to 18. The increase in ED visits for younger children was driven by the flu, and hospitalizations for the older children were driven by an increase in both flu and COVID-19.
Since the respiratory-illness season began the first week in October, 384 Kentuckians have died from Covid-19, and 51 from flu, according to the health department. One COVID-19 victim and one flu victim have been children.
News
Darnelle Clark is known for going the extra mile for her students and always showcasing her bubbly personality and passion for educating.
Clark is known for going the extra mile for her students and always showcasing her bubbly personality and passion for educating.
When she contracted the corona virus during the pandemic, her road to recovery was fraught with unexpected challenges and weak organs.
Learning to walk again became her new reality, but after months of recovering, she made it back to the classroom using oxygen full time to help her breathe.
However, just as she was starting to rebuild her life, the virus struck her again last December.
"She's very very weak and I know her lungs are really struggling and her glucose levels have been low," Dunlap said.
Clark is now receiving care from the Cleveland Clinic, and doctors say there are several treatments that can help her, but those treatments come with a hefty price tag that her insurance is refusing to cover.
Tiara Vian/KJZZ
On Friday, the U.S. Centers for Disease Control and Prevention relaxed some of its recommended coronavirus safety protocols.
The change means those with no symptoms, but who test positive, do not need to quarantine.
As you fight the virus off, you become less infectious even if youre still testing positive. If your symptoms have resolved, then you're unlikely to be spreading the virus, said Will Humble, director of the Arizona Public Health Association.
Humble also said those who test positive should still stay home and treat their condition as if they were suffering from the flu or other respiratory illnesses. He predicts the virus is on track to be associated with the common cold, but still kills a few hundred people in Arizona.
The quandemic concept has clear roots in Michael Foucaults notion of biopower [11, 12]. Foucault introduced the concept of biopower to denote state power over populations and individuals that hinges fundamentally on expert knowledge of the populations biological quality and longevity [13]. Biopower seeks to optimize a populations vitality mainly through rationalized mechanisms of population monitoring and medicalization [14]. One important expression of and prerequisite for biopower is quantification. In the 1970s, Foucault described how this practice became apparent during a smallpox outbreak in the eighteenth-century. The primary focus was no longer understanding the pathology of the epidemic itself but to track the number of the infected, their age, medical consequences, and mortality using statistical methods. In the words of Foucault: when quantitative analyses are made of smallpox in terms of success and failure [] the disease no longer appears in this solid relationship of the prevailing disease to its place or milieu, but as a distribution of cases in a population circumscribed in time or space [15]. Since then, numbers and statistics have come to play a crucial role in epidemic and crisis management. However, Foucault reminds us that metrics are not only important pieces of evidence but, simultaneously, they are expressions of biopower. Decisions of what metrics to promote or ignore, and how to measure them have the power to frame the pandemic in a certain political light and therefore shape responses.
We propose four distinct dynamics that characterize a quandemic:
A few metrics tend to dominate both political, expert, and public spheres and they exhibit a great deal of rigidity over time. The metrics are produced and reproduced by key stakeholders within and across the different spheres of influence without much open debate and discussion of alternatives. Instead, the metrics are followed and reported regularly by health agencies, politicians, and major media outlets. In addition, the same metrics dominate throughout the pandemic. While new metrics might emerge, such as vaccination rates, they largely serve to accentuate the importance of the existing metrics.
These few metrics appear to crowd-out other forms of evidence relevant to pandemic response. These alternative sources of evidence can be qualitative and quantitative in nature and represent socio-economic or public health dynamics. Examples of crucial but deprioritised evidence could include anthropological perspectives of vaccine hesitancy and community engagement, economic approaches to vulnerability, and quantitative tracking of mental health impacts (public health); gender violence (social) or differences in student attainment following prolonged periods of distance teaching (educational). While it is important to emphasize that this evidence was far from ignored during COVID-19, the quantitative metrics would often constitute the point of departure for debates and deliberations and the additional evidence would primarily be an addendum used to contextualize and qualify [16, 17].
The metrics tend to favour certain outcomes of pandemic management. During COVID-19, non-pharmaceutical interventions would almost certainly improve these metrics (to varying degrees), while the potential adverse impacts of the interventions would not be the focus on these metrics. These adverse consequences would, therefore, need to be considered on an ad-hoc basis. The benefits of lockdowns would be captured by the metrics, e.g. a drop in cases, hospitalizations, and deaths. Whereas the costs of these interventions were largely beyond these dominant metrics. Disaster management studies have long been attentive of the need to address the socio-economic consequences of both the hazard itself as well as the mitigating measures [18]. The dominant metrics during COVID-19 appeared ill-equipped to capture the nuanced and longer-term impacts of the pandemic response.
Finally, the metrics are easily standardized across countries, and give rise to competitive dynamics based on international comparisons and benchmarking. While the metrics during COVID-19 faced limited competition internally from other types of evidence, they exhibited a substantial potential for generating external competition between countries and different administrations. Pandemic successes and failures were evaluated and compared in terms of this limited subset of metrics. Political leaders were faced daily with these metrics and were often held accountable for unfavourable developments compared to other similar countries and over time. This created a textbook suboptimal situation where decision makers would pursue policies that carried concentrated and visible benefits (lowering mortality rates, for example) while keeping the costs dispersed and less visible [19]. Policymaking can be caught in a self-fulfilling loop where the initial focus on these metrics continuously reinforces the political salience of the same metrics.
To be clear, having access to standardized measures on a wide range of health outcomes constitutes best practice during pandemic management. In fact, many countries with limited capacity faced a substantial impediment to effective pandemic management because they had little access to these types of timely and disaggregated national metrics. However, a quandemic concerns the overreliance on these metrics and the resulting unproductive competitive comparisons. We observed these quandemic dynamics in the Nordic region. From the very initial phases of the pandemic, it was clear that a few metrics permeated the political and public debates. Across the Nordic countries, the main newspapers outlets carried the development of these key metrics daily on their frontpage and/or main website. Cases and fatalities came to embody the success of the pandemic response. Only towards the end of the first wave did Finland, for example, assemble a group of scientists that were to monitor COVID-19-related results in a way that paid attention to other factors including education, the economy, to technological innovation, misinformation, and resilience [20]. Sweden famously pursued slightly more lenient non-pharmaceutical interventions in 2020, motivated by the Swedish Health Agencys emphasis on additional longer-term objectives that were not easily caught in the metrics. Equity was stated as the overarching focus of agencys mission statement and was highlighted as a key guiding principle by the actors involved in key advice making during COVID-19 [21, 22]. The decision not to close primary schools down for physical attendance nationally, for example, was rooted in a concern for ensuring educational attainment, access to school meals, and the social well-being of children and had full support of the Swedish Childrens Ombudsman the highest legal authority for the rights of children [22, 23].
This approach was met with scepticism internationally, and to some extent nationally, as the dominant metrics deteriorated in the Autumn and Winter of 2020 compared to other Nordic countries of Denmark, Norway and Finland [24,25,26]. These numbers became overtly political, with the other Nordic governments using Sweden as a cautionary tale of laissez faire pandemic management. Danish and Norwegian newspapers carried many comparisons to the Swedish strategy equating the success of their pandemic response by the lower rates of cases and deaths in 2020 compared to Sweden [27, 28]. In February 2021, the Danish government emphasized that Denmark only had one fourth of the infected compared to Sweden [29]. The correctness of Sweden's initial pandemic strategy is not the point here.Rather success or failure at the time was primarily assessed by a handful of quantitative metrics that did not reflect the national pandemic response goals.Therefore, debating achievements based only on these metrics risks obscuring comprehension.
Three years later, the media and politicians engaged rigorously in yet another comparison of pandemic responses across the Nordic countries. This time the comparison was based on excess mortality rates during the pandemic and was reported in the Norwegian media, [30] Danish media, [31] Finnish media, [32] and the Swedish media [33]. The various measures of excess mortality suggested that Sweden fared well compared to the other Nordic countries, when using population-adjusted excess mortality rates for 20202022. While the new excess mortality metric was used to vindicate parts of the Swedish pandemic strategy, the point here is much broader: that such comparison still reinforces the same quandemic mindset that had been dominant in the early phases of the pandemic: a competition of biopower where successes or failures are reduced to a few select metrics. Even excess mortality rates are insufficient to fully gauge the impact of the pandemic as well as the policies implemented to combat it. It leaves out important aspects such as morbidity, the impact on education, equity, economy, mental health, and general wellbeing.
Thus, we propose that the four quandemic characteristics risk producing suboptimal conditions for balanced public debate and policymaking, as evidenced by the Nordic example. A quandemic obscures important syndemic dynamics, as more diverse scientific evidence capturing socio-economic vulnerabilities of the outbreak tends to be muffled by the few dominant metrics. Further, it increases exposure to infodemic dynamics because the dominance of these metrics might create an information void in spaces which they do not capture. Misinformation, pseudo-science, and scientific polarisation can roam in areas where these metrics fall short.
