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Global Health Care Governance in Southeast Asia

By Yuju Park

The region, Southeast Asia, is commonly referred to as a still relatively developing region, with the exception of highly developed cities like Singapore or Kuala Lumpur. Southeast Asia includes countries such as Cambodia, Indonesia, Thailand, and Vietnam, all countries that are not considered “developed” or as industrialized. Southeast Asia is actually a region where many Western countries build factories and employ its people for cheap labor. Again, with the exception of the metropolitan cities like Singapore, Jakarta, and Kuala Lumpur, the majority of Southeast Asia struggles with many crucial health problems and outbreaks. Such health influenzas and problems caught the attention of many Western and other developed countries in regards to providing foreign aid specifically for healthcare.

As mentioned in “Southeast Asia: an Emerging Focus for Global Health,” by Acuin et al., Southeast Asia has presented significant health challenges, which has included several strains of multi-drug resistant microbes, and thus several emerging and re-emerging infections that sometimes cross national boundaries. Because of globalization, diseases are no longer limited to one geographic area, and they is a very high likelihood that a disease in one area can cross the borders of another country and spread there. It is not therefore not a surprise that many developed and typically Western countries are invested in finding the cause of many of the diseases that seem to originate from Southeast Asia. Health services funded by foreign direct investment and the export of health workers, particularly in the Phillipines and Indonesia. With the help of foreign aid, healthcare systems have thus been developing in various ways throughout Southeast Asia. The response of individual Southeast Asian countries to the development of a more advanced global healthcare system has not been uniform and not all reactions have been positive. Moreover, the lack of standardization of healthcare development within Southeast Asia has led to a lack of regional health cooperation, which halts the advancement of health for all of the region’s people. Because healthcare in Southeast Asia has largely developed with the aid of developed, typically Western countries, how health care is delivered and how foreign funds are allotted have stimulated much debates – particularly about how global health care should be governed.

In “Overcoming Constraints of State Sovereignty: Global Health Governance in Asia,” Stevenson and Cooper state that because of how globalization affects the whole world, there is now such a need for global governance, which includes healthcare. Steven and Cooper argue that the global facilitation of capital, ideas, and more have introduced entities such as pollutants and pathogens around the world, which has blurred the line between domestic and foreign responsibility. This has also partly led to the loss of control by states over their domestic spheres and the uncoupling of territorialism. The introduction of pollutants and pathogens has undoubtedly led to health crises, and again, as Stevenson and Cooper state, “because global governance no longer exists as the exclusive domain of states, it is assumed here that states are no longer the sole actors modifying the norms that shape global health governance.” This mode of thinking is more aligned with a post-Westphalian model that couples the globalization process with global governance, whereas the old Westphalian model was based on the premise that states are the ultimate and legitimate controllers of their areas and people.

In Southeast Asia, there has been much debate as to how much control states and foreign actors should have in governing healthcare in Southeast Asian countries. Indonesia has been a highly publicized example of how the state has been rejecting global collective action on healthcare issues within the country itself. The World Health Organization (WHO) routinely collects physical virus samples from new infections from countries around the world through its Global Influence Surveillance Network. The network at the WHO does this for the international surveillance of samples used to facilitate vaccine production worldwide. Indonesia has struggled with avian influenzas and has experienced the highest number of AI human infections, yet in 2007, the Indonesian government began to withhold its physical virus samples from WHO, arguing that it was their sovereign right to safeguard their genetic materials and that foreign governments and large pharmaceutical companies were primarily using their virus samples to manufacture a product that Indonesia would not be able to derive profit or protection from. Indonesia even asked for WHO to return previous samples and also went as far as to threaten to close the U.S. naval research unit in Jakarta. Indonesia was thus highly criticized by other countries worldwide for challenging this post-Westphalian ideal that states must work with other states to safeguard public health in today’s globalized world. Moreover, many countries also worried that Indonesia would set a dangerous precedent for other countries. In response, WHO has attempted to mitigate this problematic issue by soliciting promises from the world’s largest pharmaceutical companies that they will not exploit international viral repositories for commercial gain.

Meanwhile, while Indonesia has refused to comply with the World Health Organization, Burma has been highlighted to completely ignore global health norms and ideals of collectively working together by rejecting and interfering with foreign health care aid that comes into the country. Burma has struggled with an HIV epidemic and it is estimated that 3.5% of all reproductive age adults are infected with HIV (Stevenson and Cooper). In addition, Burma experiences the highest number of annual deaths attributed to Malaria. But instead of allowing foreign help to aid in helping protecting such sick and vulnerable populations, Burma’s military regime has become known for fostering an environment that is known to be the disease reservoir that fuels the most infectious diseases within Southeast Asia. The Burmese regime states that states should invest in and commit to public health only domestically. While foreign organizations have tried to intervene in Burma, its regime has become notorious for interfering with them even though they are apolitical, non-state foreign organizations. The regime’s interference has been so severe that large, international programs such as the Global Fund have decided to discontinue their services in Burma because of how government implementation made implementation of the programs nearly impossible.

In the past, healthcare was thought to be a less politically sensitive factor in comparison to other aspects of development. However, with the influx of foreign donors investing money to developing countries, even healthcare has become political, and how it should be governed and managed has become a hotly debated topic. Globalization has indeed changed how health care is not just one country’s problem – it can potentially become the world’s problem because of how rampant travel across borders has become. Acuin et al., as well as Stevenson and Cooper, thus emphasize that there needs to be more regional cooperation among Southeast Asian countries in order to share health resources and collaborate in taking joint action. Countries like Burma and Indonesia have been examples of how its population suffers when health care becomes isolated with only domestic control, and its health care isolation also impedes global advancement of its diseases and health issues.

Works Cited:

Acuin, Jose, Rebecca Firestone, Thein Thein Htay, Geok Lin Khor, Hasbullah Thabrany, Vonthanak Saphonn, and Suwit Wibulpolprasert. “Southeast Asia: An Emerging Focus for Global Health.” The Lancet 377.9765 (2011): 534-35. Web.

Stevenson, Michael A., and Andrew F. Cooper. “Overcoming Constraints of State Sovereignty: Global Health Governance in Asia.” Third World Quarterly 30.7 (2009): 1379-394. Web.

Pallas, Sarah Wood, Thi Hai Oanh Khuat, Quang Duong Le, and Jennifer Prah Ruger. “The Changing Donor Landscape of Health Sector Aid to Vietnam: A qualitative Case Study.” Social Science & Medicine 132 (2015): 165-72. Web.

 

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Health Care and Foreign Aids: The Cases in India and Bangladesh

by Myung Ha Kim

Health care in developing countries has been a major international issue that many of developed countries and transnational institutions, such as the World Bank and the World Health Organization (WHO), are attempting to address so as to improve the lacking health systems in the less developed states. One of the main challenges presents in the issue of health care system development is procurement of financial sources. Since many of developing countries are not able to afford the massive amount costs to deal with health issues domestically; here is where foreign aids become important to assist the health care system reforms. Many of the global south countries are actually beneficiaries of aids from global north countries and international organizations indeed.

India and Bangladesh are examples of these beneficiaries of the foreign aids and health care development projects assisted by international agencies, but the usefulness of the aids and projects are being questioned because sometimes these global helps do not seem to improve the conditions in those developing countries. This short investigation will delve into U.S. aids’ health system development projects in India and Bangladesh to examine the impact of foreign aids on their domestic health care systems through the establishment of governmental partnerships.

Both India and Bangladesh have received from the United States especially during the president Bush’s administration as he had initiated the Millennium Challenge Account (MCA) global HIV/AIDS Initiative (GHAI) starting in 2004, which overall had their objectives for counterterrorism so that the foreign aids could promote democracy and regional stability through leading the global economic development in many of East, South-east Asian countries (Lum 2).  Although U.S. foreign aids were not directly channeled to develop health care systems in India and Bangladesh, the foreign aids were intended be invested in health care system along with building better market structures and institutional governance. Between 2003 and 2007 Bangladesh had received aids from U.S. average of 50,000 thousands USD each year, which almost half of its aids, the CSH (Child Survival and Health) funds, went into health care programs: “child, maternal, and reproductive health; family planning; HIV/AIDS programs; and TB and Avian influenza programs.” For the same time period, India also had received about 47,000 to 50,000 thousands USD annually as CSH funds for HIV/AIDS prevention and child malnutrition programs (Lum 33).

Thanks to the help of foreign aids these countries have reformed their health system with commendable outcomes. India seemed to be able to improve domestic health care as the state government had launched National Rural Health Mission (NRHM) starting in April 2005. This national policy was an extensive health reform project as to address health issues and to build better health care infrastructure through using five main approaches: “communitization, flexible financing, improved management through capacity building, monitoring progress against standards, and innovations in human resource management” (Nandan). The child mortality rate had been decreased from 20 million in 1990 to 9.7 million in 2007; the under five child mortality (U5MR) was decreased by 23 percent from 1990 to 2007, which is an laudable result (“Global Data Sheet UNICEF”). Yet, these numbers were not satisfactory for the 2015 MDG objectives to reduce the U5MR by two-thirds globally; this implies that the current decreasing rate of U5MR in India should have been accelerated (Kumar).

India’s NRHM program was able to give a successful result with the financial support from USAID, the U.S. Agency for International Development, so that the government of India could channel its funds through the country. More specific partnership program called  Maternal and Child Health Integrated Program (MCHIP) from USAID and India was launched in 2009 as what NRHM had achieved beforehand were not satisfactory and thus India needed much more to improve the health system. Indeed, USAID had important roles in building medical infrastructure in India to support their health caring; this aid packages include offering extensive nursing network and education, improved tools for immunization, and offers of vaccines. These technical supports from the U.S. had led to the Indian government’s modified version of medical care system called A Strategic Approach to Reproductive, Maternal, Newborn, Child and Adolescent Health (the RMNCH+A initiative), which shows a more concrete, global commitment of health care initiative to meet the objectives of MDG. One of the impressive achievements from this new multilateral health initiative in India was the dramatic increase in immunization coverage, which had risen from only 9% of “good” quality of immunization to 73% in 5 years after initiation (“MCHIP Country Brief: India.”).

Bangladesh was another beneficiary of USAID since 1990 as to reduce the maternal and child mortality with the offer of nutritional cares and family planning programs from the U.S (“Global Health”). As India’s healthcare projects, The government of Bangladesh had launched a partnership development program called “Country Development Cooperation Strategy” (CDCS) with USAID in 2011, which is a five-year extensive project encompassing goals of better governance, food strategy, healthcare and environmental issues. Primarily, the third goal of healthcare improvement seems to be the most crucial as USAID has spent around 40 to 50% of its assitance to Bangladesh since 2006 (“Foreignassistance.gov”). Overall, with the vision of CDCS plan and foreign assistance from USAID, Bangladesh was able to reduce the child mortality rate by 40% in a decade. Specifically, this result was achieved by three main initiatives proposed by USAID and the government of Bangladesh: promoting reproductive, nutrition services, newborn and child care, immunization diseases etc (“Bangladesh”). USAID also provided medically skilled personnel as volunteers and training for nursing as well, as it did for India. This had a great impact on medical coverage in Bangladesh with better personnels and facilities.

Many of other international organizations such as UNICEF and the World Bank have invested in promoting Bangladesh’s health care system, the CDCS program with USAID had the most direct and historical impact on lowering the total fertility rate and so it reduced the maternal mortality rate for the past five years. The overall impact was thus impressive. USAID had reported that Bangladesh actually exceeded expectations in some categories of healthcare improvements. For instance, U5MR also had decreased significantly about 71% from 1990 to 2013. There are still much to improve for its national health care system, and USAID is definitely committed to help for improvements with help from other NGOs and private sectors as well. CDCS program is therefore needed to be sustained under foreign assistance and monitoring from USAID (“Acting On The Call”).

Although these cases of foreign aids in India and Bangladesh seem to show that aids resulted in significant impact on their national health care improvements, there are still dark sides behind the implementation of health development projects as well. Externally, there seems to be no huge problems as many of international agencies, here like USAID, have offered tremendous amount of finance to work towards the MDG, internally in countries, lack of political commitment has become one major issue that degrades the efficiency of foreign aids (Kumar). This is why state capacity for a good governance system is highly significant not only for the implementation of projects but also the maintenance of the system.

 

Works Cited

“Acting On The Call: Ending Preventable Child and Maternal Deaths.” (n.d.): n. pag. USAID. U.S. Agency of International Development, June 2015. Web. 24 Apr. 2016.

Bangladesh Country Development Cooperation Strategy (n.d.): n. pag.U.S. Agency of International Development. Sept. 2011. Web. 24 Apr. 2016.

“ForeignAssistance.gov.” Bangladesh. U.S. Government Foreign Assistance, n.d. Web. 24 Apr. 2016.

“Global Health | Bangladesh | U.S. Agency for International Development.” Global Health | Bangladesh | U.S. Agency for International Development. N.p., n.d. Web. 23 Apr. 2016.

Kumar, Sanjiv. “Indians Can Do Better at Improving Child Survival.”Indian Journal of Community Medicine : Official Publication of Indian Association of Preventive & Social Medicine. Medknow Publications, Summer 2011. Web. 23 Apr. 2016.

“MCHIP Country Brief: India.” MCHIP End-of-project Report (n.d.): n. pag. USAID MCHIP. 2014. Web. 23 Apr. 2016.

Healthcare and Foreign Aid in the Caribbean

by Darian Guenther         

 Good healthcare is founded on four basic goals: “relieve symptoms, cure disease, prolong life, and improve quality of life” (4). That these goals are valid seems obvious, but their implementation is more complicated. One way of meeting these goals is through implementation of a strong sector of primary health care (PHC), because of its focus on preventing serious disease through immunizations, maternal and child care, and controlling the spread of endemic diseases. For PHC to be effectively delivered, Jasneth Mullings and Paul Tomlin argue that five conditions must be met: “development of health resources,” “organized arrangement of health resources through establishment of national health authorities, the provision of national health insurance, and the integration of public and private health services,” “delivery of health care,” “economic support,” and “management through strong leadership, policy formulation, regulation, and monitoring and evaluation” (5). In addition to PHC, some academics have argued that the “provision of basic amenities such as water and sanitation, along with improved nutrition, were perhaps more important than [. . .] medical care” (4).

 The Caribbean is currently doing a commendable job in meeting these goals of good healthcare, through their implementation of both PHC and programs concerning health education, sanitation, and good nutrition. The World Health Organization (WHO) developed the Disability Adjustment Life Expectancy (DALE) in its 2000 report as a way of comparing countries’ health; it combines mortality data with health and disability status to determine the equivalent number of years that life is expected to be in full health within a country (3). Of the sixteen Caribbean states analyzed by WHO, nine had DALE rankings of at least 57 (for reference: the United States had a ranking of 24). This placed the Caribbean in the upper third of global healthcare systems ranked (3). The WHO’s 2012 report replaced DALE with HALE, Health Adjustment Life Expectancy. While the Caribbean still performed relatively well, HALEs were typically lower than regional averages. It should be noted, however, that health expenditures per capita were also lower than the regional averages.

 Healthcare in the Caribbean has not always met this standard, due in part to its complicated past and colonial roots. During the period between 1755 and 1800, Danish colonial powers in the West Indies (a substantial portion of the Caribbean) constructed a healthcare system based on the Danish model (2). This was meant primarily to serve the Euro-Caribbean population; slave populations were taken care of by plantation doctors, nurses, and midwives. The slaves also had an unofficial health care system: Obeah. Practitioners of Obeah were experts in the spiritual world and healed using magic and herbs; colonizers viewed it as witchcraft, and it was made illegal to practice (2). Following the emancipation and abolition of slavery in 1848, healthcare declined for ex-slaves, because neither plantation doctors nor the government wanted to provide aid to them. In the latter part of the 19th century, colonial powers established General hospitals, which led to the creation of Public Health Programmes in the 20th century. Both of these systems of healthcare focused on hospitals and out-patient care, thereby neglecting aspects of PHC such as preventative care and healthcare in rural areas.

 The “health unit” system was created in the 1940s, and was designed to provide healthcare to small communities. Its design was meant to provide coverage to the maximum population through health centers and sub-centers, and it followed principles of PHC. The health unit provided ante-natal and maternal care, child welfare, control and prevention of endemic diseases, sanitation and hygiene, school medical work, good housing, and health education; it thus combined sectors of health, agriculture, education, and social welfare. It highlighted community involvement through community visits and work in the community. Through health education and community involvement, it sought to increase health consciousness in the Caribbean. The implementation of this system led to a decline in infant mortality and reduced incidents of malaria, syphilis, tuberculosis, small pox, yellow fever, and hookworm (2).

 In 1978, the Alma-Ata conference introduced an era of healthcare centered on PHC, and called for “Health for All by the Year 2000” (2). For many in the Caribbean and academics concerned with the Caribbean, the PHC approach given by the Alma-Ata was reflective of the already existent Health Unit system. Like the Health Unit system, the PHC approach provided maternal and child healthcare (including family planning), promotion of proper nutrition, prevention and control of endemic diseases, adequate and safe water supply, basic  sanitation, and health education. It likewise focused on complete coverage through health centers and sub-centers, “intersectoral coordination,” and community participation (2). It added components including the provision of essential drugs, immunizations, and appropriate technology (2).

 Although health indicators such as infant mortality and life expectancy continued to improve post Alma-Ata, the improvement was at a rate that was less than expected given the improvement pre Alma-Ata. During the pre-Alma-Ata period, in which the Health Unit system was established, life expectancy increased by twelve years; during the post Alma-Ata period, life expectancy increased nearly eight years (2). While it was expected that the Alma-Ata declaration would lead to an increased rate of improvement in these and other indicators, the Caribbean contradicted this expectation. This can be understood as the effect of several factors.

 First, the implementation of structural adjustment programs (SAPs) discouraged water, sanitation, and nutrition programs. Second, there was a reduction in public spending (related to SAPs) and political instability. Third, there were emerging diseases within the Caribbean, which were not included as a part of this health care system. During the post Alma-Ata period, there was a ten percent increase in deaths caused by non-communicable diseases. Additionally, there was the rise of the HIV/AIDs epidemic, which disproportionately affected Caribbean populations. Lastly, “many Caribbean countries rely on international organizations to supplement their healthcare delivery with financial and technical support” (2), which is problematic for several reasons.

 This financial and technical support is provided through organizations including the Inter-American Development Bank, Canadian International Development Agency, USAID, and the United Nation Development Program. Funding from these organizations comes with a downside, as the agency gets to decide how the funds are allocated and used within the country receiving aid (5). This, like SAPs, can lead to a decrease in expenditures related to social welfare, including water and sanitation programs. The Caribbean’s reliance on these outside sources of aid is also problematic because it positions the countries’ as dependent, and the amount of aid is subject to change.  Official development aid (ODA) decreased in the Caribbean from $688 million in 1991 to $212 million in 1997; this rate of decline in aid has been higher in the Caribbean than in any other part of the world (1). This decrease in aid leads to decrease in PHC spending.

 Additionally, there is a question of how effective the aid is in Caribbean countries. According to Brunton, one important “determinant of aid effectiveness is the vulnerability of the recipient country to external economic shocks and natural disasters” (1). This is of special concern to Caribbean countries, as 6 out of 10 of the most vulnerable countries in the world are located in the Caribbean (1).

 Looking forward, the Caribbean needs to undo the damage done by SAPs, including increasing expenditures in public health programs, sanitation, and health education. It should focus on the implementation of PHC, but also the implementation of programs within PHC which are relevant to current Caribbean problems (such as the HIV/AIDS epidemic and hypertension). It should also make efforts to deprivatize healthcare, as the privatization of healthcare has led to an increase in the gap between healthcare for the wealthy and healthcare for the poor.

       References

  1.      Brunton, P. Desmond. Aid Effectiveness in the Caribbean: Revisiting Some Old Issues.    Caribbean Development Bank. Web. 17 Apr. 2016.    <http://www.caribank.org/uploads/publications-reports/staff-   papers/wkgppr_3_aid_effectiveness[1].pdf>.
  2.      “Colonial Power: Health and the Healthcare System.” Virgin Islands History.       Rigsdagsgaarden.          Web. 17 Apr. 2016. <http://www.virgin-islands-    history.org/en/health-and-the-health-  care-system/>.
  3.      Hay, Paul. “Healthcare in the Caribbean.” Caribbean Journal Healthcare in the   Caribbean.   2014. Web. 17 Apr. 2016.    <http://caribjournal.com/2014/08/15/healthcare-in-the-       caribbean/#>.
  4.   MAHARAJ, SR  and  PAUL, TJ. Ethical issues in healthcare financing. West Indian med.          j. [online]. 2011, vol.60, n.4 [cited  2016-04-17], pp. 498-501 . Available from:                        <http://caribbean.scielo.org/scielo.php?script=sci_arttext&pid=S0043-         31442011000400023&lng=en&nrm=iso>. ISSN 0043-3144
  5.      Mullings, Jasneth, and Tomlin J. Paul. “Health Sector Challenges and Responses beyond   the          Alma-Ata Declaration: A Caribbean Perspective.” Opinion and Analysis (2007). Web. 18          Apr. 2016. <http://www.scielosp.org/pdf/rpsp/v21n2-        3/10.pdf>.
  6.      Theodore, Karl, and Patricia Edwards-Wescott. “An Assessment of Primary Health Care in the          Caribbean Pre and Post Alma Ata Declaration and A Way Forward.”       International          Journal of Humanities and Social Sciences (2011). Web. 18 Apr. 2016.          <http://www.ijhssnet.com/journals/Vol._1_No._8;_July_2011/1.pdf&gt;.

 

Medical Internationalism in Cuba

by Getrude Makurumidze

Graphical Abstract

getrude

Cuba’s Medical Humanitarianism

 Healthcare in Cuba is viewed as a basic human right and people from all socio-economic backgrounds have access to free healthcare. Cuban healthcare providers practice in their local communities and internationally, and there is a big emphasis on community-based care. Additionally, the Cuban health care system is based on preventive medicine as they have many physicians but scarce resources.  As a result of its ability to sustain a functioning and effective healthcare system under scarce resources, the Cuban model has had a wide-ranging impact throughout the developing world.

 Cuba has pioneered several projects through its medical internationalism in Africa, Latin America and Asia. Cuba’s strategy is an excellent working example of how comprehensive health strategies have assisted in building and sustaining healthcare capacity and in the process help save the lives of many people. Examples of Cuba’s interventions include the improvement of the Angolan life expectancy from 39 years to 42 years; reduction of average doctor-to-patient ratio in Ghana from 1: 16 660 to 1 physician for every 6 600 people; establishment of medical schools in Yemen (1976), Ethiopia (1984), Uganda (1986), Ghana (1991), The Gambia (2000), Equatorial Guinea (2000) and Guinea Bissau (2004). Notable improvements have been observed in the countries Cuba intervened in and these developments have coincided with Cuba’s capacity-building strategies (Huish and Kirk 2009).

Since the 1960s, Cuba has provided free education, including medical education, to students from other developing countries. In 2005 Cuba was making key changes in the practice and organization of health service delivery in many developing countries through the implementation of the Comprehensive Health Program. Additionally, more than 30,000 Cuban medical personnel were working in 70 countries across the globe by 2008 (Feinsilver 2006). The promotion of sustainable healthcare systems throughout Africa and the Global South by Cuba has been tremendously successful. One of the most notable aims of the Cuban model has been building “capacity within and between nation states rather than maintaining perpetual dependency on aid and assistance” (Huish and Kirk 2009). The Cuban model of humanitarian aid dissuades dependency which is an effective way of promoting proactivity among local governments and people. Secondly, “compassion and solidarity” are engrained in the medical practitioners which makes them able to intervene in any region throughout the globe (Huish and Kirk 2009).

Although the Cuban healthcare system creates altruistic physicians and the model is effective and sustainable in other under resourced countries, it puts health workers at risk. As seen in the film Salud!, Cuban doctors are generally appreciated by the marginalized and underserved populations they work with but are sometimes seen as a threat by local physicians and other healthcare personnel in the countries they serve in.(“Salud!” 2006) Health workers in these countries protest against the Cuban doctors and sometimes the Cubans are attacked and killed. It is easy to compliment altruism, but it’s harder to consider the risk altruistic acts are undertaken. At what cost?

Bibliography

Feinsilver, Julie M. 2006. “Fifty Years of Cuba’s Medical Diplomacy: From Idealism to Pragmatism.” Council of Hemispheric Affairs 41 (1). University of Pittsburgh Press: 85–104.

Huish, Robert, and John M. Kirk. 2009. “Cuban Medical Internationalism in Africa: The Threat of a Dangerous Example.” The Latin Americanist 53 (3): 125–39. doi:10.1111/j.1557-203X.2009.01045.x.

“Salud!” 2006. Filmhttps://www.youtube.com/watch?v=dthF5P7cBrg