Improve Global Health: Reduce Preventable Deaths

The LearnWell Global Lowcost Health Initiative

 

Course Number	LWH911
Objectives	This course will help you understand 1. how low-cost health measures can reduce global preventable mortality and 2. how you can contribute to the reduction of global preventable mortality. At the end of this course, you will  1. understand some of the issues that contribute to preventable deaths, 2. be equipped to start improving global health.
Credit Hours and Fee	3.0 CE Credit Hours with a fee of $0.00
Instructors	Rudolf Klimes, PhD (Indiana University), MPH (Johns Hopkins University),                        Adjunct Professor, Folsom Lake College, Folsom, CA, and Aurora Green, M.Sc.

The Global Lowcost Health Initiative to prevent 12 million deaths annually.

Welcome to this  3-contact-hour Continuing Education  course (RN-CEP 11430, MFT- PCE 39) with instant online processing and certification 24/7.  Study the course below, take the 12-question multiple-choice test and register online. If you score 75% or above, you may print your CE certificate on your printer as soon as you finish. If you have difficulty printing your certificate, click here. You may retake the test once.

Do the following for self-study. Do not submit the answers.

There is a 5 years difference in life expectancy between developed and developing countries.

A few risks cause most premature deaths.

Heart disease cost the USA the most of any disease.

Nicotine reaches the brain within ten seconds after inhalation.

In all the world, there are over 50 million preventable deaths each year.

Nine simple and inexpensive ways may save over a quarter of them.

Improve Sanitation

1.  Wash hands regularly

2.  Drink purified water (8 glasses)

3.  Build pit latrines where needed

Improve Nutrition

4. Eat a healthy diet and keep your BMI under 25

5. Give vitamin A to children, where needed

6. Use oral re-hydration, when needed

General Health

7. Quit smoking and harmful drugs

8. Walk or exercise half hour daily

9. Relax, rest and reduce stress as needed

What Can You Do?

 

1. Practice the nine areas of Global Health as they apply to you. Prevent your own premature death.

2. Pass on the information in this Global Health Initiative to your friends, neighbors and co-workers.

3. If possible, send the Global Health Initiative to professionals and persons in developing countries.

The 1st phase of Global Health in 2006-2007 deals primarily with items 1-4.

 Global Lowcost Health Initiative

According to EarthTrends, the life expectancy in 2005 in developed countries is 74.8 years, in developing countries it is 64.9 years. This is about a 10 year difference.  http://earthtrends.wri.org/

The ten leading risk factors globally are: underweight; unsafe sex; high blood pressure; tobacco consumption; alcohol consumption; unsafe water, sanitation and hygiene; iron deficiency; indoor smoke from solid fuels; high cholesterol; and obesity. Together, these account for more than one-third of all deaths worldwide.

The report shows that a relatively small number of risks cause a huge number of premature deaths and account for a very large share of the global burden of disease.

For example, at least 30% of all disease burden occurring in many developing countries, such as those in sub-Saharan Africa and South-East Asia, results from fewer than five of the ten risks listed above. Underweight alone accounts for over three million childhood deaths a year in developing countries.

In other, more developed, countries such as China and most countries in Central and South America, five risk factors cause at least one-sixth of their total disease burden. At the same time in the most industrialized countries of North America, Europe and the Asian Pacific, at least one-third of all disease burden is caused by tobacco, alcohol, blood pressure, cholesterol and obesity. Furthermore, more than three-quarters of cardiovascular disease -- the world's leading cause of death -- results from tobacco use, high blood pressure or cholesterol, or their combination. Overall, cholesterol causes more than 4 million premature deaths a year, tobacco causes almost 5 million, and blood pressure causes 7 million.

Source: 2002  http://www.who.int/whr/2002/overview/en/

In The USA

Expenditures for health care in the United States continue to rise and are estimated to reach $1.66 trillion in 2003. Much of these costs can be attributed to the diagnosis and treatment of chronic diseases and conditions such as diabetes, obesity, cardiovascular disease and asthma.

• Approximately 129 million U.S. adults are overweight or obese which costs this Nation anywhere from $69 billion to $117 billion per year.
• In 2000, an estimated 17 million people (6.2 percent of the population) had diabetes, costing the U.S. approximately $132 billion. People with diabetes lost more than 8 days per year from work, accounting for 14 million disability days.
• Heart disease and stroke are the first and third leading causes of death in the United States. In 2003 alone, 1.1 million Americans will have a heart attack. Cardiovascular diseases cost the Nation more than $300 billion each year.
• Approximately 23 million adults and 9 million children have been diagnosed with asthma at some point within their lifetime, with costs near $14 billion per year.

A much smaller amount is spent on preventing these conditions. There is accumulating evidence that much of the morbidity and mortality associated with these chronic diseases may be preventable.

For many Americans, individual behavior and lifestyle choices influence the development and course of these chronic conditions. Unhealthy behaviors, such as a poor diet, lack of physical activity, and tobacco use are risk factors for many chronic conditions and diseases. A high calorie diet and sedentary lifestyle commonly result in excessive weight gain. Overweight and obesity are risk factors for a large number of chronic diseases, most significantly, type 2 diabetes, congestive heart failure, stroke, and hypertension. Encouraging individuals to adopt healthy habits and practices may reduce the burden of chronic disease in communities throughout the United States.

Recently, public and private efforts and programs are increasingly designed to promote healthy behaviors. Employers are becoming more aware that overweight and obesity, lack of physical activity, and tobacco use are adversely affecting the health and productivity of their employees and ultimately, the businesses' bottom line. As a result, innovative employers are providing their employees with a variety of work-site-based health promotion and disease prevention programs. These programs have been shown to improve employee health, increase productivity and yield a significant return on investment for the employer. For example, a recent review of health promotion and disease management programs found a significant return on investment for these programs, with benefit-to-cost ratios, ranging from $1.49 to $4.91 (median of $3.14) in benefits for every dollar spent on the program. Several major companies with award-winning cost-saving health promotion disease prevention programs are profiled in this report and include:⁽¹⁾

• Motorola's wellness program, which stet the company $3.93 for every $1 invested.
• Northeast Utilities Well Aware Program, which in its first 24 months reduced lifestyle and behavioral claims by $1,400,000.
• Caterpillar's Healthy Balance program, which is projected to result in long term savings of $700 million by 2015.
• Johnson & Johnson's Health and Wellness Program, which has produced average annual health care savings of $224.66 per employee.

By changing the way they live, individual Americans could change their personal health status and the health landscape of the Nation dramatically.

In 2003, it is estimated that the U.S. will spend $1.66 trillion on health care expenditures.⁽²⁾ Health care spending is growing faster than the gross domestic product (GDP) and is projected to account for 17.7 percent of the GDP by 2012, up from 14.1 percent in 2001. A small number of chronic disorders-such as diabetes and cardiovascular diseases-account for the majority of deaths each year, and the medical care costs of people with chronic diseases account for more than 75 percent of the nation's medical care costs.⁽³⁾ As the population of the United States ages substantially over the next several decades, the prevalence of chronic diseases--and their impact on health care costs--will likely increase.

Each individual's health is shaped by many factors including medical care, social circumstances, and behavioral choices.⁽⁴⁾ Increasingly, there is clear evidence that the major chronic conditions that account for so much of the morbidity and mortality in the U.S., and the enormous direct and indirect costs associated with them, in large part are preventable-and that to a considerable degree they stem from, and are exacerbated by, individual behaviors. In particular, overweight and obesity, lack of physical activity, and smoking greatly increase the risk of developing the most serious chronic disorders. Most of the dollars spent on health care in the United States, however, are for the direct care of medical conditions, while only a very small portion is targeted on preventing those conditions.⁽⁵⁾ As Americans see health care expenditures continue to increase, it is important to focus on strategies that reduce the prevalence and cost of preventable diseases. This paper summarizes recent research findings on the prevalence, effects and costs of some of these key preventable conditions and highlights several award-winning business prevention programs that make common "cents."⁽⁶⁾

1. Health Project website: healthproject.stanford.edu/koop. Information presented in the report on notable employee wellness programs was obtained primarily from this website.

2. Table 2-National Health Expenditure Amounts and Average Percent Change by Type of Expenditure: Selected Calendar Years 1980-2012. CMS website/OACT projections (cms.hhs.gov/statistics/nhe/projections-2002/t2.asp).

3. CDC website: www.cdc.gov/nccdphp

4. McGinnis JM. "United States," in Critical Issues in Global Health, ed. C.E. Koop (San Francisco: Jossey-Bass, 2001), 80-90.

5. McGinnis JM, Williams-Russo P, Knickman JR. The case for more active policy attention to health promotion. Health Affairs. 2002; 21(2):78-92.

6. Health Project website: healthproject.stanford.edu/koop. Information presented in the report on notable employee wellness programs was obtained primarily from this website.

Improve Sanitation

1.  Wash hands regularly

 

The most important thing that you can do to keep from getting sick is to wash your hands. By frequently washing your hands you wash away germs that you have picked up from other people, or from contaminated surfaces, or from animals and animal waste. What happens if you do not wash your hands frequently? You pick up germs from other sources and then you infect yourself when you Touch your eyes Or your nose Or your mouth. One of the most common ways people catch colds is by rubbing their nose or their eyes after their hands have been contaminated with the cold virus. You can also spread germs directly to others or onto surfaces that other people touch. And before you know it, everybody around you is getting sick. The important thing to remember is that, in addition to colds, some pretty serious diseases -- like hepatitis A, meningitis, and infectious diarrhea -- can easily be prevented if people make a habit of washing their hands. When should you wash your hands? You should wash your hands often. Probably more often than you do now because you can't see germs with the naked eye or smell them, so you do not really know where they are hiding. It is especially important to wash your hands Before, during, and after you prepare food Before you eat, and after you use the bathroom After handling animals or animal waste When your hands are dirty, and More frequently when someone in your home is sick. What is the correct way to wash your hands? First wet your hands and apply liquid or clean bar soap. Place the bar soap on a rack and allow it to drain. Next rub your hands vigorously together and scrub all surfaces. Continue for 10 - 15 seconds or about the length of a little tune. It is the soap combined with the scrubbing action that helps dislodge and remove germs. Rinse well and dry your hands. It is estimated that one out of three people do not wash their hands after using the restroom. So these tips are also important when you are out in public.   http://www.cdc.gov/ncidod/op/handwashing.htm

 

See www.learnwell.org/handhygiene.htm

2.  Drink purified water (8 glasses daily)

 

There is no such thing as naturally pure water.  In nature, all water contains some impurities.  As water flows in streams, sits in lakes, and filters through layers of soil and rock in the ground, it dissolves or absorbs the substances that it touches.  Some of these substances are harmless.  In fact, some people prefer mineral water precisely because minerals give it an appealing taste.  However, at certain levels minerals, just like man-made chemicals, are considered contaminants that can make water unpalatable or even unsafe.  Some contaminants come from erosion of natural rock formations.  Other contaminants are substances discharged from factories, applied to farmlands, or used by consumers in their homes and yards.  Sources of contaminants might be in your neighborhood or might be many miles away.  Your local water quality report tells which contaminants are in your drinking water, the levels at which they were found, and the actual or likely source of each contaminant.  Some ground water systems have established wellhead protection programs to prevent substances from contaminating their wells.  Similarly, some surface water systems protect the watershed around their reservoir to prevent contamination.  Right now, states and water suppliers are working systematically to assess every source of drinking water and to identify potential sources of contaminants.  This process will help communities to protect their drinking water supplies from contamination, and a summary of the results will be in future water quality reports.   http://www.epa.gov/safewater/dwh/contams.html

 

Purifying Water Boiling and chemical sterilization are two ways to purify water. Any water that is obtained from sources outside the home or water that does not appear clear should be sterilized. Non-sterilized water may be contaminated with the parasite Giardia. Straining water. Strain water containing sediment or floating material through a cloth or paper filter before beginning the purification process. Heat sterilization. Boiling water is the preferred method of purification because disease-causing- microorganisms cannot survive the intense heat. Bring water to a rolling boil for 1 minute. Pour the water back and forth from one clean container to another to improve the taste. Adding a pinch of salt could also help.   Chemical sterilization. In some situations, boiling may not be an option. The alternative is to treat the water chemically. Plain household chlorine bleach may be used. Be sure the label states that hypochlorite is the only active ingredient. Bleach containing soap or fragrances is not acceptable. With an eye dropper, add 8 drops of bleach per gallon of water (16 if the water is cloudy), stir and let stand. After 30 minutes the water should taste and smell of chlorine. At this time it can be used. If the taste and smell (and appearance in the case of cloudy water) has not changed, add another dose and let stand. If after one half hour the water does not have a chlorine smell, do not use it. http://www.fema.gov/rrr/waterf.shtm

 

See http://en.wikipedia.org/wiki/Water_purification

3.  Build pit latrines where needed

 

See http://tilz.tearfund.org/Publications/Footsteps+1-10/Footsteps+9/Building+a+pit+latrine.htm

Improve Nutrition

4. Eat a healthy diet and keep your BMI under 25

 

Action List for Whole Grains Did you know that there are some great reasons to eat more whole grain breads and cereals?  They are low in fat.  They are good sources of fiber, vitamins, minerals, and protein.  They can be fixed and eaten in may ways. Here are some actions to get you started and keep you going. Try two or three actions now and try more later.  Choose whole grain varieties of bread, muffins, bagels and rolls (whole wheat, bran, oatmeal, multigrain). What's a whole grain? It's a grain that still has its outer covering, which contains the grain's fiber and many of its vitamins and minerals. Choose a whole grain (oatmeal, wheatena) variety when you have hot cereal, or a cold breakfast cereal that provides at least 4 grams of fiber for serving. Have whole wheat varieties of pancakes or waffles. In recipes that call for flour, use at least half whole wheat flour. For dinner at least twice a week, serve whole wheat noodles, brown rice or bulgur (cracked wheat).  Try higher fiber cracker varieties, such as whole rye crackers, whole grain flatbread, or some of the new mulilti-grain crackers. Check the label to make sure you're choosing a low-fat variety.  Once a week or more, try a low-fat meatless meal or main dish that features whole grains (spinach lasagna, red beans over brown rice and vegetable stir-fry). http://www.pueblo.gsa.gov/cic_text/food/guideeat/grains.html

Weight Management

 

See www.learnwell.org/nutri.htm and www.learnwell.org/weight.htm

5. Give vitamin A to children, where needed

High potency vitamin A given twice a year reduces the number of child death by 34 percent. It made the children less vulnerable to measles, malaria, diarrhea and dysentery. While WHO provides it to 400 million children in developing countries, only about one-third of children who need it receive it. A pill costs about four cents.

Between 100 and 140 million children are vitamin A deficient.

• An estimated 250 000 to 500 000 vitamin A-deficient children become blind every year, half of them dying within 12 months of losing their sight.

• Nearly 600 000 women die from childbirth-related causes each year, the vast majority of them from complications which could be reduced through better nutrition, including provision of vitamin A.

Vitamin A deficiency (VAD) is the leading cause of preventable blindness in children and raises the risk of disease and death from severe infections. In pregnant women VAD causes night blindness and may increase the risk of maternal mortality.

Vitamin A deficiency is a public health problem in 118 countries, especially in Africa and South-East Asia, once again hitting hardest young children and pregnant women in low-income countries.

For deficient children, the periodic supply of high-dose vitamin A in swift, simple, low-cost, high-benefit interventions has also produced remarkable results, reducing mortality by 23% overall and by up to 50% for acute measles sufferers.

http://www.who.int/nut/vad.htm

 

See http://ods.od.nih.gov/factsheets/vitamina.asp and http://www.who.int/nut/vad.htm

6. Use oral rehydration, when needed

 

Among children in the United States, acute gastroenteritis remains a major cause of morbidity and hospitalization, accounting for >1.5 million outpatient visits, 200,000 hospitalizations, and approximately 300 deaths/year. Direct medical costs for rotavirus diarrhea, which represents approximately one third of all hospitalizations for diarrhea among U.S. children aged <5 years, have been estimated to be $250 million/year, with an estimated $1 billion/year in total costs to society. Worldwide, diarrhea diseases are a leading cause of pediatric morbidity and mortality, with 1.5 billion episodes and 1.5--2.5 million deaths estimated to occur annually among children aged <5 years. Although the total number of deaths from diarrhea is still unacceptably high, these numbers have been reduced substantially in the 1980s and 1990s. For example, in 1982, an estimated 5 million deaths/year occurred, and in 1992, the estimated annual deaths declined to 3 million/year A substantial portion of the decrease in mortality is attributable to worldwide campaigns to treat acute diarrhea with oral re-hydration therapy (ORT). The development of ORT represents a successful collaboration between basic and applied biomedical research. The application of ORT also represents a case of reverse technology transfer, because protocols originally implemented to benefit patients in developing countries have changed the standard of care in industrialized countries as well. ORT encompasses two phases of treatment: 1) a re-hydration phase, in which water and electrolytes are administered as oral re-hydration solution (ORS) to replace existing losses, and 2) a maintenance phase, which includes both replacement of ongoing fluid and electrolyte losses and adequate dietary intake. Although ORT implies re-hydration alone, the definition used in this report has been broadened to include maintenance fluid therapy and appropriate nutrition. The full benefits of ORT for acute gastroenteritis have not been realized, especially in countries with developed market economies that have lagged behind less-developed countries in their use of ORT. One reason for this low usage of ORT might be the ingrained use of intravenous (IV) therapy or the reduced appeal of a technologically simple solution. This is especially true in the United States, where children with all forms of dehydration are treated with IV fluids rather than ORT. Approximately 30% of practicing pediatricians withhold ORT for children with vomiting or moderate dehydration. In addition, the practice of continued feeding during diarrheal episodes has been difficult to establish as accepted standard of care. Although substantial in vitro and in vivo data support the role of continued nutrition in improving gastrointestinal function and anthropometric, biochemical, and clinical outcomes, early appropriate feeding is often withheld. In 1992, CDC prepared the first national guidelines for managing childhood diarrhea. Since the last recommendations were published in MMWR, data have emerged regarding diarrhea treatment, including the importance of zinc supplementation and the value of more effective oral solutions of lower osmolarity (i.e., proportionally reduced concentrations of sodium and glucose). These recommendations update the previous report, review the historical background and scientific basis of ORT, and provide a framework for assessing and treating infants and children who have acute diarrhea. The discussion focuses on common clinical scenarios and traditional practices, especially with regard to continued feeding. Limitations of ORT, ongoing research in the areas of micronutrient supplements, and functional foods are reviewed. These updated recommendations were developed by specialists in managing gastroenteritis, in consultation with CDC and external consultants. Relevant literature was identified through an extensive MEDLINE search by using related terms. Articles were then reviewed for their relevance to pediatric practice, with emphasis on U.S. populations. Unpublished references were sought from the external consultants and other researchers. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm ORT Formula: ½ teaspoon salt 1 teaspoon baking soda 8 teaspoons sugar 8 ounces orange juice (optional) Dilute to 1 liter with water http://www.uspharmacist.com/oldformat.asp?url=newlook/files/Feat/ACF2EF8.cfm&pub_id=8&article_id=37 See also http://www.rehydrate.org/ and http://www.cps.ca/english/statements/N/n94-03.htm and http://www.nand.org/ General Health 7. Quit smoking and harmful drugs  How Smoking Harms People of All Ages Toxic ingredients in cigarette smoke travel throughout the body, causing damage in several different ways. (p. 616)   Nicotine reaches the brain within 10 seconds after smoke is inhaled. It has been found in every part of the body and in breast milk. (p. 616)   Carbon monoxide binds to hemoglobin in red blood cells, preventing affected cells from carrying a full load of oxygen. (p. 616)   Cancer-causing agents (carcinogens) in tobacco smoke damage important genes that control the growth of cells, causing them to grow abnormally or to reproduce too rapidly. (p. 44-45)   The carcinogen benzo[a] pyrene binds to cells in the airways and major organs of smokers. (p. 616)   Smoking affects the function of the immune system and may increase the risk for respiratory and other infections. (p. 616)   There are several likely ways that cigarette smoke does its damage. One is oxidative stress that mutates DNA, promotes atherosclerosis, and leads to chronic lung injury. Oxidative stress is thought to be the general mechanism behind the aging process, contributing to the development of cancer, cardiovascular disease, and COPD. (p. 619)   The body produces antioxidants to help repair damaged cells. Smokers have lower levels of antioxidants in their blood than do nonsmokers. (p. 618–619)   Smoking is associated with higher levels of chronic inflammation, another damaging process that may result from oxidative stress. (p. 619)  Citation U.S. Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004. Smoking remains the leading cause of preventable death and has negative health impacts on people at all stages of life. It harms unborn babies, infants, children, adolescents, adults, and seniors. http://www.cdc.gov/tobacco/sgr/sgr_2004/Factsheets/7.htm  Help with smoking cessation: www.somekfree.gov  and  www.learnwell.org/smokefreed.htm      8. Walk or exercise half hour daily Significant health benefits can be obtained by including a moderate amount of physical activity (e.g., 30 minutes of brisk walking or raking leaves, 15 minutes of running, 45 minutes of playing volleyball). Additional health benefits can be gained through greater amounts of physical activity.   Thirty to sixty minutes of activity broken into smaller segments of 10 or 15 minutes throughout the day has significant health benefits.   Moderate daily physical activity can reduce substantially the risk of developing or dying from cardiovascular disease, type 2 diabetes, and certain cancers, such as colon cancer. Daily physical activity helps to lower blood pressure and cholesterol, helps prevent or retard osteoporosis, and helps reduce obesity, symptoms of anxiety and depression, and symptoms of arthritis.   Cardiovascular disease (heart attacks, strokes) is the number one killer of men and women in the United States. Physically inactive people are twice as likely to develop coronary heart disease as regularly active people. The health risk posed by physical inactivity is almost as high as risk factors such as cigarette smoking, high blood pressure, and high cholesterol.  Source: http://www.fitness.gov/resources_factsheet.htm    See  www.learnwell.org/fitness.htm and www.learnwell.org/fit3.htm   9.  Relax, rest and reduce stress as needed Things to Remember When Trying to Understand Disaster Events No one who sees a disaster is untouched by it. It is normal to feel anxious about you and your family's safety. Profound sadness, grief, and anger are normal reactions to an abnormal event. Acknowledging our feelings helps us recover. Focusing on our strengths and abilities will help you to heal. Accepting help from community programs and resources is healthy. We each have different needs and different ways of coping. It is common to want to strike back at people who have caused great pain. However, nothing good is accomplished by hateful language or actions. Signs that Adults Need Stress Management Assistance Difficulty communicating thoughts Difficulty sleeping Difficulty maintaining balance Easily frustrated Increased use of drugs/alcohol Limited attention span Poor work performance Headaches/stomach problems Tunnel vision/muffled hearing Colds or flu-like symptoms. Disorientation or confusion Difficulty concentrating Reluctance to leave home Depression, sadness Feelings of hopelessness Mood-swings Crying easily Overwhelming guilt and self-doubt Fear of crowds, strangers, or being alone Ways to Ease the Stress Talk with someone about your feelings– anger, sorrow, and other emotions-- even though it may be difficult. Don't hold yourself responsible for the disastrous event or be frustrated because you feel that you cannot help directly in the rescue work. Take steps to promote your own physical and emotional healing by staying active in your daily life patterns or by adjusting them. This healthy outlook will help yourself and your family. (i.e. healthy eating, rest, exercise, relaxation, meditation.) Maintain a normal household and daily routine, limiting demanding responsibilities of yourself and your family. Spend time with family and friends. Participate in memorials, rituals, and use of symbols as a way to express feelings. Use existing supports groups of family, friends, and church. Establish a family emergency plan. Feeling that there is something that you can do can be very comforting. * When to Seek Help: If self help strategies are not helping or you find that you are using drugs/alcohol in order to cope, you may wish to seek outside or professional assistance with your stress symptoms.  http://www.mentalhealth.samhsa.gov/publications/allpubs/KEN-01-0097/default.asp    See www.learnwell.org/relax.htm and www.learnwell.org/stress.htm

Library Free modules included in the Global Health Super-course at www.pitt.edu/~super1 Global Health Council - The Voice for Global Health GlobalHealth.gov - A project of the Office of Global Health Global Health and Fitness CDC - Office of Global Health

Test  

Study this web-site for 3 hours for an approved (RN-CEP 11430, MFT- PCE 39) 3-hours Continuing Education Certificate (0.3 CEUs).  Click here for the self-correcting test , and 2) receive your certificate immediately online. There is no fee for this course and the certificate. Do NOT take the test before you studied the course thoroughly. Explore the suggested boxed websites under each of the nine topics. All is online, nothing by post-mail.