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Community-Based Interventions - Improving Maternal Health in Afghanistan

Speaker: Denise Byrd, Jhpiego
Presider: Isobel Coleman, Council on Foreign Relations
May 25, 2011
Council on Foreign Relations

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ISOBEL COLEMAN:  Good afternoon, everybody.  I think we're going to get started.  I know we're waiting for a few other people to arrive.  We have lots to discuss, so I think -- I think we're going to get going now, if that's OK.

Thank you all for coming today.  I am Isobel Coleman.  I'm a senior fellow with the Council on Foreign Relations in New York.  I don't normally do meetings here in Washington, so it's a pleasure to be here in Washington.

And this will be a somewhat unusual meeting for a CFR meeting.  First of all, this is an overwhelmingly female audience, which is interesting.  Thank you for the one -- one gentleman, for joining us here today.  I've really never see anything --

MR.     :  (Off mic) -- and the family is, I guess, somewhere.

COLEMAN:  I've never seen anything like this at a CFR meeting, I must -- I must admit.

And the second thing is this will be a conversation about Afghanistan that is not totally depressing, I think.  (Laughter.)  There are some glimmers of hope and some good news coming out of Afghanistan, and our conversation today I think will tease that out a bit.

This meeting is the first in a series that we're doing looking specifically at maternal health and community-based programs in Afghanistan to improve maternal health that we -- it's been an ongoing project with the MacArthur Foundation.  So MacArthur has funded some work here at CFR over years that my colleague, Laurie Garrett, who runs the Global Health Program, and I have collaborated on, looking specifically at maternal health issues.  But this project, because I work -- my regional focus is the Middle East and South Asia; I do a lot of work on Afghanistan and Pakistan.  This project I'm doing just -- without Laurie, but specifically looking at maternal health in Afghanistan.

And so we're delighted to have Denise Byrd from Jhpiego here with us.  They -- Denise and Jhpiego have been doing very interesting work on the ground in Afghanistan.  Denise has been living there for the past five years and as I just heard, getting out once a quarter, for a variety of reasons -- not least, no doubt, is to preserve her sanity -- (laughter) -- but during that time has overseen a number of really interesting initiatives in Afghanistan.  She's the country director for Jhpiego there.

And her bio is in the handout.  And I thought we would really just jump right in with Denise -- maybe you starting out by just explaining a little bit about your organization, what you've been doing and what the nature of the work is in Afghanistan.

BYRD:  Sure.  First of all, how many of you have heard of Jhpiego?  (Pause.)  Oh, most everyone has.  OK.

Well, for those of you who haven't, Jhpiego is an organization that was founded in 1973.  It's an affiliate of Johns Hopkins University, and we work -- we have a presence in 50 countries, work in many others.  We have more than 900 staff.  It's a wonderful organization.  And we started our work in Afghanistan under a USAID-funded project called REACH -- Rural -- I can't remember what "REACH" stands for, but REACH.  And that project was led by a partner organization called MSH.  And Jhpiego's role in REACH was to focus on providing clinical trainings to health providers, as well as establishing the midwifery education system in Afghanistan.  And I'll talk a bit more about that later.

Then, USAID invited a project called ACCESS, which is a global maternal health project, to come to Afghanistan to start a pilot project on the prevention of postpartum hemorrhage, or bleeding after birth, in home-birth settings, through counseling and distribution of misoprostol, which I'll talk more about later.  It's a pill.  And then, eventually, USAID decided to issue an associate award, or an award based out of the mission in Afghanistan, called the Health Services Support Project, and rolled in the ACCESS work and the work that Jhpiego had previously been doing under REACH into this HSSP project.  HSSP is led by Jhpiego, with partners Futures Group and Save the Children.  It started in July 2006 and, as of today, will end November 2011.  But it will be expanded -- or extended and expanded, actually -- an additional year -- or an additional 11 months.

The focus of the Health Services Support Project is on increasing utilization of health services by focusing on improving the quality of services and generating demand for those services.  So we're tackling it from both sides -- supply side and demand side.

We work on improving the quality of health services by working with the nongovernmental organizations in the country that are actually implementing the services.  Afghanistan is a little bit unique in that it contracts out all health service delivery to NGOs.  So the Ministry of Public Health doesn't actually deliver the services.  It contracts them out to NGOs, and the NGOs' staff deliver the services.

So we work very closely with those NGOs to build their capacity, to standardize the delivery of services.  The REACH project developed what they call the Basic Package of Health Services.  It's a package of services that says, at different types of facilities, what kind of staff should be available, what kind of services should be available.  We then come in and said what should those services look like.  How do we define quality?  And we've developed performance standards along the BPHS areas.  So that's one of the ways that we're helping to improve the quality, by standardizing care.

The second objective of the project is to increase the number of skilled providers and to improve their performance.  And the standards do help to improve their performance, because they tell providers who are in, often, very remote areas, out on their own -- they don't get a lot of supportive supervision -- the standards are a tool that they can use that tell them, OK, this is what it -- what quality looks like.  And these are the criteria, the verification criteria, the things I have to do in order to deliver quality services.

So we also provide a lot of in-service trainings.  So we train doctors, nurses, midwives, lab technicians, pharmacists, in a variety of different subject matters:  clinical, such as emergency obstetric care; competency-based family planning; as well as nonclinical, things like behavior change communication, interpersonal communication and counseling.  A lot of times, the way in which providers talk to patients is a huge issue; and so working with the providers to teach them how to ask questions and treat clients with respect.

And then, to increase the number of skilled providers, we have a --  you've probably heard -- well, maybe you haven't -- the community midwifery education?  Has everybody heard of community midwifery education?  Well, Jhpiego helped to establish the midwifery education system in Afghanistan.  And through this system -- and I'll talk more about this, but through this system we are training women to become midwives.  And we'll also be establishing a similar system for community health nurses; so training women to become community health nurses as well.  So that's how we're improving the performance of providers and increasing the number of providers.

The third thing we do is generate demand for services.  And we work very closely with the Ministry of Public Health's Health Promotion Department.  And we develop all sorts of advocacy campaigns:  awareness-raising campaigns, for example; safe-motherhood campaigns, raising awareness about pregnancy danger signs, things like that.  We also do a lot of community mobilization activities, where we link communities with health facilities, get them talking about quality.  You know, what does the community expect from this facility, and how can the facility meet those demands and expectations?

And then last, but certainly not least, we integrate gender awareness and practice into the basic package of health services.  So working with providers to help them understand the importance of promoting women's empowerment, decision-making; the importance of involving men, particularly in reproductive health; and also, the importance of gender-sensitive interpersonal communication and counseling.

We also provide a lot of trainings around gender, gender-awareness trainings, as they relate to standards as well, gender-based violence training.  We've also established what we call family health action groups, which are kind of like Tupperware parties -- (laughs) -- in a sense.  They're opportunities for women who are associated with the community health worker -- the female community health worker in a community -- to come together and talk about their pregnancy histories as an opportunity to then talk about safe motherhood and recognizing danger signs.

They may do cooking demonstrations to show women how to cook in a hygienic way -- you know, this is where we keep our latrine away from our water source -- and talk about things like family planning and birth spacing.  And so that's another one of the important community-based interventions that I'm not going to talk too much about today, but there are a couple of others that are really important that I would like to talk more about.

COLEMAN:  Well, maternal health is really the focus here today, and so I think, you know, the -- after the fall of the Taliban, you know, the world became aware of the shocking, you know, maternal mortality statistics in Afghanistan.

There was a famous study done -- on horseback, you know, going around to rural communities and tallying up how many women actually do die in childbirth -- and that really helped galvanize attention and helped prioritize maternal health as a development issue in Afghanistan.  And I know that a lot of your work and others' has been focused on trying to improve maternal health in Afghanistan.  So could you tell us a little bit specifically about some of the maternal health interventions that you've been doing and -- or -- and maybe even start -- why is maternal health so dire in Afghanistan?

BYRD:  That's a good question.  I think there are a lot of reasons for the dire situation, one being simply there was just lack of access.

There were not a lot of facilities back before 2002.  There were not a lot of skilled providers and specifically female providers, because obviously during the Taliban women were not allowed to work -- although many of them did work in hospitals, but the quality of the care was very, very poor -- and then, culturally, there are a lot of cultural barriers as well to women leaving the home, going to a health facility.  Most women -- well, most of the population is rural.  About 80 percent or more of the population lives in rural areas and in those areas it's customary for women to deliver their babies at home without a skilled provider.  So that's one of the main reasons maternal mortality is so high.

So in addition to cultural barriers, there are also geographical barriers where the maternal mortality survey was conducted and they identified the highest maternal mortality ever recorded in Badakhshan province.  That's a very, very remote, rugged area that you can only access on horseback, and so it's very difficult for women -- and anyone, really -- to access care.

COLEMAN:  Yes, that little sort of northern part of Aghanistan that stretches up to China even, so --

BYRD:  Maybe I can just -- show you a map here.  This -- that little part -- it stretches into China.

COLEMAN:  That little neck that goes out into -- that's Tajikistan.

BYRD:  Yeah.  So, geographical barriers, cultural barriers, lack of access -- in terms of just lack of female providers because obviously, in a country like Afghanistan, women can only be seen by female providers, particularly for childbirth.

In terms of what we're doing to address some of those challenges, a couple of things:  The first is we're -- as I mentioned -- the basic package of health services has really expanded coverage of services to large parts of the country.  I think, the numbers are debated, but sometimes 80 to 85 percent coverage now, and that -- when I say "coverage," that means within six hours walking distance, I think.  (Laughs.)  So it's still --

COLEMAN:  It might not be what we think of as coverage, but --

BYRD:  Yeah, so still a large part of the population doesn't have easy access to a health facility.  But they have more access than they did before, so that is helping.

Second, by improving the quality of care, it makes no sense to have more facilities that deliver poor quality care, right?  So we want to improve the quality of care as well as the access.  And a very important intervention that I think is making a big difference is increasing the number of skilled providers and taking care to the women where they are in their communities.  And that's the focus of today's talk is community-based interventions to save women's lives.  And some of the interventions that I'd like to talk about are low-cost, proven effective, and they're life-saving.  And so I think these are the things that are helping to address those barriers and challenges.

COLEMAN:  So one thing is the training of these now, skilled birth attendants, and through the midwifery program -- I mean, how many have been trained?

BYRD:  More than 2,500 women have graduated.

COLEMAN:  And is it a one-year or two-year program?

BYRD:  It's -- the community midwifery education program is -- started out as an 18-month program.  It's now been expanded to 24 months, and that's in response to a preservice midwifery education evaluation study we did where we identified the need for adding some additional modules to the curriculum based on the feedback we were getting from midwives.  So now it's a two-year program.

Let me just tell you a little bit of background about it.  Midwifery education existed in Afghanistan before we came along, but it was done through institutes of health sciences, and there were five institutes operating.  Students were selected through a national examination, the concourse exam, and then based on the score they received, they were placed in the appropriate programs.

So this resulted occasionally in men being selected for midwifery.  Obviously in a country like Afghanistan, that wouldn't work.  Also, it resulted in people training for midwifery who really didn't have an intention of being a midwife, who had no intention, certainly, of going to those most remote, insecure provinces in the rural areas.

So we thought, how can we get midwives where they're most needed, out in the rural, remote areas, where women are dying because they lack access to skilled birth attendants and care?  So we devised something called community midwifery education, and the main difference between hospital midwifery education and community midwifery education is how the students are selected and how they are deployed and the academic calendar year.  In terms of the skills and the competencies that they learn -- exactly the same.  Maybe 99 percent the same.  Hospital midwives may have some additional things because they're working in a different setting.

But the point was to develop a competency-based program, meaning the midwives would gain a skill, they would be fit for purpose.  They would gain a skill and then be ready to deploy and start working immediately to establish a competency-based program that was based on where there were gaps in health facilities.  So for example if there was a basic health center and it needed a midwife and there was no midwife willing to go there, then the community would come together and they would identify a woman from that village who would go to the provincial capital for her training and then would deploy, after graduation, back to that community to work in that basic health center and serve her community.  This has been very, very successful.

COLEMAN:  Do you need to be -- do these women need to be literate?

BYRD:  Yes.

COLEMAN:  And that must be a challenge in some of these communities, to find a woman who wants to be a midwife who is literate.

BYRD:  Let me tell you.  There were a lot of -- (chuckles) -- challenges initially not only finding literate women, but finding literate women whose families --

COLEMAN:  Were willing to let them go.  That was going to be my next question.

BYRD:  -- are willing to let them go to this, like, boarding school essentially.  To address the illiteracy issue, when CME first started, there was a program called "Learning for Life" which acted as a bridging program.  It would top up women's literacy skills, so that they had enough literacy and years of education to then enter the program.

There are criteria -- entrance requirements.  Now a woman must have at least 10 years of education; she must be selected by her community and have that endorsement; she must be -- she must commit to going back to that community and working in a health facility.  And the facility knows that she's coming back and working with them when she is selected.

Previously, the education requirement was lower, because it was harder to find women.  And in certain provinces where we do have problems identifying qualified women, we have waived that literacy requirement -- maybe lowered it to nine years.  But we found that if it goes too far below that, they're not able to successfully participate in the program, and so -- also, as a result of the success of the first batches that graduated, communities are now begging to have their daughters, their wives, their sisters enrolled in this program.  We are turning students away.  Even in provinces where they said, "You will never be able to start a school there, it is way too conservative," we've got women lining up.  So it's --

COLEMAN:  And are they lining up because their families see the positive impact it has in the community, because they see that they're earning money and income, that they're now in a prestigious job?  Or is it all of the above?

BYRD:  All of the above.  All of the above.  Midwives return to their communities very, very empowered, competent, able to save lives.  And often, they're the only women in the community that have mobility.  So it's not just about saving women's lives -- that's a very, very important part of it -- but it's also about women's empowerment.

We recently had the seventh annual Afghan Midwives Association congress, and we had 602 midwives from 33 of the 34 provinces throughout the country attend.  Only Helmand didn't attend, because of some security issues.  And to see all these women gathered together; and there is a midwife song that they sing and -- you know, it's really inspiring.  And you see, these women are strong.  We hear so much, "Oh, poor Afghan women," but the women I've come in contact with are very strong and empowered women.

COLEMAN:  Have you come up against any, you know -- look, there are -- international groups have built schools for girls.  Parents want them; they overwhelmingly send their girls to school.  And yet, they get burned down by extremist elements in society.  Have you had any threats or any attacks on any of the midwives or any of the midwifery programs?

BYRD:  Occasionally, we do have a student drop out because she's receiving some pressure, but it's very rare.  Given how many students we've graduated and deployed, it's actually very rare.  Occasionally, a school will come under threat, but the community rallies around it and they say:  This is our school; you know, you're not burning this school down; you know, this is not some international organization that's doing this, this is our community school, these girls are going to graduate and they're going to serve to our communities.  And they have pushed them back.

COLEMAN:  And you've never had -- so you've never had any attack on a school or --

BYRD:  No.

COLEMAN:  Not one?

BYRD:  Let me get back to you on that.  (Laughter.)

COLEMAN:  Yeah, that's best.

BYRD:  Because I don't want to say with a hundred-percent certainty, but --

COLEMAN:  But you can't think of one.

BYRD:  I cannot think of one.  I can think of threats that have then been mitigated through community dialogue.

COLEMAN:  In addition to the -- I don't mean to push off of midwifery, but -- you can finish up on that, but also are there some other interventions that -- or what specifically are the midwives doing that is resulting in the gains that you're beginning to see?

BYRD:  Well, yes, there are some other interventions.  One of the things that a midwife does -- as well as a community health worker, which I'd like to talk more about, as well -- is they counsel women and families about birth spacing and family planning.  And in a -- in a place like Afghanistan that has such a high maternal mortality ratio and a high fertility rate, contraceptive use is 300 times safer than pregnancy.  So anytime we can get women and men to use family planning, we're going to save lives.  And so that's also helped.

COLEMAN:  And just -- I don't know if you saw, but out on the table is the recent report that CFR just came out with on family planning.  It's a different -- separate program, but I encourage all of you to take a copy of that.

And I'm not -- you know, I'm not a women's health expert, but in writing this report, one of the things that I found staggering was the enormous leverage in birth spacing in terms of saving mothers and infant lives, so --

BYRD:  Absolutely.  And in a country like Afghanistan, the culture really encourages families to have a lot of children, to have big families.  And so we don't go in there saying, you know:  Don't have so many children.  Instead, we say:  Space the pregnancies; you know, have healthy timing of pregnancies and healthy spacing of pregnancies.  And it's better for the mother; it's better for the children.

And we have community-based intervention where we're training community health workers to -- actually, we're training community health worker trainers and community health supervisors to train community health workers, both male and female, to provide counseling on family planning methods, talk about healthy spacing, healthy birth spacing, and talk about some of the postpartum family planning opportunities, such as lactational amenorrhea method which -- you know, when I first heard that, I was like, "What?"  (Laughs.)  Basically, that's a method -- it's a -- it's an all-natural method whereby, if you do it correctly, following three criteria -- and Holly (sp), you can help me if I get any of this wrong -- but you have to have exclusively breastfed the baby for -- and you have to still be within six months, and you cannot have returned to menses.  So if those three criteria are met, it's 98-percent effective in preventing pregnancy.

And this is actually very consistent with the culture.  For example, the religion -- obviously, it's the Islamic Republic of Afghanistan.  There is a saying of the Prophet, and also in the Quran, that talks about breastfeeding for two years.  And so this exclusive breastfeeding message is very consistent with the culture.  But a lot of times, people don't know about it, so a lot of the activities that we're involved in is just raising people's awareness about what the culture says about breastfeeding.

COLEMAN:  If they're not breastfeeding, do they have access to formula?  I mean, what are they doing?

BYRD:  No, what's typical is, a lot of times mothers will feed the baby, like, little biscuits and tea.

COLEMAN:  Oh, I see -- start introducing food very early on.

BYRD:  Right.

COLEMAN:  OK.

BYRD:  Yeah.  So there isn't -- particularly in the villages, there is no formula.  In Kabul, you can probably get formula, but --

COLEMAN:  (You can probably get formula, yeah ?) --

BYRD:  So -- and that's the other thing.  We say not only is it going to prevent pregnancy, you know, postpartum, or after your last birth, but it's free, so -- (chuckles) -- and it's healthy for the baby, as well.  So that's very consistent.

We also address a lot of misconceptions that people have about family planning and the side effects of family planning.  And health providers actually have a lot of misconceptions about the side effects of family planning.  So it's not just about talking to the community, it's also about educating health providers.

So in addition to our competency-based family planning training that we provide for health providers, we're also involved in this community-based intervention to promote family planning after birth.  And it's actually been quite successful, and we're expanding it to the whole country now, because, as I said, it is so consistent with the culture.

COLEMAN:  And are there other interventions that are seen as effective?

BYRD:  Sure.  Well, this might be a good time to segue into this next intervention.

COLEMAN:  Sure.

BYRD:  An intervention that I'm really excited about is community-based distribution of Misoprostol to prevent bleeding after birth, or postpartum hemorrhage.  Misoprostol is a pill that was originally used in the U.S. to prevent ulcers and treat ulcers.  And then it was found to also prevent bleeding after birth.  And this is something that is, like I said, low-cost, proven effective.  Jhpiego did -- we know the pill works; we know that it works to prevent bleeding.  What we didn't know is could this pill be distributed through a community-based distribution process?  In other words, could we train community health workers to distribute this pill?

And we tested this in Indonesia, in Nepal.  And absolutely, we found that it does work.  And we also tested it in Afghanistan.  And as a result, the government of Afghanistan has asked us to expand this intervention to 20,000 pregnant women in Afghanistan.

So I'm just going to show you this video, which is of a female community health worker who we recently trained to distribute Misoprostol and provide counseling to the families -- I can't leave that out because it's -- that's a very, very important component of the work.  And so she's talking about her experience with this training and her commitment.

(Video plays.)

Wow.

QUESTIONER:  Actually, I just wanted to tell you, what she said was actually even more -- stronger than what was in the -- in all --

BYRD:  Subtitles.

QUESTIONER:  And -- yeah -- is -- like moving -- basically, what she was saying is that, you know, that now that she's learned -- of course, you saw the thing about, you know, the daughters dying.  But that -- now that they're aware of this particular medicine that can help prevent that type of bleeding, that now she feels it is a personal duty to deliver this product to the community, and that -- even though that she's as -- age has passed her by, in the sense that she's old now.  But still, she's said she would -- she intends to do it to her dying moment.

BYRD:  Now, thank you for that.

That's a pretty powerful video.  It always brings tears to my eyes when I watch it.  You know, this is a woman who lost two daughters to hemorrhage.  And she's not alone.  I mean, this is a story that you hear over and over again.  And 78 percent of the maternal deaths in Afghanistan are preventable.  And so this is one way that we can prevent the leading cause of maternal death in Afghanistan, which is hemorrhage:  bleeding after death (sic).

COLEMAN:  I'm sorry, for a non-expert:  If you take the pill, does that buy you time to get to a -- no?

BYRD:  No, it stops the bleeding.

COLEMAN:  It just stops the bleeding.

BYRD:  It stops the bleeding.  And for a long time, there were questions about whether or not an illiterate community health worker could appropriately and effectively counsel a family and deliver this pill to ensure that it wouldn't be misused.

And our experience in the many countries that we've implemented this intervention is that by -- the pill is not given until the eighth month of pregnancy.  And that's when we're -- women are very invested in their pregnancy at that time.  And they are listening carefully on how they can save their lives.

And we've had no adverse effects when we've done this in Afghanistan and other countries.  And in my personal opinion, it is a sin to not provide this opportunity to, you know, hundreds and millions of people around the world that could benefit from this lifesaving pill.

And the benefit of giving it to a community health worker and then to the woman herself is that, you know, you can have the best plans to come to a facility to deliver or to have a skilled birth attendant come to your home and deliver.  But really, the only person we can be guaranteed of, who's going to be there at the pregnancy, at the time of the delivery, is the woman.  And so why not give the woman the means to protect herself and ensure that she and her babies survive.

COLEMAN:  What is the downside of the pill if it is misused?

BYRD:  If it is taken during pregnancy, it could create miscarriage.  But as I said, our experience has been that that has not happened, that women want to protect their babies and themselves.  You know, at eight months into the pregnancy, we haven't had any adverse effects or ill effects.

COLEMAN:  And I'd like to add that the community distribution of Misoprostol has been widely used throughout Nepal and has in fact reduced maternal mortality by 50 percent in Nepal.  And there's really not been incidents of women being given the drug inappropriately through the community health workers.

BYRD:  Yeah, that's a good point.  It's funny, all these countries trying to reduce maternal mortality by improving the quality of services at the health facility.  And what's really demonstrated to work is community-based interventions.  And this is one of those community-based interventions that works.

COLEMAN:  Nandini had a --

QUESTIONER:  Nandini Oomman from the Center for Global Development.

I am very excited to hear about the fact that you are actually doing studies on Misoprostol.  I haven't seen those widely published, and I'm probably going to suggest something that others have thought about -- but I do think that it needs to be out there -- is that, just like we have lots of champions for vaccines, for child survival, it really is, I think, important that you get these results widely out to policymakers to show that there are technologies.  Because I think some of the big struggles around maternal mortality is that everybody talks about the health system, which is impossible to fix even in countries that are stable, let alone Afghanistan.

So here, where you have a community-based technology that you can actually provide through community health workers, you know, by vetting carefully, I think, the disadvantages, potentially -- but really highlighting where it could be revolutionary.  And I think we should move on that because I think there's so much --

BYRD:  That's -- we're -- this report we're coming out with this summer, it -- that's exactly what we're trying to do.  So I mean, we'll circle back with you on that.

QUESTIONER:  Great.

COLEMAN:  And the WHO just added Misoprostol to the essential drug list, I think about two, two and a half weeks ago.

BYRD:  Yeah, that's what I was just going to say.  So Jhpiego has published, but you're right.  We need to do more to get this message out that this approach works.  And fortunately, the WHO agrees.

Holly.

COLEMAN:  Holly.

QUESTIONER:  Holly Blanchard, also with Jhpiego.

If I could just add another good thing about community-based distribution of Misoprostol that was found in Afghanistan and Nepal.  Even though it's non-literate women counseling non-literate women to take this, it's very careful teaching and training mechanisms so that everyone is on board.  And the community member is very invested in her own community.  She's committed, probably more so than a midwife would be at a larger facility.

But what has also been found is that there's an increase in the women who've been counseled on Misoprostol to deliver at a skilled birth facility because she -- now she's become very much aware of the dangers of postpartum hemorrhage.  Because I think that's another concern, is that, well, if we distribute this medication, they won't go to the facility.  That's been proven wrong already, but --

BYRD:  Actually, what you're saying is the opposite.  And do you have data on that?

QUESTIONER:  It's from Nepal.

BYRD:  From Nepal.

QUESTIONER:  And Afghanistan.  Yeah.

QUESTIONER:  And also Afghanistan.  And then, I'm not sure where it's published, but I could locate it.  Or maybe, Melody (ph), you could locate it.

QUESTIONER:  Yeah, it's in our reports.  I can certainly get that data for you.

BYRD:  OK.  OK.

QUESTIONER:  They scaled up.  It's nationwide also in Nepal, and it's good to hear that Afghanistan also has scaled up, that it's now a national standard across the country.

QUESTIONER:  Hi, Allyn Taylor from Georgetown Law Center.  First of all, thank you for your presentation; it was informative.  Congratulations on your program.

I wanted to ask you a question about retention of these health workers because we know retention of health workers in poor countries, particularly in conflict zones, is an enormous challenge.  I mean, it was just last week that there was a suicide bomber in a health facility in Afghanistan.

So -- (inaudible) what -- (meet ?) any challenges, I understand this is community based, in retaining health workers, either in the rural areas or in the country as a whole?  And you mentioned at the beginning of your presentation that the people that you train are called upon to make a commitment.  And I'm wondering what the scope of that commitment is, and --

BYRD:  Sure, that's a good question.  Turnover of staff is a huge challenge in Afghanistan.  The way that we try to address that issue is through our quality assurance process which focuses on standards; there's a recognition component.  And so we try to create -- encourage the NGOs to create an environment that recognizes high performance, try to strengthen systems so they get paid on time, you know, addressing all of these challenges.

Now, some of these challenges relate to issues that are outside of our control, such as insecurity.  And there's not a whole lot that you can do about that.  But with respect to midwifery, we actually have pretty good retention of our deployed midwives.  Not perfect, of course, but compared to some of the other sectors there's pretty good retention.

And when I mention the commitment, it's the student makes a commitment to return to her community and serve her community by working as a midwife in the facility that was identified for her.

MS.     :  (Off mic) -- specific amount of time that --

BYRD:  There isn't.  And there has been talks, you know, should we make it a five-year commitment, and if not do they have to pay back; but ultimately we just decided that community support -- because the community supports her as well.  So community peer pressure -- (chuckles) -- tends to keep her there.

MS.     :  How is this paid for, is this subsidized by the community, or --

BYRD:  No, she is employed by the NGO that manages the health facility that she's working in.  So when I say community midwife, she's not a true community midwife in that she's not going around and delivering in people's homes necessarily; often they do.  But she is facility based.  But the community midwife name comes from the fact that she's identified by the community and she goes back to that community to work and serve that community.  But she is facility based and will, you know -- some of -- many of the midwives do travel to homes and provide care, but --

COLEMAN:  And when you say the community supports her -- I mean, they morally support her, you know, enthusiastically support her, but not financially.

BYRD:  No, not financially.  Although for community health workers -- the community often does in some way compensate a community health worker because the community health workers are really the backbone of the health system in Afghanistan, and they're all volunteers.  So this has been a big debate for the years that I've been there:  Should they be paid, should we not pay them?  But when I've talked to community health workers, a lot of times they have other professions; they may be farmers or --

COLEMAN:  Like that woman in the video.

BYRD:  She's an unpaid volunteer.

COLEMAN:  Unpaid volunteer, right.

BYRD:  But they get status. Often the community health worker is someone of status anyway, but they get more status as a community health worker.  A lot of times they are exempt from paying, like, the mullah (ph) tax or the --

COLEMAN:  It's an official designation, right?

BYRD:  It is an official designation, yes.  But they are volunteers, which is pretty impressive.

QUESTIONER:  Rebecca Katz from George Washington.  You may have mentioned this, I might have missed it.  But who trains them, who are the people teaching them to become midwives?  And is this --

BYRD:  The midwives?

QUESTIONER:  Right.  And is there any kind of plan -- have any of them come back and taught the next generation or, I mean, is there any kind of plan for that?

BYRD:  Absolutely.  The midwives -- let me back up and tell you a little bit about how we implement community midwifery education.  If I can just go to this map -- OK.  So this is a map of Afghanistan and the different colors represent the different donors supporting community and hospital midwifery education.  The blue are the midwifery education programs that are financially supported by USAID.

Technically, Jhpiego supports the whole country, because we serve as the secretariat of the Afghanistan midwifery and nursing education accreditation board which ensures the quality and standardization of all programs throughout the country.  In addition to that, the project -- health services support project financially supports programs by awarding grants to NGOs to implement the education program.

So Jhpiego designed the curriculum, designed the system, ensures that the faculty are trained, and now we have trained faculty. But in the beginning of the program, you know, it was similarly like we have community health nursing education now.  It's a brand new program.  We have to -- we may have a curriculum, but we have to make sure that there are faculty able to delivery that curriculum effectively.

So, similarly with midwifery.  We had to ensure that there were enough people trained to deliver that.  Now there are.  And many of the trainers in midwifery education programs are graduates of programs.  And so they come back, rather than deploying, they'll come back and teach others to become midwives.

COLEMAN:  And what is the -- you've graduated 2,500, approximately?

BYRD:  Approximately, more like 2,700 but --

COLEMAN:  And what is the ramp-up now?  Is it -- you know, that's over a period of, you know, eight years.  Is there now a higher ramp-up because a lot of this investment has been made, you can --

BYRD:  No.  And this something that we struggle with.  People see that this is a successful program and they want to invest in it.  So they say, well, let's train more midwives, let's open more schools.  But we are always pushing back, saying that we have to ensure the quality of the education.  OK?  These are competency-based programs.  They're not just sitting in a classroom getting information.  They actually go to health facilities, which are the clinical training sites, and they practice on real patients.

So you have to ensure that the clinical training site has enough women coming there to delivery babies that these midwives can practice on, and get enough practice to graduate with a competency.  And that's the thing we're always pushing back on because, yes, it's a great program, it's successful and people want to invest in it.  But we want to maintain the quality of the programs.  So we want to ensure that we -- we've got one in every province now.  34 programs throughout the country.  So I think that's appropriate.

COLEMAN:  Calyn?

QUESTIONER:  Hi, Calyn Ostrowski with the Woodrow Wilson Center.  Thank you for your presentation today. You had mentioned, and touched on this briefly, but I was wondering if you could go back to -- you emphasized the importance of gender equality and male involvement.  And you briefly touched on religious leaders, and I'm wondering if you could talk more about their role in this, and how you used -- worked with religious leaders to overcome some of the cultural barriers.

BYRD:  Sure.  We -- because of our work with the community just necessarily religious leaders are involved.  We don't always specifically target religious leaders but we do target community leaders, and so, as I said, religious leaders often are included in that group.

And we do talk to them about, particularly about -- well, one of the things we talk about is the health system, you know, what services are available.  Just raising awareness about the fact that there is free care, there is a basic health center, or CHC, or a district hospital in your community that you can refer people to because in Afghanistan a lot of people will go to a religious leader for health care.

And so if he knows where to send them and what services are available, he will often do that instead; which is a good thing.  So, like I said, we don't specifically target them, but we do try to raise their awareness about the health system in general and the benefits of some of these interventions, like birth spacing, for not just the woman but the baby and the family and the community.  Does that answer your question?

QUESTIONER:  Yeah.

BYRD:  OK.

QUESTIONER:  This is Anne Wilson from Christian Connections for International Health.  I think (access ?) also did some sermon guides for religious leaders on some of these topics, so I think you all are actually using those in Afghanistan and some places.

BYRD:  Yes.  More recently we've had to be very carefully about working with religious leaders.  But yes, there are some materials that have been developed globally which are also used in Afghanistan.

QUESTIONER:  So my name is Mona Bormet, also with Christian Connections for International Health.  I'm very intrigued by your presentation, thank you.

BYRD:  Thank you.

QUESTIONER:  We've noticed -- we do a lot of advocacy and policy work here in the U.S., talking to people around family planning and what that means.  And I was talking to some people earlier that the misconception often is, is that people sometimes think family planning is abortion.  And it's not, and we all know that, probably, in this room; I hope so.  And so a lot of the work we do is trying to inform people what family planning really isn't and that faith-based organizations support family planning.

So I know you had talked about in your presentation educational messages, and I'm wondering, you know, do you use the term "family planning"?  You mentioned healthy spacing and -- so I'm just -- I'm quite curious.  And the reason I also bring that up because CCIH is working with Muhammadiyah, which is based in Indonesia, and then a German foundation to try to do like an international advocacy campaign around family planning and why it's important from a faith-based perspective, not just Christian.  But there are faith communities that support family planning.  So I'm just curious what kind of messages or campaigns you all have done.

BYRD:  Yeah, that's a good question, and it certainly is something that is often perceived negatively because of misperceptions.  And so part of our job is to address those misconceptions, and we often use the term "birth spacing" as opposed to "family planning" because of those misconceptions around that term.  And as I said, "birth spacing" -- and particularly to -- you know, the birth spacing messages that we promote are very consistent with Islam and the culture of Afghanistan.  So we've had pretty good success in that area.

Ratha had her hand up for one.

COLEMAN:  Oh, I'm sorry; who did?

BYRD:  Ratha's hand.

COLEMAN:  Oh, I'm sorry.  OK.  And then to --

QUESTIONER:  Ratha Loganathan from USAID.  Thank you very much for a very informative presentation.

Just wanted to follow up on the -- on the intervention area, particularly with respect to creating demand.  I want to know Jhpiego's impression and MOPH's impression with respect to mobile technology.  Mobile technology's becoming a fast-growing arena, and it's a very quick and effective way to disseminate information, particularly with respect to dispelling myths, increasing people's awareness about resources and health facilities within their local communities.  So what is your impression on utilizing mobile technology and mobile resources to address increasing demand?

COLEMAN:  In my blog, Democracy in Development, I wrote a piece recently on the MAMA Initiative, which is -- I don't know if -- are you familiar with that?

BYRD:  I've heard of it.

COLEMAN:  Yeah, which is using the mobile technology just to give pregnant women basic information by mobile texting, in effect.  And so I throw that on.  Has that been used in Afghanistan at all?

BYRD:  That particular approach has not been used, but Jhpiego is very interested in mobile technologies and is exploring innovative ways to bring care and messages closer to the people.  In Afghanistan, we actually are using SMS, not necessarily to push people to care, but to -- we're using it more as a post-training follow-up.

So people that we train -- for example let's say we train someone in family planning, or let's say we train someone in infection prevention or any of the topics, we may then send, within three months, a follow-up text message to them reminding them, you know, "Wash your hands between patients" or "Did you implement the activities in the action plan you developed at the end of the training?"  And, you know, so it's more of a way of just kind of keeping in touch.  But we are exploring ways in which we can be more effective at using mobile technologies and more effective in pushing people to care, like getting them to a facility, as well as in collecting information from them, which we can then use for programming.  But so far we've only done the SMS thing.

COLEMAN:  How has the SMS thing gone with the -- those that you're using -- the workers -- the community health workers that you're staying in touch with?  Are they -- do they like it?  Is it helpful?  Do you have any insight on that?

BYRD:  The feedback we received -- and we did a little survey -- the feedback we received was that the reminders helped; you know, that they did in fact remember, oh, yes, I do need to do my action plan and implement my action plan, or oh, yes, OK, I need to wash my hands now.  Whatever the reminder was, they said that they appreciated receiving them and that they helped -- kind of anecdotal, but --

QUESTIONER:  Yes.  Hi.  I'm Ibrahim Parvanta, and I'm with CTS Global as a contractor assigned to the Centers for Disease Control and Prevention.  I was working on a reproductive health project in Kabul City.  I guess, aside from being the only male in the group -- (laughter) -- perhaps I'm the only Afghan in the group too.

Just a -- you know, just a few comments from kind of an Afghan perspective if you will.  One is that, you know, I think when we say Afghanistan, we have to separate rural Afghanistan from urban Afghanistan.  These are two different worlds in many respects, so let's keep that in mind.  Number two, the BPHS, the Basic Package of Health Services program -- that's been -- obviously -- seems like very effective, based on the evaluations that have been done -- that doesn't exist in Kabul City.  Kabul City does not have a basic package of health service program.  They're trying to implement that, but it's not there.  And I'm not exactly sure how well it's -- how it is in the other urban centers, like Mazar in the north or Herat in the west, and so on.

BYRD:  There are some EPHS programs.

QUESTIONER:  EPHS, but not BPHS.

BYRD:  EPHS is Essential Package of Hospital Services.

QUESTIONER:  Hospital Services, right.

The -- you know, and then the thing about the 80 to 85 percent coverage, that's the -- again, that's a -- it was misrepresented by a former minister.  It's really -- the potential is there to reach that many people; the actually -- the actual coverage is perhaps maybe 50 percent, but that's still a lot more than it used to be.  It's still a lot better.

BYRD:  Yeah, and like we said earlier, if you think six hours walking is accessible.  (Laughter.)

QUESTIONER:  That's right.

The -- one question I -- there's a couple of points I wanted to mention that -- you know, it's really nice to hear what, you know, what you described your program, and I'm listening to that video.  Obviously that woman was very much affected, and it affected me.

But one thing -- I think we have to put these all into perspective; there's a lot has happened in the 30-plus years of war, and that affects -- that you have to put that into the context of the psyche of the population, if you will, that's been affected, and it's everywhere.

One of the biggest problems that I've noticed -- you know, I did all my training in the United States, so -- you know, I left there as a young 20-something and now I'm in post-midcareer, you know.  In going back now I can see, you know, how different it was the way the medical community or the health care provider and the whole system of the top-down:  You tell people what to do and that whole process while in this kind of family -- whether as you call it, family planning or birth spacing or midwifery -- this whole idea of counseling and education versus telling people what to do.  I think it's -- the way the -- you know, it looks like your organization has done it and some of the others, they've brought into kind of this idea of helping -- educate people rather than telling people what to do.  That's -- it's been a -- in my experience it's always been that if one were to speak with Afghans, speak with them rather than tell them, they will actually listen.

And the interesting thing for me was that a few months ago -- I work in a community intervention project that's being implemented in Kabul by CARE International.  And they have a similar thing to the one you said the family health action groups.  They -- CARE has what they call community health "shuras," you know, or gatherings. and the same idea of people get together.

And the interesting thing was that they've established a couple of men's health "shuras" in this few districts of Kabul, and I attended one.  And it was the first one I had attended, and I was kind of nervous when I found out that the actual topic of discussion was family planning and contraception.  So I thought, oh my God, I'm going to go in there; are they going to cut off our heads?  (Laughter.)  What are they going to do, you know?  And they were all men, of course.

The interesting thing and the shocking, wonderfully pleasant surprise for me was these men were saying:  Why haven't they been telling us about this before?  And that we -- this needs to just go -- not be just within this 15 or 20 of them that were there; they said, it's not enough just among us 20; we have to get this out into the entire community.  So it's again that whole idea of the way it's presented makes a big difference.

COLEMAN:  And when they said, why haven't they been telling us this before, was this just basic information about family planning?

QUESTIONER:  Yes, and the fact that family planning is possible, that there are methods to do it --

COLEMAN:  "Possible" meaning possible culturally?  Religiously?  Technically?

QUESTIONER:  No, culturally and technically -- that was not their -- (inaudible) -- even an issue.

COLEMAN:  No, maybe -- it was a technical -- it was technically?

QUESTIONER:  (Inaudible) -- it is feasible.  It can -- you can do it

COLEMAN:  So they weren't even aware that --

QUESTIONER:  That's right.  That's right.  They were not even aware that this is possible.

COLEMAN:  OK.  Not even aware.

QUESTIONER:  You know, and there are simple methods.  Well, in Kabul City, they think, you know, more along the lines of, let's say, birth control pills or other types of medical interventions, but nevertheless the fact that those are available, I mean, the people were just saying how come nobody's told us this before?  And they were very willing.  And this was among the men.

Of course among the women -- who I work with, just like I'm in here -- I mean, in the community that I -- the programs I work in, I'm in the communities all with women.  And it's amazing how much they want to do these things.

And to me, you're right.  Afghan women are incredibly strong.  And I have said to them I think, for the next five years, it would be great if after women could rule Afghanistan.  It would fix the problem.  (Laughter.)

But my -- I have one question, and that is, you know, you said your program is going to continue perhaps another 11 months beyond November. What's the plan beyond?  And is there any kind of a -- how's this going to be -- what's the sustainability of your effort?

BYRD:  That's a very good question.  (Chuckles.)  Let me just clarify the extension period.  As part of a commitment that the U.S. government made to the Afghan government during the Kabul health conference or Kabul conference, recently the U.S. government -- and those of you with the U.S. government can chime in, but the U.S. government committed to putting 50 percent or more of its development assistance through the government, through the Afghan government.

Right now the BPHS contracts, meaning the contracts that are awarded to the NGOs to deliver health services and run health facilities, are coming from USAID, the EC and the World Bank directly to the -- well, the Ministry of Finance and then the Ministry of Public Health.  And then the Ministry of Public Health is now awarding grants or contracts to the NGOs to deliver the services.  That's been highlighted as a big -- as a big success story, that the ministry is successfully able to administer and manage these contracts.  So now they're trying to put more things through that mechanism.  It's called host country contracting.

So HSSP, along with the USAID-funded social marketing project COMPRI-A, along with the USAID-funded project called Tech Serve, which is focusing on strengthening the capacity of the Ministry of Public Health -- the three of our projects have been asked to transition, as much possible, to the ministry to this mechanism.  So this additional 11-month period is going to be about working more closely with the Ministry of Public Health to ensure that they can assume some of the responsibilities that we currently have to ensure their sustainability.  And we're going to be around to help out, to make sure that they have the capacity to do that.

And beyond that period, I think there will always be a need for some -- what we're calling off-budget -- or money coming directly from USAID to a Jhpiego or some other organization, to continue to provide technical assistance and support.  But increasingly we're going to see perhaps more of the ministries asking for that support and subcontracting out to organizations, as opposed to USAID contracting organizations directly.

COLEMAN:  OK, but it's my job to ask the questions here of -- (chuckles) -- the hard question.  I mean, how confident are you in that transition?  (Soft laughter.)

MS.     :  Perhaps I can answer that question.

COLEMAN:  OK.  We'll take the -- take it off of her.  Thank you.

MS.     :  Yeah.  First of all, I do want to highlight that the host country contracting mechanism that the Ministry of Health has embraced is one of the biggest successes in Afghanistan, and we are looking at other sectors to try to replicate this.  And you know, one thing that is very important to highlight:  This did not happen overnight.  It was started in 2002, and it was eight years of dedicated effort by USAID, EC and the World Bank.  And our implementing partners have played a significant role in building the capacity of the ministry.

Second point I do want to make is our primary focus is to ensure that the Ministry of Health has the capacity, the management, the leadership, the technical capacity to embrace their program and be able to run it.  So the goal of 50 percent on budget is on track, and that is something that we are going to continue to push forward.

The other question that we are looking at is the effectiveness and the feasibility of it.  As you know, 75 percent of expenditure -- public health expenditure is covered by donor money.  So we are looking at -- I mean, how do we make this sustainable when -- what do we need to do to ensure GIRoA Ministry of Public Health has resources of a revenue generation mechanism that can bring in -- that they can bring in to start funding their programs.  So these are very tough questions that we are asking.

But they do have the systems, and they are gearing to at least the technical capacity to receive money.  And we are entering a phase where we have to start asking very tough questions on what do we need to do to work with the ministry to start generating revenues.

BYRD:  And I think that's an important point, is, it did take a very long time to get to the point that we're at now.  And it's not likely and realistic that we will be able to successfully transfer everything we're doing in one year.  And the government recognizes that, and USAID recognizes that.  But we can begin to make that transition and begin to identify the steps that are necessary to ensure that that process can continue successfully.

COLEMAN:  Down here.

QUESTIONER:  Please, could you just say a couple words about how that's working with regard to both contraceptive procurement, supplies, and also Misoprostol?  Have you had any problems with stockouts or gaps in services?

BYRD:  With contraceptive supply, that -- for the USAID-funded provinces, Tech Serve, the other USAID-funded project, is actually responsible for procuring all of the medical supplies, drugs -- not supplies, drugs -- that are required for the BPHS and the EPHS.  That way they can take advantage of economies of scale, and they can ensure that the -- the quality of the product.

EC and World Bank have given lump-sum contracts to NGOs, and so the NGOs are responsible for procuring their own medicines and supplies themselves.  And as you can imagine, there have been some concerns about the quality of the medicines.

Because of the way in which in the USAID provinces obtain their medicines through this like one lump-sum procurement, occasionally there are stockouts, but mainly because the NGOs are not forecasting appropriately or because drugs are being prescribed irrationally.  And so part of our job is to work with the NGOs to make sure that, you know, if somebody comes in with a cough, they're not giving them an antibiotic.  (Chuckles.)

If you imagine you've walked six hours to reach a health facility, you --

COLEMAN:  You want to leave with something.  (Soft laughter.)

BYRD:  -- you want a bag of drugs when you leave, right?  (Chuckles.)  You don't want to leave empty-handed.  And so there's a lot of pressure from the -- from the community to -- you know, give me drugs; I've come -- and they're free.

So we're working with them to address that issue, so that we have fewer stockouts and more rational use of drugs.

And then with respect to Misoprostol, because this is still -- it's not a national program yet, it's something that we are expanding gradually -- because up until very recently the WHO had endorsed it, said that it should be on the essential drug list -- now that it's on the essential drug list, it's going to be easier and it'll be part of the regular procurement --

COLEMAN:  What's the time frame on that?

BYRD:  Oh --

COLEMAN:  On -- now that it -- of getting it into the system?

BYRD:  I'm not sure.  I'll have to find out.

COLEMAN:  I mean, it was two weeks ago that they put it on the essential drug list.

BYRD:  Right.  But I mean, we have it for our program --

COLEMAN:  Yeah.

BYRD:  -- because we received a donation from an organization or a company that gave it to us.  But in terms of having it scale up --

COLEMAN:  Yes.

BYRD:  -- I think they're waiting for our program and some additional evidence --

COLEMAN:  OK.

BYRD:  -- to prove that the community-based distribution works, not -- we know the drug works, but the community-based distribution.

COLEMAN:  Nandini, you had a --

QUESTIONER:  I'm very mindful of the title of your presentation, even though you didn't present it in such -- but the -- saving women's lives -- I'm wondering -- I have no doubt that the work that you're doing is making a difference, but in terms being able to capture success as outcomes, what are you actually doing to -- or what are your measures of success beyond -- to capture saving lives?  I mean, that's sort of a phrase.  What are your actual measures?

BYRD:  Great question.  And we are fortunate enough to have Linda Bartlett here with us.  (Laughs.)

The maternal mortality ratio was determined by a study that Linda was the principal investigator on back in 2002?

LINDA BARTLETT, M.D. (Afghan Maternal Mortality Study Team):  Two.

BYRD:  Two.  And she -- we are fortunate because she's the PI on the repeat, RAMOS 2, going to the same districts, with the exception of one, but that'll be captured later, to do the same -- employ the same methodology to see the change.

And Linda, do you want to say a little bit about that?

DR. BARTLETT:  Sure.  Are these on or --

BYRD:  Yeah.

DR. BARTLETT:  OK.  Yeah.  So we -- I don't know if you if you're aware of the maternal mortality study we did in 2002, where we -- we only went to four districts and four provinces, but they were selected by the Ministry of Health to represent an urban to rural remote distribution across the state of that -- and found the highest maternal mortality ever recorded in Badakhshan and very high maternal mortality generally, between 1,600 and 2,200 as the national estimate, and 6,500 in Badakhshan.

So the ministry and USAID asked us to repeat the study, and we've started in Kabul in January.  We're -- almost finished Kabul and partway thorough Laghman, which is a rural setting, and then going into the rural remote one next.  So we'll have data around the end of this year, beginning of next year.

And so not only are we trying to determine if MMR has declined but if so, we have a quite rigorous policy and program evaluation component to try to determine attribution of which programs and policies contributed to the decline of maternal mortality, to guide the program in Afghanistan further and also other very low resource settings.

QUESTIONER:  Can I ask a follow-up question to that?  Are you actually also looking at -- beyond health determinants, are you looking at nonhealth determinants, given that -- a lot of the constraints that lead to higher mortality?

DR. BARTLETT:  We are.

QUESTIONER:  Yeah.  OK.

DR. BARTLETT:  Yeah.  So security, roads, communication methods --

QUESTIONER:  Right.

DR. BARTLETT:  -- like cellphone, things like that -- we are.

QUESTIONER:  (Inaudible.)

DR. BARTLETT:  Yeah.

COLEMAN:  We're just about out of time.  Did anybody else -- did somebody in the back there have a question?  No.

This has been really fascinating.  Normally at one of these meetings I don't often learn as much as I did during this meeting -- (chuckling) -- so I'm really glad that we had a chance to really hear from your, you know, very real experiences of what's working and what's not.  And thank you.  Keep up the great work, and we'll be following it closely.

BYRD:  Thank you.

COLEMAN:  So thank you all for coming today.  Thank you for this.  (Applause.)

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