Culture Shock

On Tuesday, I re-entered my air conditioned, tap-tap free, faster paced life. I was prepared for culture shock because I experienced it after returning from Romania. However, this time, it’s different. Almost nothing has overwhelmed me and I can accept all the excess of everyday American life. I wasn’t even fazed by all my options grocery shopping today. What I’m struggling with is talking about Haiti. I assume people want a nice condensed tale - a story about helping a patient or some funny incident, basically a summary of a blog post. But I can’t find a nice tidy story. So, for now, I’ve kept pretty quiet. I can’t find a way to explain the good and the bad and do it in less than an hour. There is beauty in Haiti and there is sorrow – I don’t want to talk about just one.

I say almost nothing has overwhelmed me, because one sight in the Fort Lauderdale airport definitely overwhelmed me and my travel buddies. There are now these Best Buy vending machines in airports. I can definitely see the benefit if you forgot your phone charger or your ear phones. But also inside the machine are iPads and iPhones. Who is walking through the airport and decides on a whim they need to buy an iPad??? That one purchase, let alone the airfare that got you in front of the Best Buy vending machine, costs more than most families, in Haiti, live on for a year!     

Mike, Pat, Rigan and I trying to take in the vending machine

While I was bracing myself for culture shock, I was much more concerned with the shock that would hit our little traveler, Edwina. Edwina has lived her whole life in rural Haiti and she was traveling with us to have surgery in Wisconsin. In the Port-au-Prince airport, her eyes about popped out of her head when I showed her the hand dryer. But, by the time we landed in Fort Lauderdale, she was looking right at home eating her first ever piece of pizza, sipping on a soda and playing on the iPad. In Dallas, she paid for dinner by herself. The cashier even gave her a 10% discount for being a first-time shopper in the US. Tomorrow I start my M3 year. After being away from medical school for a year, I expect to be overwhelmed. I’m going to try and channel Edwina and make the transition with as much grace as her.   

Edwina already looking like an American

Her first solo purchase

The best of Haiti

This being my last day in Haiti, I would like to reflect on the qualities of the Haitian people in general, that I will miss most. I wanted to spend this day visiting Do Digue and different people to say good-bye; however, last night’s dinner changed those plans. A month in Haiti is clearly my body’s limit. So, instead I spent my day, in my head, thinking about Haiti.

There are three qualities I admire most.

First is their openness. You wouldn’t expect this based on their history. It seems they should be cautious and suspicious of outsiders. Instead, everyone welcomed me with open arms. Everyone agreed to participate in my survey. And beyond that, they welcomed me inside their homes, made me comfortable, found me a chair and often offered me a coconut. People thanked me for spending time in Haiti, told me they would pray for me and asked me when I was coming back before knowing my name. My translator, John, frequently reminds me that we are family. He isn’t saying this as a nice line, he truly means it. This openness extends to comments too. If you are fat, people call you fat. (Though this is a compliment in Haiti.) If you are crazy, people call you crazy. Since I’m white, people call me white. These comments would really spice up my typical polite conversation with my neighbors.

The second quality is resilience. As we left the airport, on my first day in Haiti, the first thing we saw was all the street vendors. About 70% of Haitians work in some sort of private industry – making money driving the tap-tap or moto they own, selling food, selling various goods, etc. Our driver explained, within a day after the earthquake in 2010, all these vendors were back at their spots selling. The world around them may have seemed like it was ending; but, that didn’t mean their work was. Another example of resilience arrived at clinic last week. A woman who was 38 weeks pregnant walked 3 hours, through mountainous terrain, in 100+ degree weather, just so American doctors could check her baby. She wasn’t complaining that the journey had dehydrated her to the point of needing IV fluids, she was just thankful that her baby was healthy and she had a birth kit and medicine. Really puts sitting in an air-conditioned waiting room in perspective.

The final quality is love of neighbors. People live their lives in the open here. Many houses have shared outdoor spaces were the women can cook and do laundry together. Children wander throughout the village going from mother to mother and getting love from each. This love for the people around you extends to strangers as well. The other day, Mike and Alliance came upon a terrible moto accident. The injured person probably wasn’t going to survive, but, the people around him were going to do all they could to prevent that. There is no ambulance system, so someone offered their car, with no worries about the mess or inconvenience. They treat everyone they meet as family. I will miss this most.      

And of course I will miss the mountains

Contradiction

 One of the strangest things in Haiti is dealing with money. Their currency is officially called gourde and has a conversion rate of about 40 gourde to 1 US dollar. However people also talk in, and prices are often listed in, Haitian dollars. A Haitian dollar doesn’t actually exist, it is just 5 gourdes. Calling 5 gourdes a Haitian dollar started a long time ago when the US and Haitian dollar were equivalent. Unfortunately it’s stuck around since then, though now there are 8.65 Haitian dollars in 1 US dollar. This system, combined with speaking Creole, leaves me standing for long periods of time trying to figure out how much I owe.

Weirder than the conversion system, is people’s perception of fake money. Many people like to be paid in US dollars because it is often equated to having a better job and making more money. People usually have to go exchange the money to actually use it; but, the pride from being paid in US dollars makes this inconvenience worth it. Because of this pride and the significance placed on the US dollar, people expect the bills to be flawless. I learned this the first day I was in the country. I paid my driver from Port-au-Prince to Arcahaie in US dollars and he returned thirty minutes later to exchange one of the 20s because a small piece was missing from the corner. Similarly, no one will take this 5 with a little marker on it.

The contradiction is if your gourdes look too nice, people assume they’re fake. Most people don’t carry wallets and instead just shove their money in their pocket. Most gourde is covered in dirt and oil and makes you want to bath in hand sanitizer. The 25 gourde bill below is a little too perfect still. It needs to ride in my backpack for a little while longer to become acceptable currency.

The Circus has come to Town

On Saturday, the quarterly medical team arrived. We met them at the airport in Port-au-Prince and I have to admit, it was a little exhausting talking in English all day. For the rest of Saturday and Sunday, the team got all the supplies organized and coordinated tasks for a busy week of clinic. This morning, the team loaded into three tap-taps, all filled to the brim with medicine and supplies and headed to Do Digue. To people on the street, the caravan had to look as crazy as the circus.

There are many amazing things about the clinics run by CHI. First, a new one on this trip, is that we partnered with one of our communities for the location. The community members moved church benches into an open space and covered it with tarps for a waiting area. The community meeting space was triage and vitals. People allowed their homes to be turned into exam and procedure rooms. Another house was a pharmacy and another a dentist’s office. Community members set up stands to sell food and water to people who travelled long distances. The most popular guy was the man with freeze pops.

The second great thing is that the clinics promote continuous primary care. Many of the main problems are similar to what the majority of primary care clinicians see at home: high blood pressure, type II diabetes and acid reflux. Patients need education about life style modification and long term medication. The pharmacy distributes enough medication for patients for three months. The patients can then return to clinic in three months, be checked again, have medication modified as needed and get their refills.

Of course there are problems, which are less common or virtually nonexistent, to primary care physicians back home - tons of STIs, some malnourished children, worms, hernias that haven’t been fixed and malaria. We treat everyone that comes through for worms, can test and treat gonorrhea, chlamydia and malaria and we can refer malnourished children to an inpatient center in Haiti.

The third great thing about CHI’s clinic is also new. Launched at the January clinic, in rural Haiti with chickens and goats running next to you, we have an electronic medical record. This will allow practioner to truly give continuous primary care. There is a record of the patient’s previous chief complaints and treatments. It also allows CHI to better prepare for clinics by seeing the total number of medication dispersed and to track trends in diseases over time.

Today the team was able to provide primary care to about 250 patients. Tomorrow they will be back up in Do Digue at 8 ready to see 250 more. 

Getting some IT support from back home

Ready to go

Day one medication report

Would you like a glass of water?

Anyone who has been to my house knows the fridge is usually barren. I bashfully ask visitors if they would like a glass of water, because that’s usually all I have to offer. Once I get home, however, I will be proudly asking people if they would like a glass of clean, safe water. People will probably be very confused as to why I’m so pleased to offer water and then they will have to hear about Haiti.  

Visitors, you have been warned…

The only water you can trust here is water you treat yourself. Last night, we got another big jug of water from the water truck. These trucks drive around; playing music, like an ice cream truck and you can get a 5 gallon jug filled for 25 gourde (about $0.75). The water from the truck has been passed through reverse filtration so it is probably safe from parasites, but bacteria and viruses are another question. To ensure the safety of the water, we treated with Gadyen Dlo and let it sit for 30 minutes.

So, I was a little confused when our housekeeper woke me up this morning to tell me we were out of dlo (water). In broken Creole and sign language I showed her the full jug of dlo. Then she showed me the empty cistern. We use the jug water for drinking, cooking and dishes. We use the cistern water for showering, laundry and mopping. Getting confused? This is just the beginning. To fill the cistern we have to turn on the generator because we think we broke our inverter once filling the cistern. It was either that, or due to our neighbors stealing electricity. Pa bon! So we don’t risk it and only fill the cistern with power from the generator. The problem was the generator was on the fritz. We thought it needed more gas, when that failed we changed the oil. All in all, a lot of work in the Haitian heat for some dlo.

Pa bon.

The men changing the oil. 

Blue

I often complain about the inadequacies of the U.S. healthcare system. As a believer in healthcare as a basic human right, which should be bestowed onto all regardless of ability to pay, I often lose patience. However, after Monday I admit that I don’t celebrate the adequacies enough.

We went to Port-au-Prince to bring a patient for a CT scan. If this patient lived in the states he would have had the scan in December and treatment may have been an option. Because he lives in Haiti, where you must figure out how to get to the one scanner in Port-au-Prince and pay the $300 before the scan, he didn’t and it may be too late for treatment. While waiting on labs to make sure we could get contrast with the CT, an ambulance arrived with a patient from St. Marc. One has to wonder about the journey this patient took to even reach St. Marc. There’s no calling 911 here. No one will answer. No one will come. Perhaps they walked, or took a tap-tap. If they were lucky they knew a friend with a private car. However they got there, the promise, the treatment, they thought they could find at St. Marc, they couldn’t. And off to Port-au-Prince they went.

They arrived at this superior, albeit hodgepodge hospital hoping for salvation. What they found were caring hands but a lack of coordination. Unloading the patient from the ambulance took close to 20 minutes. In that time, our labs were complete and we headed to CT. The patient in the ambulance outpaced us to the mobile CT, perhaps the worst location for them. There a code began. There a code wouldn’t end.

The mobile CT was place in the drive about 10 feet from the adjacent building. Several obstacles stood in the narrow lane. Generators to power the life-saving image machine, trees, gurney lifts and other patients waiting impatiently for care.

The family of the patient coding sat removed from the scene. The men looked in shock, the oldest female angry and resigned and the children amazed by the fun wheelchairs provide.

Haitian nurses and doctors multiplied. Blan emerged from several surrounding buildings. Equipment was located in the far reaches of the hospital because there was nothing inside but a mobile CT. Oxygen tanks, face masks, ambu bags, a defibrillator, fluids. Another defibrillator because the first didn’t work. More oxygen tanks, these hopefully filled. An adult mask instead of a child’s mask. Gloves, gloves, more gloves. Back home, all this would be at a patient’s bedside within 1 minute of pushing the blue code button. Here, the supplies were collected over 20 minutes. Here, the supplies were collected for a patient already gone. Nothing was being delayed but calling the time of death. Nothing was saved but fading hope.       

Everyday Adventures in Haiti

I love being in away from home for long enough that you start doing everyday things. No matter how mundane, the activities typically turn into adventures. While living in Romania, doing laundry lead to one of the strangest dinner dates of my life – a tight-fitting male fishnet shirt was involved.   

This week, in Haiti, my everyday adventures were going for a run and getting a pedicure. The run reminded me in many ways of the advertisements for Tough Mudders, without the registration fee or the excessive drinking. My house, here in Arcahaie, is in the middle of a banana plantation and less than a mile from the ocean. This provides for great views but several running challenges. The irrigation canals in the plantation set even, but inconsistently sized hurdles. The barbed wire separating plots was cleverly disguised at a decent pace. And the animal waste was voluminous. I returned with two barbed wire cuts, a health covering of mud on my legs and a great sweat. A memorable run, but I may try a different trail next time. We left our shoes outside so we didn’t track mud everywhere and our amazing housekeeper thought we wanted them cleaned. She magically made them look nicer than when I bought them.

Yesterday, Mike and Alliance needed to get haircuts and I decided to accompany them to market mostly to enjoy the air conditioning at the barber. But, when we got there, we realized they did pedicures and I decided to give my mosquito bite covered feet a treat. The Haitian women that were getting pedicures alongside me made fun my shoes. Keens, though practical for rocky, uneven terrain, are truly troubling on the eye. They also asked me how much a pedicure in the states costs. They were shocked that we pay $20, since the grand total for mine yesterday was $2.50. Besides this conversation, the experience was very similar to a pedicure back home. Due to the language barrier, either silent or the workers talking among themselves, perhaps about you.

Tippy Tap

This title may sound like some sort of drinking game concocted around a keg late one night, so I’m sorry to disappoint if that’s what drew you in. It is actually the name of an ingenious hand washing station for outside a latrine. This morning we built one in Do Digue.

Here’s what you need: 3 branches, some rope, a bar of soap, a gallon jug, some rocks and sand, a piece of rebar to pound out the hole, and of course a machete.

Raul, the owner of the house with this latrine was very effective at making the machete a multi-purpose tool. Mike did a respectable job for a “blan” (white person) and I stayed back and played with the kids.

Raul, the pro. 

Mike's respectable work.

The kids and I got off the bench towards the end to bring the rocks over and to add the soap. Then we all sang a song to remember when to wash our hands.

Lave me w ak savon, ak savon!

Lave me w ak savon, ak savon!

Avan w manje e apre nan twalet

Lave me w ak savon, ak savon!

Wash your hands with soap, with soap!

Wash your hands with soap, with soap!

Before you eat and after the toilet

Wash your hands with soap, with soap!

The finished product!

This is all part of the latrine project I talked about in my previous post. This Sunday we are having a community meeting to start collecting the families’ contributions to the latrines and to plan a building schedule. Once again I’ll ask, if you can, consider contributing to the cause.

To make a donation: http://www.indiegogo.com/projects/chi-composting-latrines-in-haiti?c=home

  

Everyone Poops

I would guess most have encountered the book “Everyone Poops” at some point in childhood or parenting. The book is helpful to some of us who are a little shy about this act. There’s nothing to worry about, Everyone Poops! The book explains that babies poop in diapers and everyone else goes in toilets. There is never a question of no toilets. Even the most stubborn toddler knows, if they need to go the bathroom and are willing to use a toilet, one is available.

Here in Haiti, that’s not the case. 

Do Digue is a rural village, with a population of about 600. It is also one of the villages Community Health Initiative (CHI) partners with. They have just one working latrine for the entire population and that was built last year. The only alternative is going on the ground. Besides the huge privacy and dignity issues, there is the large problem of sanitation. Open defecation puts the entire community at risk for diseases like cholera and rotavirus.   

The primary occupation in Do Digue is farming. Decades of embargos on trade lead a large portion of the population to turn to subsistence living, relying heavily on trees for charcoal production. This unchecked practice resulted in vast deforestation and erosion of essential top soil. Thus, today, crop yields are meager.

The people of Do Digue are sick of their children getting sick. They are sick of their children not having enough to eat. And CHI is sick of it with them. So now there’s a plan. Do Digue is planning to build thirty composting latrines, this year, with CHI’s support. The latrines have a large enough pit to collect a family’s business for one year. After a year, the latrine is moved to a new pit and the first is covered for one year. The year allows the waste to turn into compost the families can use as fertilizer. The goal, reduce diarrhea induced death and improve privacy, dignity, sanitation and crop yields with one project.

So here is where you can help out! Each latrine costs $250. So for 30 we need to raise $7500. Each family receiving a latrine is contributing $25. This is a huge investment for families that live off about $1 a day. This is how committed they are to change. The families will also contribute time and labor to the construction of their latrine. Another huge investment under the Haitian sun. If you can, please consider making a donation. If you can’t, please consider sharing this cause with some friends. Remember, your friends poop too.

To make a donation: http://www.indiegogo.com/projects/chi-composting-latrines-in-haiti?c=home

The one working latrine in Do Digue

The tippy tap, a handwashing station, outside the latrine

A small family farm in Do Digue 

My First Week, in Two Minutes

My first week in Haiti has flown by and I’m guessing the subsequent weeks will continue to pick up speed. The learning curve for the first week was large. It included, figuring out how to use a generator, solar panels and an inverter for electricity, learning how to fill a cistern to shower, becoming accustom to tap-taps and motos, adapting to being a walking spectacle by being “blan” (white) and determining the right cocktail of sunscreen and bug spray. The last one is still eluding me and thus the Benadryl stick has become my best friend. This list was just the learning curve for basic living. The learning curve for my project was equally as steep. 

A group like this usually joins me on journey, entertained by the blan.

An easier adjustment

No matter the amount of reading and preparation you do for a project, nothing compares to work on the ground. This week gave me the chance to meet with the supervisor of the water program here, the water program’s quality control workers, the newest CHI employee Alliance (who used to work directly for Gadyen Dlo, the water program we subcontract with) and my translator John. We were able to have several productive conversations and this information, combined with the results of the program evaluation survey I’m conducting will help direct the future of the program.

On Friday, I was finally ready to begin the survey process. I got 10 done in the day, which I thought was pretty good when account for the heat and the walking. This next week will be dominated by surveys. I enjoy this process because I get welcomed into people’s homes and thus far they have felt comfortable sharing numerous concerns with me. The other highlight to the survey process is that I get to spend the day with my hilarious and angelic translator John. He loves to say that the first time he looked in the mirror, he screamed at how ugly he was and told his mom she must have a dirty belly to make him. He will say anything self-deprecating, as long as it gets a laugh. Good company to have when you are hiking in 95° weather. I say his is angelic because he has adopted three children though he has very little monetary wealth. His dream is to open an orphanage and if his love for the kids of Haiti could build it, it would be open tomorrow. This past March, a crew of journalists came with the CHI quarterly clinic. One of the articles they wrote was on John, it can be found here: http://pulitzercenter.org/reporting/haiti-arcahaie-iowa-medical-birth-lifesaving-malnourished-medika-mamba.

Dana (another MPH student) and John, my translator, on our longest hike yet. We started on a road right by the ocean.

A brief history of Haiti

As I noticed in Romania, American high school history classes are great at avoiding topics in history that paint the U.S. in bad light. Yes, we talked about some of our unbecoming past; but, generally just things that were too big to avoid. Haiti’s history with the U.S., and France, and most of the developed world is not pleasant, and in the scope of their history too big to avoid; yet, I know it wasn’t part of my curriculum. To be able to practice public health or healthcare in a country it is of vital importance to understand the culture and history. So I thought I’d share with all of you the highlights.

In 1492, Columbus landed on the island of Hispaniola (present day Haiti and Dominican Republic). Within a few centuries of his arrival, the entire native Taino population died, mainly due to new pathogens. This was the first impact of globalization in Haiti. The demise of the native people, made colonization of Haiti a simple task, and in 1697 the French began ruling. The French turned Haiti into a slave colony for sugar production, mahogany exportation and as a source for American slaves. By the late 1700s, the slave population made up more than 85% of the island and an independence revolution began. In 1804, Haiti became the first independent black nation and the only slave colony to win its independence. This independence came at a high price however. The revolutionary war destroyed the colonial infrastructure. Additionally, most European nations, in addition to the United States, put trade embargos on Haiti destroying their ability to become economically independent. To make things even worse, the French being incredibly sore losers, made the Haitian government pay retributions for winning the war. The amount imposed, if done today, would be $21 billion. This debt payment took 80% of Haiti’s annual budget until the 1950s, leaving little money for development.

The twentieth century is when the United States really began influencing Haiti’s history. From 1915-1934, the U.S. Marines occupied Haiti as an attempt to secure U.S. sugar interests. Then the U.S. implemented an ineffective development plan, which was been attempted in many other countries with similar consequences. President Clinton, during a hearing of the Senate Foreign Relations committee, in 2011, explained it well,

“Since 1981, the United States has followed a policy, until the last year or so when we started rethinking it, that we rich countries that produce a lot of food should sell it to poor countries and relieve them of the burden of producing their own food, so, thank goodness, they can leap directly into the industrial era. It has not worked. It may have been good for some of my farmers in Arkansas, but it has not worked. It was a mistake. It was a mistake that I was party to. I am not pointing the finger at anybody. I did that. I have to live every day with the consequences of the lost capacity to produce a rice crop in Haiti.”

Finally, we get to the recent history that most people are familiar with: the devastating natural disasters of the last 5 years. Starting with four hurricanes devastating the island during a short period in 2008, culminating with the 7.0 magnitude earthquake on January 12, 2010 and most recently flooding due to Hurricane Sandy. These disasters have destroyed a lot of the infrastructure that did exist and have caused 2 million Haitians to be displaced.

The history of Haiti is fascinating. I don’t pretend to do it any justice here. It is intertwined in complex ways with many countries, is rooted in African tradition, filled with people who have family in the States or France, similar in climate to the rest of the Caribbean; but, entirely unique.     

Right next door....yet, a world away.

Yesterday morning, I boarded a short 1 hour and 15 minute flight from Miami to Port-au-Prince, Haiti. This is not much longer than the flight from Cedar Rapids to Chicago, but the change in the reality of the world, in these two remarkably close locations, is unbelievable.

Today, in Miami, the city that spends the most on healthcare per capita in the country, 3 out of 5 people will die in ICUs at the cost of about $10,000 a day. This morning, at breakfast, we were discussing the need for advance directives with a few of our Haitian co-workers. The idea of needing to direct when to end care and allow death to take its course is foreign, in a land, where 1 in 9 children die before the age of 5, most commonly due to a diarrheal disease.

Leaving healthcare behind, let’s move to the differences in life, I take for granted at home. Turning on the tap and getting safe water and always having a toilet to use that is connected to a safe sanitation system. If we let the sequestration affect clean water and sanitation for one day, I’m certain Congress could find a speedy solution to the federal budget. Here in Haiti, unfortunately there is no speedy solution to the water and sanitation problems. Prior to the earthquake in 2010, only 55% of Haitians had access to an improved drinking water source. Additionally, 49% had little to no access to any type of sanitation system. The combination of lacking sanitation and water infrastructure means ample water-borne diseases including rotavirus, E.coli, salmonella, shigela, campylobacter, and as of October 2010, cholera. To meet my water needs in this environment, about 3 liters per day, yesterday I brought two liters from Miami, bought one sealed safe bottle on the street and bought a gallon from a water truck. The water truck drives around like an ice cream truck, with music and all. They use a reverse filtration system and claim that the water is safe, though tests of truck water are frequently positive for fecal coliforms. So after buying the gallon, we treated it with the Gayden Dlo system to guarantee its safety. This is much more laborious than walking to the facet and complaining about the taste of water in Coralville. For people living on as little as $1 a day this isn’t just an inconvenience, it is a large expense.   

I can tell you two giant advantages to Haitian life, thus far, the gorgeous view off our balcony and fresh coconuts in our yard. I will be trying my hardest not to take these for granted like I do water and sanitation in the U.S.  

I'm back...and off to Haiti!

After about two years of silence, my blog is back! I left Romania with such good writing intentions. Unfortunately reflecting, in writing, on my final classroom year of medical school seemed boring, for lack of a better word. I thought I would spare you all. My classes this year, the course work for my Masters of Public Health, were very interesting and conducive to writing, and thus my professors asked for many papers, leaving little writing energy for blogging. I’m sorry, Grandpa. But, on Sunday, I leave for Haiti to complete my Public Health Practicum and I would love for everyone to come with me.

The Public Health Practicum is the chance for Masters students to take what they’ve learned in the classroom and apply it to a real public health situation. For my practicum, I will be evaluating an in-home water purification system called Gadyen Dlo, in Arcahaie, Haiti. I will be spending a little over a month in Haiti, and my time will be split between travelling to homes to perform water surveys and tests, contacting local schools to set up water educationals and researching other cost effective water purification systems, in use, in Haiti and other developing nations.

Haiti presents numerous public health challenges and numerous NGOs are there trying to address them. Unfortunately, lack of coordination between NGOs often exacerbates the problem. This is something I will be exploring through reading this summer and would love any thoughts people have in the comments below. The NGO I’m partnering with, Community Health Initiative (CHI), works exclusively in one area, Arcahaie. The founders realized that they could either do a little good over a large area of Haiti or could do a lot of good in one concentrated area. They choose the later, the approach I prefer in international aid. CHI has partnered with the community, since 2009, and empowers the community to identify the top priorities. Water quality was identified as a top priority recently, and in October 2012 the Gadyen Dlo program was implemented. 

I have much more to share about Haiti’s history and culture, about Gadyen Dlo and water quality and purification, about public health in theory and in practice, and about adventures in Haiti; but we have the next month for all of that. Right now, I will pause and go pack.