Parallel Health Care Systems Research Articles

Health Status and Access to Healthcare for Uninsured Migrants in Germany: A Qualitative Study on the Involvement of Public Authorities in Nine Cities

Non-governmental organisations (NGOs) regularly report data on their work with uninsured migrants (UM) within a (so-called) parallel health care system. The role and involvement of public authorities therein have yet been underrepresented in research. Our aim was to gain a better understanding of public authorities’ role in the parallel health care system and their view of the health situation of UM. We conducted qualitative semi-structured interviews with 12 experts recruited by purposive sampling from local public health authorities (LPHAs), state-level public health authorities (SPHAs), and social services offices (SSO) in nine cities, recorded, transcribed, and subjected the data to qualitative content analysis. LPHAs are more often directly involved in providing medical services, while SSOs and SPHAs function as gatekeepers for access to social benefits, including health insurance, and in grant-funded projects. NGOs keep substituting for the lack of access to regular health care from public institutions, but even in settings with extended services, public authorities and NGOs have not been able to provide sufficient care through the parallel health care system: Experts report gaps in the provision of health care with respect to the depth and height of coverage, due to the fragmentation of services and (ostensible) resource scarcity. Our study highlights the necessity for universal access to regular health care to overcome the fragmentation of services and improve access to needed health care for UM in Germany.

A Hypertension Parallel Healthcare System Based on the ACP Approach

Hypertension, the most common chronic disease, is an enormous risk factor for cardiovascular and cerebrovascular diseases and vascular events, which has become a significant global public health problem. However, the etiology and pathogenesis of hypertension are incredibly complex. In conventional medicine, the intervention and treatment focus on the blood pressure (BP) indicator. At the same time, the Traditional Chinese Medicine (TCM) theory provides diverse perspectives, more indicators, and optional treatment. In addition, the parallel intelligence theory based on the artificial systems, computational experiments, and parallel execution (ACP) approach is proper research and practical methodology for solving management and control problems for the treatment of hypertension. In this paper, we proposed a parallel healthcare system (PHS) framework to describe patients’ conditions and diagnoses, trace the disease evolution progression, and analyze and optimize available therapeutic regimens. At last, we constructed a PHS for hypertension under TCM theory which applied to the treatment of actual volunteered patients and achieved positive effects.

Letter from Trinidad and Tobago: No final battles in the weary war on COVID‐19?

Letter from Trinidad and Tobago: No final battles in the weary war on <scp>COVID</scp>‐19?

COVID-19 and its effects upon orthopaedic surgery: The Trinidad and Tobago experience.

The World Health Organisation (WHO) declared coronavirus disease 2019 (COVID-19) a pandemic on March 11, 2020. COVID-19 is not the first infectious disease to affect Trinidad and Tobago. The country has faced outbreaks of both Chikungunya and Zika virus in 2014 and 2016 respectively. The viral pandemic is predicted to have a significant impact upon all countries, but the healthcare services in a developing country are especially vulnerable. The Government of Trinidad and Tobago swiftly established a parallel healthcare system to isolate and treat suspected and confirmed cases of COVID-19. Strick ‘lockdown’ orders, office closures, social distancing and face mask usage recommendation were implemented following advice from the WHO. This approach has seen Trinidad and Tobago emerge from the second wave of infections, with the most recent Oxford COVID-19 Government Response Tracker report indicating a favourable risk of openness index for the country. The effects of the pandemic on the orthopaedic services in the public and private healthcare systems show significant differences. Constrained by shortages in personal protective equipment and inadequate testing facilities, the public system moved into emergency mode prioritizing the care of urgent and critical cases. Private healthcare driven more by economic considerations, quickly instituted widespread safety measures to ensure that the clinics remained open and elective surgery was not interrupted. Orthopaedic teaching at The University of the West Indies was quickly migrated to an online platform to facilitate both medical students and residents. The Caribbean Association of Orthopedic Surgeons through its frequent virtual meetings provided a forum for continuing education and social interaction amongst colleagues. The pandemic has disrupted our daily routines leading to unparalleled changes to our lives and livelihoods. Many of these changes will remain long after the pandemic is over, permanently transforming the practice of orthopaedics.

Tiered healthcare in South Africa exposes deficiencies in management and more patients with infectious etiology of primary adrenal insufficiency.

ObjectiveWe wished to determine the prevalence, etiology, presentation, and available management strategies for primary adrenal insufficiency (PAI) in South Africa (SA), hypothesizing a prevalence greater than the described 3.1 per million. There is great inequity in healthcare allocation, as two parallel healthcare systems exist, potentially modifying PAI patients’ clinical profiles, private being better resourced than public healthcare.MethodsAn online survey of physicians’ experience relating to PAI.ResultsThe physicians were managing 811 patients, equal to a prevalence of 14.2 per million. Likely causes of PAI in public/ academic vs private settings included: AIDS-related [304 (44.8%) vs 5 (3.8%); p<0.001], tuberculosis [288 (42.5%) vs 8 (6.0%); p<0.001], autoimmune disease [50 (7.4%) vs 88 (66.2%); p<0.001], malignancy [27 (4.0%) vs 7 (5.3%); p = 0.500], genetic including adrenoleukodystrophy (ALD) [5 (0.7%) vs 16 (12.0%); p<0.001], respectively. Overall, more patients presented with nausea [101 (74.3%) and vomiting 89 (65.9%), than diarrhoea 76 (58.9%); p = 0.008 and 126 (15.5%) in adrenal crisis. Features suggestive of a crisis were hypoglycaemia [40 (78.4%) vs 42 (48.8%); p = 0.001], shock [36 (67.9%) vs 31(36.9%); p<0.001], and loss of consciousness [25 (52.1%) vs 27 (32.9%); p = 0.031]. Greater unavailability of antibody testing in the public vs. the private sector [32 (66.7%) vs 30 (32.1%); p = 0.001], [serum-ACTH 25 (52.1%) vs 16 (19.5%); p<0.001] and glucocorticoids were [26 (54.2%) vs 33 (40.2%); p = 0.015]. Many patients, 389(66.7%) were not using identification, indicating that they need steroids in an emergency.ConclusionA survey of South African physicians suggests a higher prevalence than previously reported. Patients presented with typical symptoms, and 15.5% presented in adrenal crisis. Significant disparities in the availability of physicians’ expertise, diagnostic resources, and management options were noted in the public versus private settings. Greater awareness among health practitioners to timeously diagnose PAI is required to prevent a life-threatening outcome.

Adult cardiac surgery in Trinidad and Tobago during the COVID-19 pandemic: Lessons from a developing country.

Background and AimThe coronavirus disease 2019 (COVID‐19) pandemic has seen the cancellation of elective cardiac surgeries worldwide. Here we report the experience of a cardiac surgery unit in a developing country in response to the COVID‐19 crisis.MethodsFrom 6th April to 12th June 2020, 58 patients underwent urgent or emergency cardiac surgery. Data was reviewed from a prospectively entered unit‐maintained cardiac surgery database. To ensure safe delivery of care to patients, a series of strict measures were implemented which included: a parallel healthcare system maintaining a COVID‐19 cold site, social isolation of patients for one to 2 weeks before surgery, polymerase chain reaction testing for COVID‐19, 72 hours before surgery, discrete staff assigned only to cardiac surgical cases socially isolated for 2 weeks as necessary.ResultsThe mean age at surgery was 59.7 ± 11 years and 41 (70.7%) were male. Fifty‐two patients were hypertensive (90%), and 32 were diabetic (55.2%). There were three emergency type A aortic dissections. Forty‐seven patients underwent coronary artery bypass graft surgery with all but three performed off‐pump. Fourteen cases required blood product transfusion. One patient had postoperative pneumonia associated with chronic obstructive pulmonary disease. The median length of stay was 5.7 ± 1.8 days. All patients were discharged home after rehabilitation. There were no cases of COVID‐19 infection among healthcare workers during the study period.ConclusionThese strategies allowed us to maintain a service for urgent and emergency procedures and may prove useful for larger countries when there is decrease in COVID‐19 cases and planning for the restart of elective cardiac surgery.

The role of the specialist nurse in parenteral nutrition : An observational study of complications with home parenteral nutrition in adult cancer patients

Background : In France, home parenteral nutrition (HPN) is managed by two parallel healthcare systems : in approved specialist centers (HPN > 12 weeks), and outside of these approved specialist centers (HPN<12 weeks). Objective : To prospectively evaluate infectious and vascular complications in adult cancer patients undergoing HPN administered via a central venous line, outside of approved specialist HPN centers. Methods : Our observational prospective study included adult patients with cancer, hospitalized for 48 hours or more, and under HPN. They had a WHO performance status of ≤ 2 and had had a nutritional consultation before discharge. Results : 25 patients were included in the study, with a median age of 63 years [19–74]. Weight loss of ≥ 5% was reported in 79% of patients. The Ingesta score was < 7 in 96% of cases. 87% of patients presented chill or body temperature variation episodes, with a median of 2 episodes [1–6] per patient. The median delay between end of hospitalization and the first chill episode was 11 days [1–85]. A vascular complication (obstruction without thrombosis) was reported in one patient. Discussion : This high number of infectious episodes requires improvement of patient care when it comes to strictly adhering to the recommendations. Getting the approved specialist HPN centers to work together and share care protocols could be the first important step.

Prevalence, and health- and sociodemographic associations for visits to traditional and complementary medical providers in the seventh survey of the Troms\xf8 study

BackgroundPatient-centered culturally sensitive health care (PC-CSHC) has emerged as a primary approach to health care. This care focuses on the cultural diversity of the patients rather than the views of the health care professionals. PC-CSHC enables the patient to feel comfortable, respected, and trusted in the health care delivery process. As users of traditional and complementary medicine (T&CM) rarely inform their conventional health care providers of such use, the providers need to identify the users of T&CM themselves to avoid negative interaction with conventional medicine and to be able to provide them with PC-CSHC. Since the patterns of traditional medicine (TM) use are different to those of complementary medicine (CM), the aim of this study was to investigate the prevalence, and the health- and sociodemographic associations for visits to TM- and CM providers in an urban population.MethodThe data were collected through two self-administrated questionnaires from the seventh survey of the Tromsø Study, a population-based cohort study conducted in 2015–2016. All inhabitants of Tromsø aged 40 or above were invited (n = 32,591) and n = 21,083 accepted the invitation (response rate 65%). Pearson chi-square tests and one-way ANOVA tests were used to describe differences between the groups whereas binary logistic regressions were used for adjusted values.ResultsThe results revealed that 2.5% of the participants had seen a TM provider, 8.5% had seen a CM provider whereas 1% had visited both a TM and a CM provider during a 12-month period. TM users tended to be older, claim that religion was more important to them, have poorer economy and health, and have lower education compared to CM users. We found that more than 90% of the participants visiting T&CM providers also used conventional medicine.ConclusionA considerable number of the participants in this study employed parallel health care modalities including visits to conventional, traditional, and complementary medicine providers. To offer patient-centered culturally sensitive health care that is tailored to the patients’ treatment philosophy and spiritual needs, conventional health care providers need knowledge about, and respect for their patients’ use of parallel health care systems.

Phone calls and political ping-pong: nodding syndrome and healthcare provision in Uganda

ABSTRACTThis article pays attention to the poorly understood nodding syndrome (NS) and its political connotations, while exploring a case of mortality in northern Uganda. The appearance of a novel set of symptoms combined with heated debates in national media and parliament, resulted in the creation of a parallel healthcare system for children afflicted by NS. This article increases our understanding of the role of the state in healthcare provision and the range of factors influencing the outcomes of, and perceptions of, healthcare programmes. The political constellations that arise from the emergence of NS should be seen within a historical framework of regional politics. The government is perceived as an important actor in the delivery of healthcare, but is also subjected to a lot of distrust that has built up over recent decades in northern Uganda. The response to NS raises questions on the status of Acholi as citizens of Uganda and reveals feelings of detachment from the national healthcare system. By publicly questioning the role of government, the affected families have become participants in the political arena.

Blockchain-Powered Parallel Healthcare Systems Based on the ACP Approach

To improve the accuracy of diagnosis and the effectiveness of treatment, a framework of parallel healthcare systems (PHSs) based on the artificial systems + computational experiments + parallel execution (ACP) approach is proposed in this paper. PHS uses artificial healthcare systems to model and represent patients’ conditions, diagnosis, and treatment process, then applies computational experiments to analyze and evaluate various therapeutic regimens, and implements parallel execution for decision-making support and real-time optimization in both actual and artificial healthcare processes. In addition, we combine the emerging blockchain technology with PHS, via constructing a consortium blockchain linking patients, hospitals, health bureaus, and healthcare communities for comprehensive healthcare data sharing, medical records review, and care auditability. Finally, a prototype named parallel gout diagnosis and treatment system is built and deployed to verify and demonstrate the effectiveness and efficiency of the blockchain-powered PHS framework.

Disease-specific differences in the use of traditional Korean medicine in Korea

BackgroundThough traditional Korean medicine plays an important role in the Korean parallel health care system, there is limited information about the preference and usage of traditional Korean medicine compared to Western medicine because they have different disease classification systems. The aim of this study is to determine the relative preference for traditional Korean medicine using data acquired nationwide.MethodsData from the 2008 Korea Health Panel were analyzed to determine the preference of medical services by disease. The use of traditional Korean medicine use is defined by the type of medical institution they used. Disease types, number of visits and out of pocket expenditures were analyzed.ResultsTraditional Korean medicine was used in only a small number of cases that were emergencies or hospitalization. However, in terms of outpatient services, traditional Korean medicine was used in 7.8% of all cases and represented 9.9% of total medical costs. Among disease groups, traditional Korean medicine use was higher in patients with nervous system and musculoskeletal system diseases. And patients with musculoskeletal and nervous system diseases such as arthrosis were the most likely to use traditional Korean medicine particularly in an outpatient setting.ConclusionsKorean characteristics of service use resemble the complementary and alternative medicine use in other countries in terms of disease group, and the complementary and alternative medicine should be considered to estimate the burden of disease in countries with parallel health care systems, such as Korea. This is the first study determined the actual preference of traditional Korean medicine for specific chronic diseases.

EXISTING AND EVOLVING IN TWO MINDS: BELIEFS IN RELATION TO HEALTH AND ILLNESS EXPRESSED BY OLDER SOUTH AFRICANS

The aim of the study was to illuminate beliefs in relation to health and illness expressed by older Africans within the context of a society in transition – South Africa. An ethnographic research approach influenced by the interpretive phenomenological tradition was selected to gain an understanding of the participants’ experiences. A focused ethnographic design was employed, using group and individual in-depth interviews and participant observations. Sixteen elderly persons (ten females and six males) from Hammanskraal, a rural area north of Pretoria were involved in the research. The findings illuminate a world understanding, where body and mind are inseparable and relationships provide the foundation for improving and maintaining health and being cured from illness. The ongoing transition that the elderly in South Africa experience influences health and illness beliefs, with a need to adapt to existing parallel health care systems, Western biomedicine and African traditional medicine. As the study draws attention to the importance of caring for the elderly to be contextualised, it is recommended that the care of the elderly be applied to the unique needs of the individual involved. Failure to do so may otherwise have severe consequences such as an apparent high risk of developing stereotypes, which can lead to cultural misunderstandings, prejudice and discrimination.

Lime for Chest Congestion, Bitter Orange for Diabetes: Foods as Medicines in the Dominican Community in New York City

Lime for Chest Congestion, Bitter Orange for Diabetes: Foods as Medicines in the Dominican Community in New York City. Several plants serve a dual purpose as foods and medicines in the Dominican immigrant community in New York City. Data show that foods used for self–medication by this community are plants that are well known and readily available in an urban environment, such as lime, bitter orange, garlic, cinnamon, onion and shallot, coconut, watercress, ginger, soursop, and radish. These plants are significant for Dominicans in New York City for treatment of non–communicable diseases, colloquially called “lifestyle diseases” (such as diabetes, obesity, high cholesterol, hypertension, and asthma/chest congestion), self–limiting diseases (including common cold, flu, cough, acute bronchitis), and female reproductive health (such as vaginal infections and infertility). Our findings emphasize the contemporary role of traditional medicine as an alternative and parallel healthcare system that dynamically adapts to current urban epidemiological trends. The double use of foods as medicines has important implications for urban outreach projects, such as Green Carts and community gardens, that play a role in disease prevention of vulnerable populations, especially those living in areas identified as food deserts.

The World of Quacks: A Parallel Health Care System in Rural West Bengal

Health as a matter of right is recognized throughout the world for its intrinsic value. India as a signatory to the Alma Ata Declaration is committed to provide ‘Health for All’ irrespective of any discrimination on the grounds of rich or poor and urban or rural. The National Health Policies are formed on the basis of this principle. But inequality of opportunities, the gross mismatch between the stated objectives and the resources available and the inability of the state to bring quality health care within the rich of all has increased the vulnerability of the people particularly the rural segment and led to the emergence of a new tier of physicians, running a parallel heath care system and playing a formidable role in the rural health care market as rural health providers. This group of self –styled practitioners called quacks, despite in expertise is doing a good business in the villages taking advantage of the lacunae in the public health care system. As testimony to their legitimacy, they manage certificates from unauthorized and unrecognized institutions. Against this backdrop the present write up attempts to highlight the mode of operation of quacks in the villages in West Bengal and also to explore the nature of functioning of institutions that create quacks

Utilization of traditional healers in South Africa and costs to patients: Findings from a national household survey

The use of traditional medicine is widespread in developing countries. We report on the utilization of traditional healers, using data obtained in a 2008 national survey of 4762 households in South Africa. Only 1.2 per cent of survey participants reported utilization of traditional healers. Respondents' reasons for visiting traditional healers included continuity of care and a belief in their effectiveness. Traditional healer utilization rates (0.02 visits per month) were considerably lower compared to utilization rates of public sector clinics (0.18 visits per month) or hospitals (0.09 visits per month). Almost three-quarters of the poorest quintile spent more than 10 per cent of their household expenditure in the previous month on traditional healers. Given the use of two parallel health-care systems, policy-makers should develop strategies to protect poor South Africans from out-of-pocket payments for health care. Simultaneous utilization of these systems evidently absorbs expenditure from low-income households significantly.

South Africa's Health: Traditional healers in South Africa: a parallel health care system

“Traditional healers are a very caring people, and extraordinarily skilled in psychotherapy and counselling. Some of them do a damn good job. Of course there are certain horrible ones who poison their patients at every turn,” said Professor Ralph Kirsch of the Department of Medicine in the University of Cape Town Medical School. Traditional healers existed in South Africa before its colonisation by the Dutch in the 17th century. They have flourished in the face of competition from modern medicine. About 200000 traditional healers practise in South Africa, compared with 25000 doctors of modern medicine; 80% of the black population use the services of traditional healers.1 Traditional healers are enshrined in the minds of the people and respected in their community, and they are often its opinion leaders. The theory underlying traditional medicine in the several black ethnic groups of South Africa is essentially similar.2 Disease is a supernatural phenomenon governed by a hierarchy of vital powers beginning with a most powerful deity followed by lesser spiritual entities, ancestral spirits, living persons, animals, plants, and other objects. These powers can interact, and they can reduce or enhance the power of a person. Disharmony in these vital powers can cause illness. Thus, ancestral spirits can make a person ill. Ingredients obtained from animals, plants, and other objects can restore the decreased power in a sick person and therefore have medicinal properties. Inyangas are herbalists and possess extensive knowledge about curative herbs and medicines of animal origin (table I). Ninety per cent of inyangas are male. View this table: TABLE I Traditional healing agencies in South Africa1 Isangomas are diviners; they determine the cause of illness by using ancestral spirits, and 90% of them are female. A person cannot choose to become a diviner. Only a person “called” by the ancestors can become one. …

Utilization of pediatric health services in Jerusalem.

The high rate of utilization of health services and rising health care costs in Israel, have prompted the need for reform of the health care system. Preventive and curative aspects of mother and child health care in Israel have traditionally been addressed by independent but parallel health systems. Prior to the pilot integration of these services, current patterns of utilization of health services by children during their first year of life, and determinants of use, were analyzed. Mothers of 651 children from five neighborhoods, representing the middle-low, middle and upper social class Jewish population were interviewed. Overall, a high degree of compliance with recommended visits to the preventive family health centers was found, with an average of eleven visits to the public health physician or nurse. The children also made an average of 12 visits to curative practitioners. Combined with all other health care consultations, these children averaged 26 health care visits in the first year of life. This pattern of frequent visitations, and its determinants, is discussed in context of the current framework of parallel health care systems. Multivariate analysis revealed that the birth order of the child was the key factor in determining the number of preventive visits, while the mother's perception of her child's health status held the major influence on the number of curative visits. No association between utilization of services and social class was discovered. Comparison of utilization patterns arising from this study with subsequent investigation of the planned integrated services allows for the assessment of the effects of a major change in the structure and delivery of pediatric services.

The implications of role expectations for birth assistance among Bariba women

Throughout the Third World, a notable trend has been the proliferation of parallel health care systems in which cosmopolitan medical services co-exist with a variety of indigenous health care services, and client populations must make decisions regarding the preferred choice among the existing alternatives. Correspondingly, Bariba women in People's Republic of Benin, West Africa, who seek obstetrical care have an increasing number of available options from which to select, including government hospitals, maternity clinics, private clinics, and a variety of indigenous practitioners. An examination of the factors influencing choices of birth assistance among Bariba women suggests that attributes of indigenous midwives such as status characteristics and type of training serve as significant considerations for clientele selecting obstetrical care. Characteristics discussed as salient features of the midwife include religion, age, marital status, education, apprenticeship, and certain personal qualities such as courage and lack of modesty. In addition, features of the midwifery role are delineated; for instance, the role of indigenous midwife involves a great deal of variability in contrast to that of the government nurse-midwife, which appears as a more narrow specialization. In order to fulfill role expectations, the indigenous midwife must demonstrate attributes which fall within an acceptable range to the client population, thus rendering her reasonably homophilous. Homophily is defined as ‘the degree to which pairs of individuals who interact are similar in certain attributes such as beliefs, values, education, social status’. The data suggest that a healer, in this instance an indigenous midwife, is selected in order to accomplish a particular task. A client assumes certain characteristics of the role occupant are requisite for the healer to be effective and competent. Clients and midwives are found to be homophilous in that they share concepts of causation, beliefs, values and role expectations. Where the healer is not homophilous with the client, the absence of homophily operates to deter prospective clients from utilizing obstetrical services. Thus in the case of the rural client/government midwife relationship, the respective role occupants are shown not to be homophilous. In contrast to the indigenous midwife, the government midwife does not share significant attributes, values and expectations with her client and this lack of homophily deters prospective clients from selecting the government midwife as an option for birth assistance.

Choosing among Parallel Health Care Systems in a Bariba Community

It is increasingly common in developing countries to find the proliferation of parallel health care systems in which cosmopolitan and indigenous health services co-exist. The basis of people's decisions to select from among these health care options is not, however, thoroughly understood. In this paper, based on research conducted in the People's Republic of Benin in 1976-77, I intend to consider one dimension of health service utilization - namely, alternatives for obstetrical assistance utilized by women in a Bariba region of Benin. In subsequent sections, I will attempt to delineate a set of factors influencing women's choices of obstetrical care in this rural African setting and draw conclusions regarding the decision-making process among pregnant Bariba women. This research was conducted in northwestern Benin, particularly in the District of Kouande. The primary research site was the village of Pehunko, which has a population of about 2000 and is primarily Bariba. The Bariba are one of the three most populous ethnic groups in Benin, numbering perhaps 300,000 and extending into western Nigeria. Pehunko was chosen as the focus of this research because of its location as a crossroads market center, through which communications from surrounding settlements flow regularly. Pehunko is located at the intersection of several settlements with maternity care services and is the center of an agglomeration of villages. Pehunko, then, seemed to serve as an illustrative site to

Choosing Among Parallel Health Care Systems in a Bariba Community

It is increasingly common in developing countries to find the proliferation of parallel health care systems in which cosmopolitan and indigenous health services co-exist. The basis of people's decisions to select from among these health care options is not, however, thoroughly understood. In this paper, based on research conducted in the People's Republic of Benin in 1976-77, I intend to consider one dimension of health service utilization - namely, alternatives for obstetrical assistance utilized by women in a Bariba region of Benin. In subsequent sections, I will attempt to delineate a set of factors influencing women's choices of obstetrical care in this rural African setting and draw conclusions regarding the decision-making process among pregnant Bariba women. This research was conducted in northwestern Benin, particularly in the District of Kouande. The primary research site was the village of Pehunko, which has a population of about 2000 and is primarily Bariba. The Bariba are one of the three most populous ethnic groups in Benin, numbering perhaps 300,000 and extending into western Nigeria. Pehunko was chosen as the focus of this research because of its location as a crossroads market center, through which communications from surrounding settlements flow regularly. Pehunko is located at the intersection of several settlements with maternity care services and is the center of an agglomeration of villages. Pehunko, then, seemed to serve as an illustrative site to