Public Retreating from Health Information?

The conventional wisdom in public relations and medical education is that consumers have an insatiable appetite for health information. I came across a study recently by the Center for Studying Health System Change that suggests the contrary: the public may have reached the saturation point in seeking medical information and may in fact be turning its back on information that explains medical conditions and treat alternatives.

The findings, published in January, said 50 percent of Americans sought information about personal health concerns, down from 56 percent in 2007. The percent of individuals searching hardcover books, newspapers and magazines declined by nearly 50 percent (to 18 percent) during this period.

While this might be explained by the general decline of paper-based media, online resources did not offset it, the use of which for health-seeking information only increased from 31 percent to 33 percent between 2007 and 2010. While the decline was seen across all demographic segments, older Americans, people with chronic diseases and the less educated led the retreat away from health information. The Center findings are supported by the Deloitte 2011 Survey of Health Care Consumers in the U.S. that found only 43 percent of Americans look online for information about treatment options –considerably less than the 55 percent use in 2009.

 What explains this retrenchment? The Center suggests one reason is the across-the-board decline in print media generally. It is true that the “news hole” for health news is shrinking in newspapers. But it is an incomplete explanation, since older people remain fans of to the printed word and can find alternatives when their local newspaper pink slips its health columnist.

 Another partial answer is that the recession and its aftershocks slowed down health spending generally-- Health Affairs last month reported the slowest growth in health spending in 51 years. If one can’t afford to go to the doctor, one also won’t wish read about his ailments? I think there are other explanations as well: We may have simply reached the saturation point: every consumer who is interested in health information is availing himself to it. (That may account for the plateauing of interest, but alas, not its decline.) Another possibility: We know there is an across the board decline of consumer trust of all information sources. While online sources were once immune, this may be changing as consumers try to hack through the thicket of health websites and often stumble on inaccurate articles, extraordinary claims and conflicting advice. Maybe, they might presume, the old way to get info was just fine: ask one’s doctor.

 What are the implications for public relations?

 We must continue to be students of “information anthropology,” closely examining the news gathering habits of specific groups or audiences and lay out for our clients the most likely and efficient ways to reach groups. This may mean discarding long held believes such as the importance of The New York Times and the newsweeklies; to be fair, it also may mean turning away from social media channels if definitive research suggests this is not where the eyeballs are.

 The media tracking monitoring services should see this as an opportunity to provide greater service by helping illuminate these channels. If the public is cynical about online health content, we must do a better job assuring them of the accuracy and appropriateness of content we are responsible for. Does this mean an industry-wide “Good Housekeeping Seal?” Perhaps, if that’s what it takes to build consumer confidence.

Back after a vacation...

Two years ago, maybe two and a half, who’s counting, I started this blogaganza, hoping to keep my writing skills derusted and hoping to make some pithy observations about this bizarre world on which I am planted. A world of communications and health care public relations, a world of politics, of rowing and general “stuff” that seems interesting or contrary.

This is my first new post in more than a year.

So what happened? What happened is exactly what befalls many wannabe bloggers. They overthink, they feel that every entry must be perfect beyond words and they freeze realizing that they can’t live up to these expectations once or twice a week. So nothing happens.

Having just completed David Meerman Scott’s The New Rules of Marketing and PR, I am convinced that excuses are for sissies, and if I really am a marketer, then I better start acting like one. Start more conversations. Consider social media as the earth’s cocktail party. Start getting “me” out there again. So here it goes.

So, Michael, what’s happened in the last year or so?

No need to go into details. They’d bore you anyway. But I am obligated to mention a few items, some happy, some not.

Starting with the negative side of the ledger, last year both Marlene and I lost our remaining parents: Marlene’s dad died last January, simply not waking up from a “routine” operation. My mom passed away in her sleep last March. We are now the senior generation around the Thanksgiving table, the keepers of the traditions and the secret recipes.

I briefly worked full-time for a British communications agency that desperately tried to learn the ways of the USA.

The good stuff is far more entertaining.

My consulting business flourished last year, thanks to a wonderful opportunity to promote a dramatically different way of treating major depressive disorder. Thanks also to some extra-special corporate assignments, writing messages for several of the world’s greatest health care organizations.

Marlene left the legal profession and became a fair-housing advocate; for the first time she really loves her work.

And last, but not least, I’ve gone back to school, sort of. Last summer I enrolled in the Boston University MS in Health Communications program. It’s an unforgiving commitment of way too many hours, but it’s a great, great learning experience. And to those who say, “why, you could teach that course,” I just say “bull.” There’s so much I do not know. That keeps me happy. As does getting back on this blog.

Christmas Eve 2010...


Friends---

Christmas is just hours away and 2010 is inching towards its end. A new year is approaching; a year we can hope will be filled with happiness, prosperity and good health for all.

2010 brought Adam to university life, new careers for Michael and Marlene and a major health opportunity for Matt. We mourned the passing of our beloved Bete Noire, the almost magical dog, and Butterball, queen of cats, but still have memories of how they filled our lives with happiness, animal wisdom and fur balls (Butterball, at least).

From our family to yours, a belated happy Hanukkah, a very merry Christmas and rising tides for all!

Marlene, Michael, Matt and Adam Durand

Christmas Eve 2010...

The Incredible Shrinking Health News Hole

Not long ago I had lunch with a former colleague who headed media relations at a multi-national pharmaceutical company. She was lamenting how so many of her former "contacts" at newspapers and magazines had baled out of the traditional news business and either joined web site operators or enlisted on the dark side by joining public relations agencies.

Her observation reminded me of an article I wrote for O'Dwyer's last year, documenting how quickly the news business is decomposing. Here is a version of that article...

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How large is the “news hole” for health care information in the U.S. media? As news outlets reshape themselves, cut costs and focus on areas of most appeal to their viewers and readers, this is a disquieting question for public relations practitioners involved in the medical and pharmaceutical industries. The answer both points to the challenge health care public relations practitioners face and a path forward.

A report published in December 2008 by the Henry J. Kaiser Foundation (www.kff.org) and the Pew Research Center’s Project Excellence in Journalism suggests that health care coverage in national and local media may be shrinking faster than the polar ice caps, leaving those dependent on traditional media for health care information stranded like polar bears on ever-diminishing ice flows of news.

According to this study health news was the 8th most covered subject, with 3.6 percent of media space devoted to the topic. This is three times more coverage than education or transportation, but an asterisk compared to the elections and politics (21.3 percent of the news hole), foreign affairs (13.6 percent), foreign news (11 percent), or even crime (6.6 percent) or disasters and accidents (4.2 percent).

The Kaiser and Pew researchers examined front-page coverage in small, medium and large market newspapers as well as network morning and evening news programs, cable programs, radio and even general interest internet outlets during an 18 month time span in 2007 and 2008,

The network evening news programs (ABC World News Tonight, NBC Nightly News and CBS Evening News) dedicated the largest percentage of their ‘casts to health news—more than 8 percent, outshining newspapers, with 5.9 percent of their front page articles focusing on health care; radio with health comprising 3.6 percent of news coverage; network morning programs (Good Morning America, Today and CBS Morning News) with 3 percent of health programming and online general news outlets such as Yahoo News and MSN dedicating 2.2 percent of their “front pages” to health. Cable outlets, which once helped spearhead health reporting, devoted only 1.4 percent of coverage to health issues.

In terms of the topics most often covered, nearly 42 percent of news covered was disease specific, with cancer, diabetes and obesity, heart disease and AIDS/HIV being the disorders most frequently mentioned. Health policy issues and public health evenly divided the rest of the coverage pie.

The report has some major limitations. The analysis of newspaper coverage only included front-page articles, thus ignoring science and health sections of papers such as The New York Times and Wall Street Journal. It did not include health-dedicated Web sites such as WebMD and HealthCentral.com. Likewise, by focusing on general news broadcasts of the cable outlets, the study did not account for specials produced by experts such as CNN’s Dr. Sanjay Gupta.

Nevertheless, the study quantifies what many have long suspected, that the opportunities in traditional news outlets are shrinking.

Of course, the skimpy news hole for medical news is just one more symptom of the degenerative condition of mainstream media generally. It is no secret that loss of both eyeballs and advertising revenue has led to cutbacks across the news spectrum. The New York Times earlier this month noted that the Cox newspapers chain, owners of The Atlanta Journal-Constitution and other papers has paired its Washington bureau from 30 reporters eight years ago to zilch-o reporters today.

The reduced commitment to health reporting can be observed at annual medical congresses such as The American Heart Association’s Scientific Sessions and the yearly meeting of the American Society of Clinical Oncology. While in years past network news divisions and national newspapers would report on-site from the meeting, increasingly coverage is achieved by phone interviews and wire service reports—if the meetings are covered at all.

For more than a decade, when Americans were surveyed about the domestic issues of most concern to them, health care ranked as issue number one. Even today, with the economic crisis dominating virtually every other subject, Americans remain deeply interested in health and wellness.

Why then, is health news less prominent in coverage? There are several reasons, including the relative complexity of some medical stories, the cost of fielding medical teams and the competition with other subjects. The cable news outlets, once homes to robust medical reporting teams have largely shifted their emphasis to confrontational politics and news “analysis,” leaving less room for straight-forward stories about scientific developments. MSNBC’s “Morning Joe” Scarborough and Fox New’s Bill O’Reilly aren’t that interested in t-cells and microbes.

One observer of the ups and downs of health news is Dr. Bruce Dan, executive medical editor of The Patient Channel on NBC’s Digital Health Network, and a former senior editor at The Journal of The American Medical Association.

Dr. Dan says that when he was starting his journalism career 25 years ago at the ABC affiliate in Chicago, “stations desperately wanted to have their own TV doctors on the air, and they found it advantageous to feature these new doctors and health segments. Week-long sweeps pieces on any number of diseases were heavily-promoted, and breaking news on the latest health topic popped up almost every day.” The novelty, he says, has now worn off, and health news has to compete for coverage with every other topic area. “Ironically, as the number of commercials for pharmaceutical products increases,” he says, “the commitment to news coverage of medicines has decreased.”

Going hand in hand with the less consumer coverage, public relations executives are finding fewer opportunities with the professional press. While a decade ago there were half dozen general interest physician publications, including Medical World News and The Medical Tribune, there are now just memories.

Where do these developments leave us?

The good news—for both consumers, journalists and public relations practitioners—is that while there is less coverage in traditional news outlets, health care information is alive and well in specialty publications and on the internet. For instance, while mental health and illness doesn’t garner much general press attention (commanding just 1.6 percent of news coverage according to the Kaiser/Project Excellence survey), publications such as bp Magazine and Esperanza are offering in-depth coverage of mental illness (bipolar disorder and depression respectively). There are now many publications directed towards individuals with other illnesses such as diabetes, heart disease and HIV infection.

Similarly, there are now scores of Web resources for people interested in mental illness, including MentalHelp.net, SelfhelpMagazine, Mental Health Matters plus the renowned sites of advocacy groups such as the National Alliance on Mental Illness and the Depression and Bipolar Support Alliance.

A lot has been written about the veracity of Web health coverage and it is a concern that most sites do not have the strict fact-checking procedures or traditional commitment to objectivity of conventional news outlets. Over time, however, I believe consumers will gravitate to those sites that offer scientifically accurate and balanced coverage of health and medicine.

The Kaiser/Project Excellence report shows that some topics are simply better covered than others, likely because these diseases are of interest to more people. Cancer, diabetes and heart disease rank high. Alzheimer’s disease and ALS rank low. This suggests what generations of smart public relations people know: to win a placement, “the pitch” must be tailored to show why it would be relevant to the news outlet’s audience. That’s not rocket science, but amazingly the point is often lost.

While the morning news programs have often been regarded as the jackpot placements for health news, prospects for placements on these shows, at least in the all-important first half hour, are dim. “The first half hour of the morning news shows dedicated only about a third as much of their time to health as did their counterpart half-hour news programs that appeared in the evening,” found the Kaiser-Pew report. This suggest that to win a morning placement—rare under any circumstances—public relations people must look beyond the first 30 minutes, usually regarded as the hard news block, and must demonstrate beyond a doubt the relevance of the story to the audiences that view the programs after 7:30 am.

The health care pitch is not dead, it is just harder to achieve in mainstream media. Tina Chiara, a senior media relations specialist at Ruder Finn, notes "contrary to what most may think, there are still many opportunities in traditional media despite the surge of online coverage. Traditional media still exists but with fewer and fewer staff so many reporters are not only open to newsworthy ideas but worthwhile contributions in terms of products, companies and context for stories. You just have to spend more time figuring out what will interest readers and viewers."


Finally, the loss of health care opportunities in traditional media should remind us yet again that public relations must not be equated to press relations. To continue to be so defined is a recipe for slow extinction. Likewise, we can never simply rely on practicing our craft tomorrow the way we did it ten years ago, or even last May. The media world is changing and the opportunities for us are shifting. Some opportunities are gone, while others remain bright and within reach.

# # #

Dead Marketing

Dead Marketing


I am indebted to PRNewser for a brief summary of a great little book, Marketing Lessons from the Grateful Dead: What Every Business Can Learn from the Most Iconic Band in History.

Last weekend I read the book, which took all of about two hours to cover about 150 small pages and roughly nineteen learning from, if not the most iconic band in history, certainly one of the greatest “brands” in rock-n-roll. My connection with the Dead is thin, but not non-existent, I’ll explain that in a moment.

I’m a believer in transplanting wisdom from one field to another, quite different field, hence I instinctively like the proposition that the Dead have a lot to tell us.

Marketing Lesson’s theme, reinforcing a lot of other books, staring with David Ogilvy’s Confesisons of an Ad Man, is that if you try to establish a brand, or attempt to sell a widget just like every other marketer, or widget salesman, you are limited to winning a small-medium or maybe even large helping of the widget pie, but won’t achieve greatness. The Dead didn’t deliberately exclaim, “let’s set rock marketing on its ears;” rather they followed what to them was simply the right path to doing the right thing and the dividends of this strategy were success for thirty years and creating a brand that continues to ensure long after founder Jerry Garcia’s death.

So what did the Grateful Dead do that was so counter-instinctive?

For one, allowing anyone to record their concerts. Imaging if tonight you sashayed into an Eminem concert at Madison Square Garden armed with a tape recorder and a large directional microphone. If you were lucky you’d get thrown out. More likely you’d be busted. But the Dead took a totally opposite approach, even arranging special areas for amateur recorders. It wasn’t simply that they wanted to be nice guys. They instinctive knew that fans would exchange tapes and talk up their concert experiences, thereby creating more buzz and enthusiasm for Deadom. This policy, by the way, didn’t seem to hurt album sales one bit and today there is a vast collection of concert material in the public domain.

Unlike most bands, which toured to support recordings, the Dead again upset the business model: albums were simply a way to reinforce their concert schedule. This might have diminished their relationship with the record label, but established a much stronger revenue base.

Long before anyone ever heard of customer-relationship marketing, Garcia and the boys built band loyalty by rewarding their most ardent fans with special promotions and great seating.

There more in this little book that reaffirms that you don’t need an MBA to by savvy at selling.

Growing up in the San Francisco Bay Area in the sixties and being addicted beyond the point of no return to “folk music” (OMG!), I often saw Jerry Garcia, Bob Weir and Pig Pen, aka Mother McGee’s Uptown Jug Champions, at The Tangent in Palo Alto and Off-Stage in San Jose. Jerry usually presiding over the five-string.

But here’s the defining moment: one evening, my pals and I were wrapping up an evening of body surfing near Pescadaro, south of San Francisco (Don’t ask. We were young and Foolish). Walking by a small club out by the Coast, we noticed some new kids in town. The Grateful Dead. Mother McGee’s boys had traded in the banjos and acoustics for electric guitars and drums. “I can’t believe the Champions have sold out and gone rock-n-roll” I whined. To add insult to injury, they were charging FIVE DOLLARS a ticket to see the show.

“No way I’m going to pay that,” I said. And didn’t.

As the years went by, I saw the Dead in San Francisco, LA, Vegas and New York. But never scored fivedollar tickets.

Four New Ideas—
And How Public Relations Helps Make Them Real


“In Pharma 3.0, companies will not be selling pills as much as managing entire patient experiences…companies will need to build the long-term relationships with patients that will become increasingly integral to their brands.
Ernest & Young “Progressions” Global Pharmaceutical Industry Report
2010

Yes, yes, there are a welter of change agents affecting the pharmaceutical industry and the larger health care enterprise. Many of them have been talked into the ground by industry observers, politicians and members of the health care communications community.
Ernest & Young recently published Progressions, its 2010 Global Pharmaceutical Industry Report. The report is full of good observations, but I was most interested in four seismic changes that they predict are having a profound and for the most part positive influences on health care and health communications.
1. Patient Empowerment Transforms to Patient Responsibility
Kind of sounds like a Republican Party catcall, but it’s a pretty accurate description of where the patient movement is going. Fifteen or twenty years ago we were talking about how the patient was becoming a partner in his or her health care and how the doctor was no longer the god in the white coat.
The democratization of information brought on largely, but not entirely by the Web, accelterated this. But just as the patient now has a voice in treatments, his responsibility towards risk-sharing is also rising. Just look at your drug co-pay scheme. You can receive the latest and greatest medication, vaccine or antibiotic, but you may be asked to contribute $40 or event $80 a month from your pocket for the treatment. Contrast that with a generic medication which may cost you just $10 or $20 dollars.
There are often extremely good reasons for using a newer medication. But as costs rise, the patient (and the doctor) will need to weigh its value versus older generic drugs.
Some predict patient responsibility may become even more urgent as some health care plans and companies consider rewarding employees practicing healthy behaviors or imposing higher insurance rates on over-weight employees or employees who smoke. For a number of reasons penalizing obese employees is bad public policy, but the idea is certainly on the table.
Public relations can help companies explain the relative benefits of branded medications and who should most profit from them. We can also work with companies outside of the health care arena on employee wellness initiatives.
2. The Transformation to Pharma 3.0.
This is Ernst & Young’s term, but the notion is not theirs alone. Pharma 1.0 could be considered “the good old days” in which a blockbuster drug would put wind in a company’s sails for years. A billion dollar molecule could contribute ten, twenty even forty percent of a company’s income. The problem was that as the patent ran out of gas, the company desperately had to refuel with another blockbuster or two. If was much like a treadmill, with its speed constantly increasing.
Pharma 2.0 was the diversification model: sell lots of drugs, but sell other things too, from over-the-counter brands to sutures. Abbott and Baxter led the way with this model, but others caught on as well.
Pharma 3.0 (which nicely merges with patient responsibility) is a new way of looking at the core business of the drug company: rather than simply selling medicines, it is selling health outcomes. So if company X is in the diabetes business, sure, it is developing a glucagon-like peptide analog, but it is also offering disease management programs for physicians and patients, drug persistence programs and other tools to help get the patient to where he or she needs to be.
Public relations plays a integral role here, as we are in a great position to help companies increase patient compliance and persistence through educational programs such as interactive learning modules and other tactics.
3. The New Players and New Partners
Health care companies are enlisting usual and not so usual partners in helping achieve Pharma 3.0. For instance, Bayer Healthcare has linked with Microsoft and the National Multiple Sclerosis Society to create “MyBrainGames” an online mental games center for people with MS.
Bayer has also partnered with Nintendo to create “Didget” a glucometer for kids with type 2 diabetes that can be plugged into a Nintendo game console. Novartis, Vodafone and IBM have created “SMS for Life,” that uses mobile phones and other technologies to manage supplies for people with malaria.
Relatively simply technology is allowing us to do great things. Johnson & Johnson, the federal government and other partners have launched Text4Baby, a service that sends SMS messages about nutrition, health and other important topics to pregnant women, based on their due date. A simple but effective service for women with limited access to other resources.
With so many potential partners in the greater health care space, public relations has far more opportunities for client partnerships. As many of these initiatives are centered on communications, who is better to help out than our industry?
4. The Value Proposition & Value Mining
It doesn’t take a health economist to figure out that in a cost-conscious environment, finding the relative worth of a medication will be the price of entry. There are many ways of looking at comparative effectiveness, far more than we can review here.
There’s a new spin on the value proposition, however. It’s called value mining.
In the old days, clinical trials and outcomes data were the private property of pharmaceutical companies. Outsiders, even clinical investigators, would get information only when the company thought it was time. Not so anymore.
According to Ernst & Young, regional health companies such as Partners in Boston and Intermountain Health in the west are using historical, empirical data to determine effectiveness of drugs already approved by the FDA. Armed with outcomes on thousands of patients, and computers capable of scrutinizing dozens of variables, these companies are running “parallel universe” clinical trials by simply and cheaply examining historical data to see which drugs work best on which patient groups.
Yes, this is turning clinical trials on their heads, looking backward instead of prospectively for outcomes. But how can biopharmaceutical companies deny the value of reams of data on thousands and thousands of patients? Communicating precisely the meaning of these retrospective trials and their implications for payers will be a massive challenge.
Patient responsibility, Pharma 3.0, new players and value mining are four change agents that cannot be ignored. They may not sound as sexy as the profound changes we are seeing as a result of the digital health transformation, but their impact, I believe, will equally great.

2.75 Cheers for Kaiser

2.75 Cheers for Kaiser Permanente

I spent last weekend on the San Francisco Peninsula, primarily attending to my mother, who spent the prior week in the hospital. Mom is 13.75 dog years old, and at that age, well, age becomes a conspirator, and you become its plot.

This becomes relevant since her care at the Redwood City Kaiser Permanente facilities is emblematic of how we can deliver good health care, at a reasonable price, even for those in their late, late years.

Part one. She complained about breathing troubles and scheduled a physician’s appointment at Kaiser. In quickly, diagnosed with chronic obstructive pulmonary disorder and hospitalized all within an afternoon. It helps that the walk-in clinic is a stone’s throw, or wheelchair ride, from the Kaiser hospital.

I am not writing here about her transitory mental confusion, the concern over whether she can continue living alone in a retirement community and the need for at least temporary round-the-clock attendants. We’ll save those for another day.

Part one and a half. The attending physician phoned me and spent all the time required spelling out her medical diagnosis (guarded) and various living arrangement options. I decided to check out the situation myself, hence the visit to the Bay Area.

Part two: the follow-up. I accompanied mom on her follow-up visit, about a week after she was discharged. American Airlines thoughtfully contributed to the drama by cancelling my late evening flight back to New York; my rescheduled return gave me just four hours from Kaiser visit to wheels up. Being a New Yorker, I anticipated the horrors of waiting and waiting for her appointment and grinding teeth trying to get back to SFO on time.

But the nice surprises started the minute we entered the clinic. A short line in a comfortable reception area; the request to pony up $10.00 for her visit (I couldn’t get my blood pressure read for ten bucks here in the Empire State), then a short elevator ride up to “clinic F.”

Clinic F was nicely furnished, with magazines from this century; pictures of the physicians staffing the clinic and their bios nicely displayed on the walls. Moments after arriving, mom’s name was called and she was led to her physician, a woman who’s treated her for several years. I am watching the clock. Not bad.

Thirty minutes later I am called into the exam room, where the attentive physician reviews mom’s chart with me, discusses with both us her medication schedule and answers both our questions with alacrity and no sense that she has to make way for the next patient.

All in all, the report is positive and her health improving, though it’s doubtful there are triathlons in her future.

Kaiser Permanente some time ago computerized its medical records, so everything the physician needed to know is at her fingertips. Oops--one problem: the computer crashes, making it impossible for her to e-mail the on-site pharmacy mom’s new prescriptions. So we move to another exam room and a more cooperative computer.

Time elapsed: ninety minutes; seventy of which were with the physician. Then down to the pharmacy, where an electronic display chimed that mom’s prescriptions were ready. The pharmacist threw in one of those weekly pill dispensers for free.

Outside, we passed through the pleasant gardens soaking in the California sun. Then to the street where the Redwood City policewoman waived the red “no parking” regs, so mom could have an easier time getting into my rental care.

Back to her retirement community, a bid farewell, then off to the airport with plenty of time to make the flight.

How does Kaiser manage great patient care, fast service and pleasant surroundings all wrapped in a $10 co-pay?

Medicare helps and don’t let anyone tell you seniors don’t like it.

The medications Kaiser dispenses are not best in class. When have you been prescribed lovastatin, the first “statin” drug, approved about 25 years ago? But lovastatin works pretty well if you don’t have galloping dyslipidemia.

You won’t find Kaiser doctors in Castle Connolly’s “best doctors in America.” Don’t expect Johns Hopkins or Stanford Med graduates. But they are thoughtful, caring and in mom’s case know primary care medicine as well as anyone you could hope for.

Kaiser’s medical information system is seamless, electronically linking departments, clinics and the pharmacy. But if the computers don’t work, you gotta move.

These points contribute to “how does Kaiser do it,” but they don’t fully answer the question. I’d really like someone to enlighten me.

Someone critical of President Obama’s enacted Patient Protection and Affordable Care Act said that sooner or later all of us will be going to Kaiser-like facilities.

If so, we could do a lot, lot worse.