Saturday, May 2, 2009

Appropriate Health Plans

  • Health plans designed for the poor (“Appropriate Healthcare”) should be cheap, accessible and should address the major causes of morbidity and mortality.
  • The top seven health problems in Kenya, making up more than 65% of the mortality, are malaria, lower respiratory infections (e.g. pneumonia), HIV, prenatal problems, nutrition, TB, diarrheal disease.
  • Cost effectiveness is a helpful way to think about allocating healthcare when resources are limited, particularly in the developing world.
  • Health fairs and local health workers could be two ways to address these major health issues in a cost-effective manner.
  • An appropriate Kenyan health plan should focus on the most cost-effective ways to address the seven major Kenyan health problems.
Note: this is far too long (and probably too technical) for a blog. I apologize in advance to my normal reader.

Introduction
“Health Insurance” as it is modernly conceived serves two major functions. Firstly, as the name implies, to insure that you’re taken care of if something really bad happens. The more recent (and perhaps important) part is health maintenance. Health insurance pays for annual checkups, screening exams, and (increasingly) over the counter meds like allergy meds. So it’s not really health insurance. And this is what the public health people love: prevention. In the developed world, these two things are bundled together because we’re really rich and don’t really care. We need ‘em both, so why bother paying for health maintenance and health insurance separately? This is likely why no market for stand-alone health maintenance programs has emerged. Also, the kinds of death we want to afford when we buy health insurance require expensive hospitalizations, chemotherapy, and bypass surgeries. So, because these things are ridiculously expensive, so is the whole package of American “Health Insurance.”

But when we think about appropriate goods and services, which I’ll define as, “goods and services useful and affordable to poor people,” we need to think about economy. While we cannot forget that people in the developing world are dying of cancer and heart disease, traditional Coronary Artery Bypass Grafts aren’t even close to appropriate for those earning a dollar a day. If we were picking apples from a tree, we shouldn’t have a “Top branch or bust” strategy. There is plenty of fruit that we can reach while we’re still on the ground.

There are things people are dying and suffering from (we cannot forget what is called ‘morbidity’ in our consideration; that is, suffering short of death) which are easily prevented and cured. We want to take care of the easy stuff first.

If a healthcare plan were to be designed for the poor, it would have to meet these criteria
· It must be cheap, cheap, cheap
· It must be accessible
· It must addresses major causes of mortality and morbidity

We want to avoid the hospital. That’s where things get really expensive. In fact, we want to avoid the clinic if it’s at all possible. And transportation. And waiting. And we need to make sure we pay for the important stuff. We need to beware good intentions: we do not want a comprehensive plan covering everything but nobody.

Kenyan Problems
In considering this question, I’m going to look at some data from Kenya (believe it or not, “Africa” isn’t a country). Here’s some data from the World Health Organization from Kenya on the top five causes of overall mortality (compiled in 2002).[6]


ConditionMortality (thousands) %
#1 HIV/AIDS14438
#2 Lower respiratory infections3710
#3 Diarrheal diseases 247
#4 Tuberculosis 195
#5 Malaria185
Cost Effectiveness Analysis
The cost effectiveness analysis perspective will be very useful here. It contradicts the (probably true) belief that human life is invaluable and says essentially, “The reality is that we have limited resources; how can we do the greatest good with them?” Here’s a super-simplified example.
You go to the doctor and the doctor, after running some tests, comes in and tells you, “I have some good news and some bad news. The bad news is you have Really Deadly Disease (RDD) which, if untreated, will kill you tomorrow.”

You, having nerves of steel, are cool and collected. You ask flatly, “What’s the good news?”

“The good news is that there’s a cure! Well, it’s not really a cure. It’s a drug you have to take for the rest of your life. As long as you take it, you’ll be healthy. The day you stop taking it, you’ll die. And the drug costs $45,000 per year.”
In this example, someone (your insurance, hopefully) has to pay $45,000 for every year of life you enjoy. This is usually adjusted for quality and so we usually say Quality Adjusted Life Years or QALYs (you would discount life lived in a sub-optimal state; you might count 1 year as a paraplegic as 0.5 QALYs). Compared to the alternative (instant death, which costs nothing), you have an incremental cost of effectiveness of $45,000/QALY. That is something we can pay in the developed world, and because of such expensive treatments, is why our health insurance costs what it does.

QALYs and Development
In thinking about the developing world, we have extremely limited resources. We’re not talking about whether the line should be at $45,000 or $46,000/QALY. This kind of analysis has a much more powerful impact on developing countries. If a health-minded NGO wanted to do an intervention, are anti-malarial bed nets, antibiotics, or AIDS treatments more cost effective? Can more life be saved with one over the other?

In Kenya, healthcare spending is $105 per capita in 2006 (by PPP, not by exchange rate). Only a fraction of that has been by the government: $586 million (2% of $29.3 billion GDP) [1]. So even assuming we have $105 to work with (it’s very likely that most of that is a lot of spending by the richest in Kenya), what is more cost effective? Treating Malaria or Malaria bed nets? And whatever of those is better, is that more cost effective than treating HIV? And is HIV treatment better than antibiotics for pneumonia?

If I was an NGO who had $1 million and I wanted to do handouts, what should I spend money on? Should I fight AIDS and invest in HAART (Highly Active Anti Retroviral Therapy)? Or should I buy ITNs (Incecticide Treated Nets)? For HAART, it’s $1000 to save a life year[3]; for ITN, it’s $86. In other words, I could save over 11,000 people from Malaria for a year (assuming $4/net I’d have to buy 250,000 nets to do this), or I could save 1,000 people from HIV for a year. Of course there’s more people suffering from HIV, but with limited resources (as all NGOs have), the focus should probably be on addressing Malaria first. But then again, vaccinations against Pneumonia (Hib) are even more cost-effective ($62/year saved). And what about treatment for Pneumonia?

This is the sort of analysis which must be done as this work progresses. Any fool can shout about how big a problem is. It takes a wise man to find a solution. This is the mindset with which the remainder of this paper was written. Though there is not the data to do a numerical analysis, the things which have been chosen are gross approximations of what may be actually cost-effective.

An Overlooked Problem (A Ripe and Low-Hanging Fruit)
Why haven’t we ever heard about the #2 killer in Kenya (and from what I’ve heard, much of Africa)? We hear about AIDS all the time. And diarrheal disease all the time. And TB and Malaria. But why don’t people talk about “Lower respiratory infections”? And yet according to Kenya’s Ministry of Health, 1 in 37 Kenyans goes to a clinic for Pneumonia each year [9].

Here’s the ironic thing: they’re the easiest one on that list to treat. Everything else (with the possible exception of diarrheal disease) requires rather extensive measures. But Lower Respiratory Infections (aka “pneumonias”[8]) are usually easy to diagnose and easy to treat (certainly by comparison). X-rays are nice, but they’re usually just to confirm what the doctor can find out from getting a good history and physical. Stethoscopes aren’t that expensive[7]. And neither is first-line pneumonia treatment: Amoxicillin w/ clavulanate (“Augmentin”) [5] which can be gotten for $1.34 in Kenya[4].

That’s what you call affordable. For someone living on $1 a day, a $4 ITN with long-term (but no short term) benefits is a hard sale. A $1.34 drug which lets a person get back to work/play/school/home in a few days is a much easier sell. But there is presently no cheap way to get at it without spending a day to go to the clinic, paying for transport, waiting for a doctor, paying for the visit, get diagnosed and then hope they have the medication you need. The out of pocket cost is too high, not to mention the opportunity cost (instead of earning money, time was spent going to the doctor).

Idea One – Local Health Workers
How do we make it easier to treat pneumonia? Train local health care workers. Buy them stethoscopes (or loan them the money for stethoscopes and let them pay them off by working) and let them sell their services to their neighbors. It would be their job to purchase a small amount of pharmaceuticals and sell them to those who need them. If disease tracking was a concern of the local dispensary, they could require the worker document each case and only sell a new batch of drugs with the delivery of patient records. The patient form could require a signature and include the price of the drug (to limit health worker corruption), and describe the level of training of the worker. Or if we really want to be fancy, we could use SMS to communicate in real time to the dispensary.

The bottom line is that a person with pneumonia for, say, $0.25 can get a diagnosis and accordingly be offered treatment: “Yes, this is Pneumonia; I’ll sell you the drug for $1.32” or “No, this is not Pneumonia; I won’t sell you the drug.” This would provide broad and easy access to pneumonia treatment, and reduce mortality and morbidity of the #2 killer in Kenya, in addition to providing supplemental income for the health care workers.

Idea Two – Health Fairs
As transportation seems to be a major issue, bring the clinic to the people. This is what well-intentioned white doctors do all the time, and are able to help hundreds or thousands of people on a single day.

The organizers would stock up on common meds (“common” will quickly be defined after the first of these; likely antibiotics, de-worming meds and vitamins; it may be a good thing to do community surveys about before the first one). Ideally, doctors and nurses would volunteer or already be paid (by the national government); if not, their daily wage would be a part of the cost. Para-medical personnel (health representatives) would act as medical students under the doctors present, learning what they could (so as to better help people between fairs) and aiding in the streamlining of patients. Other volunteers would be needed for paperwork, administration and set up. Also, this should be done on a weekend or holiday where the opportunity cost would be lower (people don’t have to miss work/farming).

It could be discounted or (more likely) free for those on the healthcare plan; a fee would be charged for those who aren’t (reasonable, of course). All health related business could take place on a single day. Nets could be retreated. Sick people could get their meds (or at least people sick from diarrheal disease and pneumonia). Children could learn hygiene. In addition, with good record-keeping, this could be an excellent venue for tracking health statistics (a pre-interview could record recent births, deaths and illnesses in their family, relatives, friends, neighbors). These fairs could be rotating and occur as often as there was demand and funding.

Conclusion
Imagine we had a health plan which addressed the seven strategic Kenyan areas (HIV, Lower Respiratory Infection, Malaria, TB, Diarrheal disease, Neonatal/Maternal health, and Nutrition). For the expensive and well-funded diseases, it would act as a referral network, perhaps providing transportation to well-funded HIV centers. It would cover treatment by local health workers or health fairs for simple pneumonia and diarrheal disease, in addition to some simple nutritional supplementation if anemia is suspected. It would provide annual insecticide for bed nets. It would pay for a trained birth attendant. And it would pay a certain amount for emergency transport for serious illness.

By focusing on the extremely cost-effective interventions and omitting the more drastic ones (direct treatment of HIV, paying for hospitalization), healthcare may become affordable to even the poorest[13]. Much change would be necessary before this could be realized. It is certainly not possible with the present system. But it may become possible with a few intelligent changes and a community to support it.

The Challenge: To design a healthcare plan that would prevent and treat the most deadly and painful diseases accessibly and affordably; to drastically reduce the morbidity and mortality of the rural poor with $1.00 per month per person[10].

Notes
[1]Stats taken from GapMinder (which draws from reliable sources like the World Bank) http://spreadsheets.google.com/pub?key=pk7kRzzfckbzz4AmH_e3DNA&gid=3
http://spreadsheets.google.com/pub?key=phAwcNAVuyj0XOoBL_n5tAQ

[2] http://www.google.com/url?sa=t&source=web&ct=res&cd=4&url=http%3A%2F%2Fwww.netspear.org%2Fdownloads%2F3rd%2520network%2520conference%2520presentations%2FDay%2520one%2FThe%2520cost%2520of%2520care%2520for%2520pneumonia%2520and%2520cost-effectiveness%2520of%2520Hib.ppt&ei=u_f7SdqBMZOytAOZ_-XjAQ&usg=AFQjCNHhb-Lj9TTLYtS0CIhbbpgxbDy1Jg&sig2=KJRGvmFXAtkm9Iake4dbxw

[3] Technically this particular study used Disability Adjusted Life Years (DALY); it’s similar to a QALY but figured out with a slightly different method. Fundamentally it’s saying the same thing.

[4] http://www.kemsa.co.ke/datagrids/kemsa_commodity_catalogue.php Item - PHA0545. 105.25 Kenyan Shillings which, according to Google, becomes $1.34 as of 5/2/09.

[5] 96% of pneumonia should be sensitive to this treatment in the US; it may even be higher in Africa because of less antibiotic usage. Taken from “Diagnosis and Treatment of Community-Acquired Pneumonia” by the American Academy of Family Physicians. M. NAWAL LUTFIYYA, PH.D., ERIC HENLEY, M.D., M.P.H., and LINDA F. CHANG, PHARM.D., M.P.H., B.C.P.S. http://www.aafp.org/afp/20060201/442.html

[6] http://www.who.int/whosis/mort/profiles/mort_afro_ken_kenya.pdf . It is very interesting to note that in Kenya’s Ministry of Health annual report, they came to different conclusions. They talked about morbidity in the executive summary and said #1 was Malaria and #2 was respiratory infection. It seems they’re making their conclusions based on who shows up to the hospitals. If I’m right about the data source, this discrepancy probably means that HIV patients aren’t showing up to governmental healthcare facilities. Perhaps they don’t have the money for treatment. Perhaps there stigma. Perhaps they’re going to NGO sites who don’t communicate with the government. In any case, it’s a problem. Beware: it’s terribly written and goes on for a page of the Executive Summary complaining about how bad the data is and why it was that bad. For that report, check out: http://www.health.go.ke/Healthfacilities/Annual%20Report%20_%20HMIS.pdf

[7] I remember buying decent quality stethoscopes for my group at $30 each; they get down to $7 on the internet… not that I’d trust a $7 stethoscope.

[8] Looking at the MOH report, they seem to think “Pneumonia” and “Respiratory Disease” are two separate things (some of the charts inconsistently call it “Other Disease of the Reparatory System”… I’m assuming ‘other’ than Pneumonia). Maybe in Kenya, they call typical pneumonia “pneumonia” and atypical pneumonia “other disease of the respiratory system.” Without ever defining their terms, it is impossible for me to know what “Respiratory Disease” means, or what possibly could be hospitalizing hundreds of thousands of Kenyans that is not COPD or pneumonia. But that’s just one chart. Further down there’s another that disagrees with it, saying that Pnemonia is the most significant disease and “Other Respiratory Disease” is nowhere to be found. Being unlabeled, I can’t quite tell what each of the charts is measuring and why they’re different. Bottom line is that Pneumonia is a big problem.

[9] http://www.health.go.ke/Healthfacilities/Annual%20Report%20_%20HMIS.pdf p143. This seems way too high. I would guess two things are working together: nutritional vulnerability (immunosuppression) and misreporting. I doubt many clinics actually culture their patients. It’s probably easier to give an antibiotic than X-ray or culture sputum. So any productive cough becomes “pneumonia.” Not that I’d recommend any changes to the protocol; a good H&P should have decent enough specificity and sensitivity.

[10] Assuming $1/day x 2 adults = 2/day*30 days/month = $60/month/family. Assuming 4 children/woman, the average family has 6 members and $60. If the health plan cost $1/person/month * 6 people = $6/month, then that would come out to 10% of a family’s income, which is roughly what the rich and middle-class pay in developed countries (the poor pay a much larger percentage in developed countries). Perhaps this is still too high to be feasible, but it puts it in the right ballpark. Maybe it could be even cheaper. The right thing to do is find out (as with any product) how much people are willing to pay, and then design a plan at that price point.

[11] Though the data they present does not support them, Anemia was complained of by the MOH; this is likely prevalent and under diagnosed. I read elsewhere that protein insufficiency is a problem, especially for children. It may be (though this theory is a total stab in the dark) that this is part of why everyone gets pneumonia.

[12] There is a lot of potential synergy with these seven and other areas of development. Improving water and sanitation would prevent a large amount of diarrheal disease; improving agriculture outputs (esp. protein, vitamin A; raising chickens and eating their eggs and livers would do wonders) would improve nutrition. Of course, business development improves all areas with more money to spend on needed things.

[13] Another consideration is that without the limited ‘insurance’ side, it’s not necessary to make this a monthly ‘plan’. In essence, a health plan without insurance is simply pre-paying for health services from the buyer perspective. The primary advantage to doing so for the buyers is to help them set aside money aside regularly for services we (the provider) think they should buy. The primary advantage to the provider is that health money can be pooled and invested in the community’s health; for example, no one person could make a health fair where doctors are within walking distance and services, by virtue of massive volumes, are inexpensive. But there is a small insurance component to it: not everyone is going to need emergency transport, not everyone is going to get pneumonia, not everyone is going to come to the health fair.

Also, with a limited plan, it limits moral hazard (doing dangerous stuff because you're covered) by only providing limited treatment to diseases which aren’t preventable, and prevention to diseases which are expensive to treat (HIV, Malaria). Because services are limited, it prevents providers from feeling the incentive to do more things. They’re not paid commission on the drugs they sell, and they only have a limited number of services. This would be taking Britain’s approach to limiting healthcare spending: limit the supply of medical services (you can’t get an expensive MRI if there aren’t any near you).

2 comments:

  1. A few things:


    "While we cannot forget that people in the developing world are dying of cancer and heart disease, traditional Coronary Artery Bypass Grafts aren’t even close to appropriate for those

    earning a dollar a day.
    I am not sure if this correct information. I learned that these are largely diseases of the developed world, and that the developing world is disproportionately affected

    by the other diseases you mentioned.


    I also think that there are a few important considerations which you neglect to mention (though I hope you already recognize or will come to recognize as being essential the success of a

    healthcare plan designed for the poor, or any so-called "development project") is CULTURE, LOCAL GEOGRAPHY, and CAPITAL.


    CapitalWho will provide the time and money to train local health workers? Even if we fundraise money, or pay out of pocket, will the income from patients be enough to sustain the purchase of

    medicine, maintenance of the clinic, salaries, etc. once the NGO leaves? These endeavors require a tremendous source of starting capital. Sure, NGOs may be able to provide this. But once

    the NGOs leave, it is the responsibility of either the local government or national government to sustain this rudimentary healthcare infrastructure. However, currently, national governments do

    not place healthcare as a priority, so their policies, and subsequently, the distribution of funds, certainly reflects this. This is in part because of geopolitics. Some of these national

    governments have been burdened by debt accrued during past authoritarian governments installed by Western countries (from exploitative economic self-interest), so must simultaneously try

    to pay off that debt while trying to develop infrastructure for things like healthcare. This is why a lot of attention lately has been on advocating for the World Bank and International

    Monetary Fund to write off those debts. So you see, what you end up describing setting up a healthcare system which is not supported monetarily by the national government. The question

    is, is that sustainable? Where is the money going to come from?


    In your footnotes, "There is a lot of potential synergy with these seven and other areas of development. Improving water and sanitation would prevent a large amount of diarrheal disease;

    improving agriculture outputs (esp. protein, vitamin A; raising chickens and eating their eggs and livers would do wonders) would improve nutrition. Of course, business development improves

    all areas with more money to spend on needed things."
    However. Well, there are many things that I would like to respond to in that last sentence. Which gets into my next point about

    culture and local geography.


    Culture and Local GeographyThe success of ANY development project, whether in the realm of improving water sanitation, improving agricultural "output", or starting sustainable business relies on an understanding of the

    local CULTURES within each country and the local geography--political, cultural, AND ecological geography. For instance, there are several stereotypical failed (though well-meaning) types of

    development projects, which we ("we" being the benevolent Western countries and I use "benevolent" sarcastically) have largely failed to learn from. There are two particular examples from

    food production which I would like to share:


    (1) Seeds One approach targeting food production has been to improve the "productivity" or "yield" of the seeds. However, this gets into complex geopolitics. Biotechnology firms

    have jumped on the opportunity to customize corn seeds, which grow well in temperate climates like in California, to the climate zone of the target country in Africa. HOWEVER, while these

    corn seeds do have higher yields -- much greater yields than those of the native African species of corn -- their growth relies on large quantities of (a) water sustained over the course

    of several months, (b)fertilizer (which is petroleum-based, and must be bought from foreign sources), among other factors. MOREOVER, these bioengineered corn species are not

    adapted to the local pests, so their growth also relies on large quantities of (c)pesticides.

    THUS, (a) farmers are forced to utilize foreign irrigation "development projects" (which I will get into next) to deliver water to these greedy bioengineered plants, while the native African

    corn species that they used to grow could depend on the seasonal flood and rainfall patterns of that respective locale. (b) Because these bioengineered corn species depend so

    heavily on fertilizer for their impressive yields, and fertilizer is a petroleum product, these yields are inextricably tied to the price of petroleum. When fertilizer is subsidized by an NGO for two

    or five years, the farmers are fine. However, once those subsidies run out, the farmers must purchase fertilizer themselves. And that is at the whim of the petroleum market. When petroleum

    prices increase, the price of fertilizer increases, and farmers cannot afford to fertilize their "high-yield" bioengineered corn bestowed upon them by their foreign "benefactors". WHEREAS, the

    soil upon which African species of corn grew -- especially in the Sahel region of West Africa -- were fertilized seasonally by the feces of the nomadic herders' herds.(c) Because these

    bioengineered corn species do not have the resistance to pests or the genetic diversity that native corn species would have, farmers must purchase pesticides, in addition to their water and

    fertilizer expenses. However, the native pests will eventually evolve to be resistant to these pesticides (not unlike antibiotic resistance of bacteria) and the bioengineering companies must

    continually engineer new forms of high-yield corn, and IRONICALLY, injecting bits of the genetic diversity of African corn species in their seed banks.

    My point in relaying this example is that it applies to the failed "Golden Rice" (with vitamin A) which you mention. Of course, you may argue, isn't something better than nothing? Well sure,

    but by failing to consider cultural and local geographical factors, these development projects -- including those that target public health issues and health infrastructure -- surely will fail

    because they are not sustainable. This means that the successful (or perhaps it is more appropriate to say, the "more successful") development projects, and in the case of public health-

    directed development projects, will utilize the existing cultural infrastructure (i.e. religious beliefs, family structure, societal structure--patriarchal/matriarchal/etc., education/socialization

    system, local governance, etc.) already in place (i.e. village healers, who also care for spiritual health) to affect positive change in some aspect of community health.


    (2) IrrigationThis is another example in which a well-meaning development project has failed, and has done more harm than good. Though, perhaps if approached differently, it could have been more

    successful (and by this, I mean effective). I would write it all out (and perhaps I should, since you may not remember if I tell it to you over the phone), but for the sake of limiting the word vomit

    in this rather, lengthy, comment of mine, please ask me the next time we talk, and before you go to Kenya. There is a lot more to say on this subject.

    ReplyDelete
  2. I learned that these are largely diseases of the developed world, and that the developing world is disproportionately affected by the other diseases you mentioned.You learned wrong! :) Actually, we’re both right. They are indeed ‘diseases of the developed world’ (as in we get them more than other diseases). In the developing world, they’re a bigger-than-you-thought-and-growing problem (especially as people start living past 40). WHO’s report on Global Burden of Disease is superb (Google it), but this image is prettier: Image it is the responsibility of either the local government or national government to sustain this rudimentary healthcare infrastructure. Actually most healthcare systems around the world are split between private and public dollars. And modern medicine started private and then shifted public. In the US, we’re about at 50/50; before the Great Society, government only paid for small amount of healthcare. Today in the US, Rich and middle class pay ~10% of their income for healthcare; poor people pay a higher portion. In thinking about these problems, we often underestimate the capabilities of those we are helping; $1/day isn’t $0/day. Even if a farmer can save $0.01/day (one tenth of the proportion the rest of the world pays for healthcare), he could buy his family an ITN in about a year, which would significantly improve their health. Nevertheless, it is certainly fair to say that there is a level of poverty where savings is not feasible (it is reasonable for a man to not save even a grain of rice if he is starving), and perhaps that level is at $1/day; I’ll find out.

    So you see, what you end up describing setting up a healthcare system which is not supported monetarily by the national government. The question is, is that sustainable? Where is the money going to come from?I didn’t state this, but I assumed an inconsistent national system, so one of the goals is to minimize the need for national government aid. Ideally, I’d like to have it cheap enough that even the rural farmers we’re working with can afford to pay for it out-of-pocket. If the government steps in later and give free healthcare, wonderful; that’s money our farmers can invest elsewhere.

    My point in relaying this example is that it applies to the failed "Golden Rice" (with vitamin A) which you mention.I am very ignorant on agriculture. I actually didn’t know that one of the fortified nutrients of “Golden Rice” was Vitamin A. I am very thankful for your full post on the history; I’ve only heard that superficially and I appreciate knowing it in greater depth. When I said “improving agriculture outputs” I meant it simply and naïvely. I meant simply “more food” without prescribing a means to that end apart from maybe thinking about livestock (chickens) for protein and vitamin A. I mentioned Vitamin A because it’s what has been reported as a common nutritional deficiency in Kenya.

    by failing to consider cultural and local geographical factors, these development projects -- including those that target public health issues and health infrastructure -- surely will failYou are absolutely correct! This was an assumption. And if I am to be a good engineer, I need to state my assumptions. Thank you for pointing out its omission.

    for the sake of limiting the word vomitNot at all! I am extremely appreciative of your comments! Especially as full a critique as this one! Do not ever feel like a post is too long! I would love to hear about irrigation next time we talk.

    ReplyDelete