|
background resources in PDF |
|
|
|
some CAM/IM publication links |
|
|
|
|
Written by John Weeks
|
|
Sunday, 14 December 2008 |
|
June 23, 2009
The good news is
that, if you missed the 2009 North American Research Conference on
Complementary and Integrative Medicine, May 12-15, you can still access
much of the wonderful cornucopia of what it offered. Innovision Health
Media created an internet-available, searchable database of the 300+
abstracts of the keynotes, workshops, diverse symposia, posters and
discussions which 810 of us from 24 countries had a chance to sample.
This article introduces you to a few of my favorite things regarding
the Conference's interdisciplinary content, educational sessions, whole
systems and health services research. Make a mental note to attend the
third in a line of these every-3rd-year gatherings, sponsored by the
Consortium of Academic Health Centers for Integrative Medicine and 26
Participating Organizations, as tentatively planned for 2012. More
June 18, 2009
Poll
on health reform finds public favors investment in prevention over
treatment by 4 to one margin ... Obama on acupuncture and prevention
... U.S. Senator Murray goes to bat for expanding chiropractic to all
VA facilities ... Bravewell Collaborative announces "important evening"
in Washington, D.C. November 4, 2009 ... AAAOM renews push for
acupuncturists in medicare, federal employee benefits ... Chiropractors
challenge Office of Inspector General Report on over-payments ...
Massage accrediting agency names Henrioulle as executive director,
Schwartz as top volunteer ... Association of Chiropractic Colleges in
expanded role internationally, meet with Sebelius at WHO meeting ...
International organization of health services researchers in
complementary and integrative medicine meets in Brisbane, educator
meeting in England ... Society for Integrative Oncology focuses on
whole systems, interdisciplinary practices, at November 2009 meeting
... MSNBC series negative on CAM, 76% of in reader poll "skeptical"
about alternative medicine ... Oregon Public Broadcasting stimulates
online debate over prescriptive rights and primary care in naturopathic
practices ... Gawande's New Yorker article on money-making
corrupting medicine makes Obama's must-read list ... 2.5-year-old
community acupuncture clinic, Communi-chi, provides 5000th patient
visit ... Educators offered free access to online version of American
College of Physicians CAM book. More
June 17, 2009
So what does the
youthful new president of the United States of American think about
complementary and alternative medicine? Despite very positive comments
about the importance of prevention, we've seen nothing on this topic
from Barack Obama other than a campaign-era letter of support for
chiropractic. Thanks to a questioner in a public forum last month, we
now have more of an answer. Here is the transcript of those comments,
in full. The short answer: Obama wouldn't mind a massage, thinks
science has shown some value in acupuncture, and links this subject
with his administration's efforts to promote a prevention orientation
via healthcare reform. Obama is articulate about the resistance to
prevention orientation in both the political and healthcare arenas. It's a rich exchange involving science, prevention and politics, mixed in with a little humor. More
June 17, 2009
In mid-May, the
private-sector powers-that-be in US healthcare announced that they had
a plan to cut $2-trillion from US medical expenses over a 10 year
period. The much-publicized offer from the American Medical Association
plus American Hospital Association plus insurers plus pharmaceutical
industry (with a token union thrown in) was characterized as "unlikely
bedfellows" by an AMA spokesperson. Sounds like a lot of money to give
back, doesn't it? Never mind for a moment that when Obama asked them
for details, they only found $1.7-trillion. But some simple
mathematics, informed by thinking from the Institute of Medicine (IOM),
suggests that this target is not only extremely unambitious, it may be
a largely self protective gambit. The differential between what the ruling stakeholders in US medicine are willing to consider
ceding back to the public and what they ought to be ceding based on an IOM-based projection for a
rational, non-wasteful, less harmful system, is between $633-billion and $1.15 trillion per year. Rather than unlikely bedfellows, we seem to be seeing here the circling of the wagons by medicine's economic oligarchy to hold onto the profits from waste. More
June 10, 2009
In Michael Levin's controversial perspective in a recent Integrator column he wrote: "Pepsico knows the truth: taxes, not education, reduces (poor lifestyle choices)." His column provoked Integrator adviser
Sheila Quinn to this thoughtful look at the obstacles to good education
penetrating our thinking, and shifting our habits. Quinn's conclusion is
also that mere education is limited: "Health has to be FOR something."
Quinn, recently the co-author of 21st Century Medicine: A New Model for Medical Education and Practice,
urges that we as a community, together with our policy-makers, spend
more time exploring the carrots of positive incentives rather than
merely the sticks of higher taxes. Could be a key step toward U.S. Senator Harkin's new "wellness society." More
June 9, 2009
Two
recent articles underscore a key battleground in healthcare reform the
conflict between patient-centered care and any other foci, whether MD
interest, money-making, or some combination. The Institute for Health
Improvement's Donald Berwick, MD, MPP, arguably the most influential
physician of our time, offered a 10-page critique of prior health
reform efforts in Health Affairs. He declares himself an
"extremist" on behalf of a patient-centered and consumerist approach to
care. Meantime, physician-journalist Atul Gawande, MD, writing in the New Yorker,
explores the Texas town of McAllen, where healthcare costs are highest
in the nation. He concludes that the culture of medicine has been
systematically overrun by the money-making motives in McAllen's
physician and delivery community. Gawande resists arguing for it, but
makes clear that it is employed physicians, rather than for-profit
physician entrepreneurs, who are more likely to put patients and
teamwork, first. Late-breaking: The New York Times reports that Obama has made the Gawande piece mandatory reading. More
Issue #63 - May 31, 2009
May 30, 2009
Integrator writer
Daphne White, CHTP, wrote two April 2009 features on Obama's $1.1
billion comparative effectiveness research (CER) initiative which Obama's budget
director Peter Orszag believes is a key to reforming our medical system. White's
insightful piece spoke of the "Kabuki Play" in the first "listening
session" on the initiative. This article details the impact of White's
work as both journalist and an advocate for the integrative practice
community playing a role in this dialogue. Noted here are links to the
inclusion of White's testimony in a government report of the meeting, a letter to
the Coordinating Council from Integrator reader Emily Kane, ND,
LAc, and the linking to White's articles by Stanford Wellsphere, the
Association of Clinical Research Organizations and others. More
May 28, 2009
Vicki and Ron
Simms back ambitious new integrative oncology center at UCLA ... U
Virginia adds acupuncture to employee benefits ... California budget
crunch sweeps acupuncture, chiropractic, other services out of Medicaid
... Sullivan column presents employer booklet as key guide to health
reform ... Cherkin acupuncture-toothpicks study generates significant
press ... Minnesota Medical Association dedicates entire monthly
magazine to integrative medicine in its state ... NARCCIM research
conference draws over 800 from 24 countries ... Massage Research
Foundation under Diana Thompson, LMP makes strides in stimulating
research in that field ... Tai Sophia Institute: snapshot of a growing
budget ... Holistic nurses expand certification offerings ... AANP, the
naturopathic professional association, announces new journal and
website ... Natural Products Foundation publishes data on the
$60-billion that the dietary supplement industry contributes to the
economy ... American Botanical Council reports growth of the botanical
industry in 2008 to $4.8-billion ... Frank Nicchi, MS, DC elected
president of the Association of Chiropractic Colleges ... Researcher Gert Bronfort, DC, PhD honored, plus
transitions for Crites, Schwartz and Corcoran. More
May 21, 2008
Antonio
"Tino" Villani has trafficked in pain for 30 years as a managed care
executive and as a chiropractor. The two stakeholders, as he writes,
are part of a huge industry that has grown up as we moved, culturally,
from bearing pain to muting it. But Villani attributes his greatest
learning about the subject to the period when he was leaving his
practice and seeking to empower his patients to take more charge on
their own. His book, Pain is Not a Disease, is a very approachable read which is a great device for re-thinking our relationship to pain. It is laced throughout with quotes that deepen reflection and help in Villani's goal of transforming our relationship to pain. I conclude this review with some thoughts stimulated by the book regarding two recent experiences with pain prescriptions. More
Issue #62 - April 28, 2009
April 28, 2009
In this section of a two-part series, Integrator
contributor Daphne White, CHTP focuses on the political-economic
dynamics behind the $1.1 billion "clinical effectiveness research"
(CER) initiative. White examines what she calls the "Kabuki play" -
intense dynamics as the medical industry seeks to gut the value of the
initiative, while not appearing to do so. Would you assume that this
initiative would look at cost or would inform the care people receive?
As White points out, Congress appears to already have caved in on key
aspects of apparent value. One wonders if CER can be the point of
leverage for reform which White House Budget Director Peter Orszag
thinks it can be. And if Orszag can't get what he wants out of CER,
what might the integrative practice community extract from this big
money battle in which maybe we can't, well, talk about money. In White's other piece on CER, she explores the potential value of CER for the integrative practice community. More
April 28, 2009
The idea of
"comparative effectiveness research" (CER), the new $1.1 billion
economic stimulus program, strikes a happy chord for many in the
integrative practice community. Isn't this the appropriate research
terrain for showing value of integrative care? In this first of two
part Integrator series, reporter and regular Integrator contributor Daphne White, CHTP, shares how she attended the "listening
session" of the government's CER advisory board to understand what was
going on and see if the integrative practice community was showing up.
White ended up taking off her journalist hat and testifying. She shares
her perspectives on why and how the
integrative practice community should be involved. White's other piece on CER is a
very well-reported analysis of the "kabuki dance" she witnessed as
vested medical interests developed their strategies to make sure that
the CER initiative does not gore their own oxes. More
April 28, 2009
On March 5, 2009, Barack Obama convened a White House Forum
on Health Reform in which the administration underscored its commitment
to take on the nation's crisis in its medical processes. A month later, on
April 8, 2009, Obama acted again by establishing the White House Office
of Health Reform. For perspective on these developments and what they
mean to integrative practice, the Integrator turned to Wayne
Jonas, MD, president and CEO of the Samueli Institute, where Jonas has
led the development of the ambitious, and long overdue, Wellness
Initiative for the Nation (WIN). In this invited column, Jonas notes
shortcomings of current thinking and the pressing need for an "Executive office to focus
specifically on developing policies and programs for lifestyle-based chronic
disease prevention and management, integrative health care practices and health
promotion." This posting also includes the full Executive Order. More
April 28, 2009
The
American College of Physicians, representing the nation's internists,
turned to integrative medicine leader Bradly Jacobs, MD, MPH to take
the lead in their textbook on complementary and alternative medicine.
The book, An ACP Evidence-Based Guide to Complementary and Alternative Medicine, lives up to its
billing To evaluate evidence, the editors use, uniquely for this field,
the GRADE Working Group method, also favored by the WHO, the Cochrane
Collaboration and others. Appropriately, the editors also introduce
readers to some of the challenges regarding evidence for these fields.
While the chapters are provided almost entirely by MD authors, the
co-editors include a substantive appendix on "Systems of Practice" for
which they took consultation from leading members of complementary
healthcare disciplines. The success of the text, excellent for its
audience, may be a plebiscite on whether medical doctors, and
internists in particular, believe it's finally time to pay attention. More
April 25, 2009
Holistic
nurses take on Catholic Bishops over Bishops' position against Reiki
... Oregon Collaborative for Integrative Medicine, nation's top
inter-institutional effort in integrated care, expands action ...
Minnesota Center for Spirituality and Healing strikes strategic
alliance with Alternative Medicine Clinic of Hennepin Faculty
Associates ... Community Acupuncture Network seeks NADA alliance in
opposing first professional doctorate for acupuncture and Oriental
medicine field ... Survey shows low uptake of key NCCAM research by
internists, acupuncturists, naturopathic doctors and rheumatologists
... Significant CAM/IM chapter by Academic Consortium for Complementary
and Alternative Health Care in new textbook, Collaboration Across the Disciplines in Health Care
... AAAOM hires DC lobbying team, including former NIH and
Congressional staffer Beth Clay ... Chiropractors set up ChiroVoice.org
to foster patient communication with members of Congress during reform
era ... Pioneering work of Joe Chang, MAOM, LAc shows initial
penetration of licensed acupuncturists in military services ...
IHPM/Intel pilot of onsite manual therapies program show positive
outcomes. More
April 18, 2009
In this
response to the Bravewell Collaboration's listing of evidence-based
medicine (EBM) and reimbursement reform as key factors in any
healthcare transformation, David Cundiff, MD points out that "randomized
controlled clinical trials and other tools of EBM are mostly funded by
special interests and interpreted by researchers paid by those special
interests." Thus "the evaluation of EBM trials is and will remain
controversial." Cundiff, author Money Driven Medicine, argues that one-third of the HEDIS measures which shape insurer decisions on what get covered, are "highly questionable." Sponsors of these measures, Cundiff notes, include a who's who of major pharmaceutical firms. Can one even imagine a level playing field for an evidence-based inclusion of integrative, natural therapeutic approaches? More
April 14, 2009
Did you know
that Pepsico is threatening to move all its operations out of New York
if the state passes a "sin-tax" on soda pop? Integrator columnist
Michael Levin recognized in this story that the giant firm has a rather
strong perspective on whether economic incentives can be a powerful
stimulus for behavior change. Levin uses the story to wade into
questions raised in a recent British Medical Journal article on
what it will take for people to make healthy decisions. Fascinating
piece. Levin invites you to weigh in on the topic. More
Issue #61 - April 8, 2009
April 8, 2009
NCCAM challenged in Washington Post piece ... Consumer Reports
finds highest satisfaction with chiropractors for back pain ...
Economic downturn and consumer-directed healthcare appear to be good
for supplements sales ... American Health Journal and AANP team for
6-part PBS series on naturopathic medicine ... Massage licensing boards
under attack in 2 states ... InnoVision, publisher of ATHM and
other peer-reviewed journals in integrative practice purchased, exits
Chapter 11 ... Lobbyist Peter Reinecke and Jeanne Drisko, MD on
Obama's HHS nominee, Kansas Governor Kathleen Sebelius ... Disease
management giant Healthways appoints Mark Nolting, ND, LAc to head up
integrative medicine ... Andrew Weil's foundation scores coup in
appointing former medical school dean James Dalen, MD, MPH to executive
director ... Two Integrator contributors, Stephen Bolles, DC and Erik Goldman organize conferences on key integrative practice themes, the Vis Medicatrix Naturae, and business success, respectively. More ...
April 3, 2009
The alpha
and the omega of the IOM Summit is the Bravewell Collaborative. The
organization of philanthropists laid down $445,000 to sponsor the
gathering. Bravewell now plans significant additional investment to ensure
that the outcomes have legs in shifting US healthcare. Just after the
Summit concluded, Bravewell issued a statement which included eight
"key factors which should be included in health reform." Here is the Bravewell
list. Are you aligned? What did the Bravewell downplay or miss which
you felt were key health reform outcomes which the IOM Summit began to
shape as consensus? More
April 3, 2009
Molly Punzo, MD, is a veteran integrative medicine practitioner who
established an early program at Hartford Hospital in Connecticut. After attending the February 2009 Integrative Healthcare Symposium and
the first day of the IOM Summit, Punzo argues that the "CAM/IM
movement" is losing its promise, partly through the dominant
therapeutic and economic influence of reductive, green-pharma. While
Punzo doesn't address this, a fascinating question arises: Is it possible that the IOM Summit may be viewed as a corrective measure for not just
conventional medicine, but for the integrative practice movement? I
take a first stab at this in the comment field and invite your
responses. More
March 30, 2009
Interested in making a difference in U.S. health policy? Curious how to
formulate a message and take it to your Congressional representatives
and their staff? Wish to hob-nob with literally hundreds of legislative
staffers? If the answer is yes, you've a chance to do so May 2-4, 2009.
The American Association of Naturopathic Physicians (AANP) has stepped
out of the typical professional box and is opening its "DC-FLI" -
Federal Legislative Initiative - to any individuals who have interest
in the federal legislative process. As Integrator adviser and AANP board member Bill Benda, MD, writes in his invitation from the AANP: "Wellness
and prevention are on the agenda for healthcare reform. Whether they
become law is another matter, and essentially depends upon applied
political pressure – by us." The agenda, I am told, is not naturopathic
centric, but health-centric. Here's hoping that many of you will take
advantage of these training sessions on a range of themes, a lobby day
and a Congressional Reception and Health Fair which last year drew 300
staffers and a handful of Members of Congress and staff, sumptuously
fed by Whole Foods Natural Markets. Take a look at this unique
invitation and schedule of events! Perhaps it will appeal and serve
your needs. More
March 29, 2009
Among the 650
participants in the IOM Summit were a few score professionals who were
invited by the IOM, and in some cases contracted, for specific roles.
Among these were Mary Jo Kreitzer, PhD, RN, FAAN, director of the
Center for Spirituality and Health at the University of Minnesota and a
long-time promoter of inter-disciplinary education and practice.
Kreitzer had dual roles. She was contracted to lead multidisciplinary
team on a paper and she presented on a plenary panel. Elizabeth "Liza"
Goldblatt, PhD, MPA/HA had four significant roles: Planning Committee,
moderator of the panel on which Kreitzer served, facilitator of an
"assessment group"on imagining the future of integrative practice, and
wrap-up panel member. The third report here is from Michelle Simon, PhD,
ND who was invited to be a member of an assessment group on "designing and
building the economic incentives." Simon focuses on her take-home of
key tactics to resolve systemic issues. Enjoy the diversity
and overlap of perspectives. We have the ways to do what we need. Do we have the will? More
March 11, 2009
One sign of the
IOM's good faith effort to bring the best people to the table for the
Summit was the invitation the IOM extended to Richard Sarnat, MD, to
participate in one of the Summit's influential working groups. Sarnat
co-founded Alternative Medicine Integration Group, the business that
has brought us two of the most significant integrative care
effectiveness experiments in the nation (HMO in Illinois, Medicaid in
Florida). Sarnat takes the opportunity to summarize his perspectives on
health reform, suggesting innovative polities, research models and
business practices that came from discussions at the IOM. He lays out
what he believes will support health-oriented, integrative practices
that will break the cycle of of our degenerative addiction to
disease-focused interventions. Sarnat calls on all of us to provide the
grassroots backing that he believes such change will require. More
March 8, 2009
The Integrator is
honored and pleased to present two submissions from editors of leading
publications in the field, relative to their experiences at the recent
Institute of Medicine Summit which each attended. Claire Johnson, DC,
MSEd is editor of Elsevier's Journal of Manipulative and Physiological Therapeutics,
the leading peer-reviewed journal in the chiropractic profession.
Johnson ticks off key principles listed by IOM president Harvey
Fineberg, MD and notes that "integrative healthcare" was an "inclusive"
term, increasingly used, aligned with these key principles. Goldman, a
past Integrator contributor, offers a different take
altogether, a kind of run-and-gun, hopeful-skeptical, guerrilla warfare
dispatch of field notes from an event that often left him wondering.
Goldman, a former bureau chief for Elsevier's International Medical News
Group, edits Holistic Primary Care, which reaches over 100,000
primary care offices of MDs, DOs, DCs and NDs with each publication.
Enjoy the diversity of perspectives from two respected colleagues.
March 7, 2009
When the Integrator's
Daphne White, CHTP observed the February 26, 2009 US Senate hearing on
integrative healthcare chaired by Senator Tom Harkin (D-IA), she chose
to focus on Harkin's introductory comments in which he calls for an
"end to discrimination against alternative healthcare practices." White
then reviews the comments of the sterling panel of Oz, Weil, Ornish and
Hyman.The odd point is that Harkin and Mikulski, after specifically
focusing both of the week's hearing on "integrative healthcare" -
language preferred at the parallel IOM Summit - Harkin announces an
interest in changing the name of NCCAM to "National Center for
Integrative Medicine." White has captured a provocative dialogue. Has
our time actually come? What time is it? We've got a challenge to make
sure Harkin and his colleagues get that right.
Issue #60 - March 2, 2009
March 2, 2009
Plan on the North American Research Conference, May 12-15, Minneapolis! ... New
Jersey med school and massage school for tie in accredited massage
program for service to the underserved ... Resource on school-based
yoga ... Northwestern Health Sciences University has unique
opportunity for new VP/provost ... Licensed acupuncturists beefing up
"action agenda" ... Educator Steiner Leisure in huge contract for massage,
acupuncture, spa, fitness services ... IM leader and Integrator adviser
Bradly Jacobs, MD, MPH, re-emerges at Sausalito-based Carvallo Point
... More on policy: Does the Obama $634-billion for healthcare reform
include a real shift toward wellness? ... Congrats to TAI for an
investment in a relationship with U.S. Senator Mikulski, plus AP
article on IOM, Redwood on Jonas' WIN, and Peer Barry Chowka tearing
down the house. More ...
March 2, 2009
We have just
completed the most significant week for integrative health care, at the
policy level, in the history of the known universe. Two U.S. Senate
hearings. The 3-day Institute of Medicine Summit. Many superlatives
were expressed about our time being now. Yet in this very week,
president Obama announced a $634 billion health care fund in which the
follow-up media said nothing on integrative care, and barely mentioned
wellness and certainly no paradigm shift. Many of you were present at
the hearings an Summit. Others, like me, were unable to be present
except through the wonders of modern technology. (Links included
within.) Take a listen or read. What did you think? What are our next
steps? What do you think needs to be more visible? Less pronounced? How
can we gain traction? Participate in this Integrator forum: Send your comments, and a jpg for you mug if you like if I don't already have it - and let's see what we are thinking? More
February 26, 2009
For many of
us, this weeks' "integrative health policy week" in Washington, DC
actually began with the robust Integrative Healthcare Symposium (IHS)
in New York City where a multidisciplinary gathering of 1300 met to
explore policy, practice, science and business issues. Nancy
Gahles, DC, CCH, RSHom (NA), an advisory board member for IHS, offers her review of
pros and cons of the meeting. She explores roadmaps-for-the-future policy panels which
included Wayne Jonas, Josephine Briggs, Mary Jo Kreitzer, Bill Benda
and others. Some of what she experiences she celebrates. At the same
time, Gahles, president of the National Center for Homeopathy, challenges
the MD-centrism of much of the content and wonders whether these roads
will take us "back to Rome?" It's a thought provoking,
homeopathic-centric review. If you attended, what did you think about
the inter-disciplinary balance at the IHS? Thank you Nancy. More ...
February 24, 2009
Integrator
readers: Here is a treat. Beltway resident, reporter and healing touch
practitioner Daphne White, CHTP reports for us on the historic February
23, 2009 U.S. Senate hearing on the "principles of integrative health
care" chaired by Barbara Mikulski (D-MD). Milkulski gets it. White
quotes her: “'Wellness is not a silo, prevention is not a
silo.'” Then: "Integrative health needs to be at the center of all health care
discussions: 'Is that what you are saying?' Mikulski asked. Yes, the
panelists answered." White's article guides you to the hearing, and to links to the submitted papers of each of the panelists. Enjoy this report. More ...
February 23, 2009
When I published my list of the Integrator Top
10 from 2008 and left open #10 for your input. First, Bill Manahan, MD,
offered his own list of 10 ideas for revisioning healthcare, and a
couple of people quipped that the honoring of the AANP was too high, or
premature. Then a half-dozen other ideas drifted in. I have been slow
to assemble these. Here they are, finally, in various forms: Pathways
to Wellness, the Myrna Brind Center, the National Center for
Homeopathy, the "new family care
doctor's office," and a suggestion that we take a collective
back-patting for the resilience we are showing as a community. More ...
For earlier articles, please click below:
Issues #55-#56 - Nov-Dec 2008
Issues #47-#50 - July-August 2008
Issues #45 & -#46 - May-June 2008
Issues #43-#45 Mar-April 2008
Issues #41 & #42 - Feb 2008
Issues #39 & #40 - Dec-Jan '08
Issues #37 & #38 - Nov 2007
Issues #35 & #36 - Oct 2007
Issues #33 & #34 - Sept 2007
Issues #30-#32 - July-Aug 2007
Issues #28 & #29 - June 2007
Issues #26 and #27 - May 2007
Issue #25 - April 2007
Issues # 23 & #24 - March 2007
Issues #21 and #22 - Feb 2007
Issues #19 and & 20 - Jan 2007
Issues #17 and #18 - Dec 2006
Issues #15 and #16 - Nov 2006
Issues #13 and #14 - Oct 2006
Issues #11 and #12- Sept 2006
Issues #9 and #10 - Aug 2006
Issues #7 and #8 - July 2006
Issues #5 and #6 - June 2006
Issues #3 and #4 - May 2006
Issues #1 and #2 - Apr 2006
All Postings to Aug 15, by Subject Matter
IAYT-Sponsored Series on the Future of Yoga Therapy
Or go to Archive, lower right column, on the home page.
Technorati Profile
|
|
Last Updated ( Tuesday, 23 June 2009 )
|
|
|
|
Subscribe to the Newsletter |
|
|
|
Do the Math: The Medical Industry Plan to Cut $2-Trillion is a Gambit to Save Their Bacon
Pain is Not a Disease: A Look at Antonio Villani's Book on a Timely and Costly Topic
