Via Alex Tabarrok at Marginal Revolution, Michael Mandel has produced an excellent example of a point that is a repeated theme around here: artificial scarcity in healthcare. In his report Dr. Mandel considers the case of a medical device, Melafind, and its failure to receive approval from the FDA.
Melafind is (or was) a handheld computer vision device and expert system designed to detect and identify skin melanomas, the most serious form of skin cancer. Melanoma is common and, sadly, on the increase.
In order to get approval, Mela Sciences, the company that created MelaFind, did a multi-year study of the accuracy of the device compared to a panel of dermatologists. The company claims that it passed the test that the FDA had agreed to.2 Indeed, on some dimensions of the study the device did better than the panel of dermatologists. Nevertheless, the FDA staff deemed the device “not approvable,†saying that MelaFind “puts the health of the public at risk.â€3 Despite the strong negative response from the FDA, the company requested that the device be assessed by a panel of dermatologists, statisticians, and other medical experts. The advisory panel met in November 2010 and voted narrowly to recommend approving MelaFind.4 Nevertheless, the FDA has not yet approved the device.
Why has the FDA withheld its approval:
- The device did not do better than the experienced dermatologists in the study (“the FDA review team does not believe this is a clinically significant difference between MelaFind and the examining dermatologistâ€)
- The device was tested on lesions identified by experienced dermatologists, not on the broader set of lesions that might be identified by “physicians less experienced than these dermatologists.â€
- The device did not find every melanoma in the sample (“Since the device is not 100% sensitive, if use based on the device’s diagnostic performance reduces the number of biopsies taken, harm could ensue in the form of missed melanomas.”)
- The device was not demonstrated to make inexperienced physicians the equal of experienced dermatologists (“Currently, formal training is offered to physicians to become board certified dermatologist and thus be able to diagnose clinically atypical lesions. The FDA review team would have to compare this board certification training to that offered by the sponsor to those physicians operating MelaFind to determine if it is found adequate.â€)
No first generation device could meet the standard that’s being set out here and by withholding its approval the FDA is ensuring there will be no second generation. It is inevitable that investment will dry up for approaches and devices that can’t get approved.
If Melafind’s case is as its being reported the FDA would appear to me to have exceeded its statutory authority and, again assuming that the facts are as outlined, if the FDA’s actions has acted within its authority, its authority should be revised.
From my point of view there’s a larger lesson here. The FDA should be determining effectiveness and safety not pickiing winners and losers. A standard of “must do better than experienced dermatologists” and “must be 100% sensitive” is telling (are all board certiied dermatologists 100% sensitive?).
The FDA is voting to preserve the status quo. Accordiing to the BLS the median dermatologist earns $215,000 a year, the median GP $180,000, and the median PA half that. Not every lesion is biopsied and it would be needlessly expensive to do so. If the FDA is trying to establish medical policy it should be considering whether many more inspections, aided by Melafind, would be more effective not to mention less expensive than an infrequent or nonexistent examination by a dermatologist.
The essential question is not just one of effectiveness and safety but of how healthcare is supplied. The FDA apparently has a vision of a future in which a relatively small number of highly trained physicians have incomes rising far faster than the average persons and far faster than GDP, something we very clearly cannot afford. My vision is that in every drugstore there will be descendants of Melafind that can inspect, identify, and painlessly remove malignant melanomas of the skin so inexpensively that it will encourage their frequent use. The future should be one in which healthcare is abundant, not artificially scarce.
This is just so contemptible of the FDA. The average American never sees a board certified dermatologist. If they’re lucky they see their GP once a year.
As it happens I was at my dermatologist yesterday (I had a round of harmless but scary basal cell, so I got religion,) and he said basically if everyone with fair skin saw a dermatologist every six months the death rate from melanoma would plummet. Something that kills thousands of people every year could be dealt with using in-patient surgery with a local. Or even prevented altogether by cheap and easy freezing.
An app that found another 20% or so of early stage melanomas could save a couple thousand lives, cost nothing, save tens if not hundreds of millions of dollars.
That brings up an area in which I think there’s great potential for growth: USB add-ons for phones and pads.
As a guy who actually had melanoma and thus requires frequent checkups and occasional biopsies, reading this really pissed me off. I was lucky that mine was caught early thanks to a good GP who thought it looked weird and then gave me a referral to a dermatologist. If GP’s had this device they could do more routine skin checks. Obviously, if a mole looks weird and the device says it’s not melanoma the GP could still do a referral to a dermatologist for the expert opinion.
Secondly, I agree that the idea that a device should be so accurate that a doctor’s judgment is unnecessary is ludicrous, which appears to be the FDA’s standard.
I think apps like this have their greatest potential outside of the doctor’s direct purview. I don’t know if this app could do it, but you could surely devise an app that scanned your entire body and stored the HD image and compared it to a second scan done 6 months later. It would highlight areas of change, and then take a closer look at the specific area and give you a simple “See a doctor” warning or a “Don’t worry about it.”
As you suggest, Dave, the market for medical attachments to a phone or pad could be amazing. With a camera enhancement a phone app could screen for oral cancers, and as with skin cancer keep a record of previous scans far more efficiently than a dentist can do now.
In the meantime at the very least doctors could switch from paper to iPads. I’m moving so I picked up my medical records to take with me. Half an inch of paper. Is there any reason it’s not a PDF I could email to my future doctor? Or better yet that lived in the cloud so it would follow me effortlessly to an emergency room?
Michael,
I would love that app. As it stands, I have my wife take pictures of my various moles that need watching and then I manually compare them to earlier pictures and bring prints to my dermatologist if needed. They actually have equipment to do the whole-body picture (my derm told me about it a couple of years ago), but it wasn’t covered under my insurance and wasn’t available locally. It’s also more convenient for me to do it at home than to have to make an appointment, go to an office, and deal with insurance and such.
Records are definitely a PITA as well, especially for referral doctors.
Michael- There are not really any good electronic medical records. We desperately need some. There are a couple of ok ones, AFAICT, for outpatients. The ones for inpatients are all flawed. The ones for the OR require that I spend more time filling them out than paying attention to the patient unless it is a long case.
Steve
On the other hand, In Medicine, New Isn’t Always Improved
Your beloved government regulation at work.
Drew:
I don’t think the government is the reason why the pediatricians at the office in Newport Beach can’t share records with the office in Costa Mesa. Feels a lot more like private sector incompetence.
Same for billing that has to go first to Blue Cross to be routinely rejected then sent on to me by snail mail.
Same with the fact that I can’t get Zocor approved on the 24th when I’m at the CVS but can get it three days later requiring an extra trip. And same with my doctor’s need to see me for an office visit to renew a scrip even though she runs no tests and I’ve been on the stuff for 15 years or so without side effects.
Then there’s the fact that the closest I’ve yet been to a serious problem (MRSA) came from a lazy doctor who didn’t bother to wash her hands before checking lymph nodes and loading the razor burn with lovely little germs.
Blame the gubmint is really mostly bullshit in real life.
Just so my position is clear, I don’t believe that we should dump the FDA. We’ve been there, done that, don’t want to go there any more. What is needed is better oversight, possibly a re-write on the FDA’s statutory authority, and a change of culture.
Defective departmental cultures are endemic in the government. To some degree that’s inevitable but, paradoxically, I don’t think the solution is anarcho-capitalism. In part I think we’re paying the penalty for extraordinary political stability over an extraordinarily long period of time.
Michael –
The “private sector” is simply following the lead of their overlords, the government model third party payer system. And all that you bitch and whine about today like an old woman is really just a hopstop on the way to full government takeover of health care. Gird your loins, dude. If you really cared about your personal situation, and the general populace, you’d quit whining for the feds, and call for a real private sector solution. God forbid the feds make judgment on your lipid profile.
But you are either blinded by ideology, or just want to foist your personal bad gene luck on the rest of us. I know your parasitic type.
BTY – my initial adverse cholesterol diagnosis: 660. Heh. Almost the devil number! Unlike you, I don’t advocate that my neighbor bare the costs. I have reacted accordingly. You? Although a man of reported financial means (or are you a liar?), and an advocate of greater taxation for your neighbor……..you want to suck at the public teet for your personal issue, Zocor piggy. Suck. Suck. Suck, Little Piggy.
Sure you would pay more taxes, if only you could, as you tell us all the time, Michael. Sure you would.
Drew:
So, explain this to me. The pediatric practice we use has two offices available to us — different days. And the Newport office and the Costa Mesa office can’t somehow manage to share records. Call the one office and they have no idea what’s going on at the other office. All owned by the same doctors. So walk me through the steps on how this is the fault of the government.
As soon as you explain that to me, feel free to proceed with your rather odd rant about how, by paying $2400 a month against a $3,000 deductible to insure a family of four, I’m sucking at the federal teat.
Michael and Drew,
To me your argument is like two people debating whether Hitler was worse than Stalin (Godwin’s law invoked).
Frankly, I don’t have an ideological axe to grind so I couldn’t care less whether government or private sector health care is relatively worse. In my opinion they both suck and furthermore they are symbionts so arguing we should favor one over the other is rather pointless.
I think someone is blowing up what is really “sent back for testing” – in particular if the device is to be used by non-dermatologists, it’s vital to test that way.
“Test as delivered.”
You do not use dermatologists as test users and then deliver to GPs.
(Bullet point two is the big gotcha.)
(JP who has worked on FDA cleared medical electronics.)
Andy:
I agree. I think inefficiency, corruption and stupidity are equal opportunity afflictions. I don’t have religious faith of any kind: God, Capitalism or Government.
” If you really cared about your personal situation, and the general populace, you’d quit whining for the feds, and call for a real private sector solution. ”
Which would be what? Please provide an example anywhere in the world where this has worked for health care.
Steve
Michael –
Look, just busting your ballxs. You come here routinely and tell us how you’d just “write 10 more pages a day” to pay for tax increases. You tell us you are involved in projects that “people are throwing money at me.” Well, so the tax increases you advocate for everyone might cost you, what, $10K, 20K, 30K a year?? And you are here telling us you need government support for your Zocor??
How does that work, dude?
As for this:
As soon as you explain that to me, feel free to proceed with your rather odd rant about how, by paying $2400 a month against a $3,000 deductible to insure a family of four, I’m sucking at the federal teat.
Its called a premium, a dead weight expense paid against the risk of catastrophic expense borne by others. Its called insurance. Get real with us, Michael. I know you know better. That was awful.
Micheal –
I forgot to post this. And I’m actually being dead serious now. I’ve been on statins, resins, done the niacin thing etc. Nothing really worked. But hear me on this. Please really think about it. My numbers came down when I started taking fiber (psyllium husks) every day. As I understand it, cholesterol is re-absobed in the gut as a natural body function. But if you have large amounts of soluble (sp?) fiber floating around it will absorb the fats and, uh, they will be eliminated. Ahem.
Our resident doc, steve, may have a point of view. But it has worked for me.
Now, I know you will want ObamaCare to pay for your husks……sorry, I couldn’t resist.
Seriously, I know of no adverse side effects. Please try it for your health. We need your sorry ass around. But drink alot of water. Alot.
Drew:
When did I ever say I needed government help? For anything?
This isn’t about me. I’m in the process of moving from Irvine to Tiburon which, not to put too fine a point on it, does not have a lot of residents on welfare. (I’m going to guess the number is zero.)
I don’t want to shock you but I care about the people who can’t afford to eat 28k a year in insurance. I don’t want my fellow Americans to die because they can’t pay their bills. Don’t want them hungry or homeless or uncared for. So I’m willing to pay so they won’t suffer too much.
And since I’m a thorough-going atheist I don’t believe in magic, including the magic of libertarian economics or the self-serving, sophomoric drivel of Randism.
Dude, I have three ongoing book series on shelves right now, and a fourth rolls out in March. My wife has a series, two single titles in the can, another under contract, and yet another series in negotiation. (Granted we do have a certain strange genius for getting rid of money as soon as we get it.)
It would be great to hold onto 100% of that income, but I am not an island, I am a citizen of the United States, the nation without whose protection and stability and institutions I would have nothing. My children are Americans. I owe my country. And more than that, I love my country. And that to me means caring about the citizens who didn’t have the un-earned good fortune to be born with a lucrative talent.
(As for cholesterol, I have the numbers of an athlete. Statins worked great for me and Zocor is cheap and generic. But I honestly appreciate the advice.)
“When did I ever say I needed government help? For anything?”
I have a long memory. That’s how this whole (extended) thread started. With you complaining about the need for government health insurance because of your inability to get insured because you moved, if memory serves, from N Carolina.
I applaud, and award you the monthly good citizenship award for, your concern for your fellow citizens. But in the extreme, that’s called Communism, and simply doesn’t work. So the debate is not about concerns, but what are the limits, and what is practical. No sane person is talking about retaining 100% of income. But there are limits to what the burden on the productive, such as you, can be. And after all, if you personally feel you can contribute more, there is no law restricting you, at least last time I looked. You do that, right?
steve routinely comes on and tells us that single payer medical systems work in other countries. Not by my standards. They restrict costs by restricting access. Bad result.
I’m happy to hear you and the wife are doing well in your chosen professions. I’m all about success stories. But this is the classic progression: people become successful and comfortable, decide THEY can pay more, fail to understand that even if every last nickel of income of high earners is confiscated it funds government for a precious few weeks, but advocate policies that of arithmetic necessity flow down to earners of lesser means……. Problem.
Your philosophy has won for years. Decades, actually. But we are broke, Michael. We are about to be bugs on the windshield.
None of that involved federal anything. It was between me and Blue. Then it involved the state of CA because the state of CA has a work-around for group policies. What I pay now is not subsidized, it’s what Blue wants to charge for a group policy for a corporation.
Now, I happen to think that’s a huge waste of my time and energy and Blue could have saved everyone a lot of trouble by writing the individual policy. And I don’t think it’s because Blue thinks I’m unprofitable at 28k a year, I think they choose to focus on the most profitable, lowest risk policies without regard to the human or societal costs. I think that’s just the kind of thing we need government for. For when companies decide screw it, we don’t care, we make more money selling rancid meat than cleaning up our factory, and etc…
I don’t accept, and never have, that corporations or officers are somehow exempt from basic standards of decency. There’s no opt-out on morality. So when Blue decides to boost their return on investment so they can reap higher bonuses for corporate officers by throwing millions of people to the wolves, I think we have a case for government intervention.
But none of this is about me not believing I should pay a reasonable rate, or expecting you to pay it for me. I expect not to have monopolies decide to cut off profitable services in order to concentrate on more profitable services. When they do, they’ve invited government intervention.
And in the extreme, Drew, libertarianism is anarchy. And that also doesn’t work. Isn’t it great that we don’t live in the world of reductio ad absurdum? Here in the actual world the entire developed world has government guaranteed health care. The entire developed world. And they pay a hell of a lot less than we do.
We have the lowest effective tax rates in decades. People of means can afford to pay more, as they do in, say, Denmark, a country with a thriving economy, or in France which lost fewer jobs during this recession than we did.
There are precisely zero successful real world examples of your philosophy in action, Drew. Not a one. Every single country that you or I would ever care to live in is an example of what you call my philosophy.
“And in the extreme, Drew, libertarianism is anarchy. And that also doesn’t work. Isn’t it great that we don’t live in the world of reductio ad absurdum?”
Nice straw man. I already said I don’t believe in keeping 100% of income. How ’bout you come clean with a specific number.
“Here in the actual world the entire developed world has government guaranteed health care. The entire developed world. And they pay a hell of a lot less than we do.”
And the systems stink. Not a compelling argument, Michael.
“We have the lowest effective tax rates in decades.”
No we don’t. I’ve posted on this meme about the tax to GDP ratio a number of times. Its the haven of the inumerate, and the willfully dishonest.
More later.
No, they don’t stink. In fact they deliver superior quality health care to virtually everyone, for far less than we spend. If they stank we’d be seeing shorter lifespans and more infant mortality and maternal mortality and we see just the opposite.
Go back to the Clinton numbers. We all managed to survive that. You’re here, I’m here.
If we really wanted to solve some problems I think we’d move to some version of single payer — Medicare for all — we’d break the AMA’s death grip on doctor training, we’d make more drugs OTC or on-advice-of-pharmacist, we would allow (or encourage the states to) tightly-controlled euthanasia, we’d increase SS retirement age, raise taxes a few points on the well-off, maybe raise a point or two on the middle class as well, kill off subsidies to oil. phase in gas tax increases, connect the dots between foreign policy and military spending, fully legalize pot, and move to increase legal immigration for the most qualified.
Drew- The data for statins is pretty convincing in their ability to decrease risk of an MI. They do have a problem in that people respond differently to different drugs, so you may need to experiment within the two broad classes. One of the interesting things we have found is that add them in right before some major surgeries, they reduce adverse events, even before you would expect them to hav much effect on cholesterol.
That said, I have always thought that good diet, fiber is part of it, takes care of a lot of problems. I would keep the fiber.
Steve
By the way, the long-term object of allowing controlled, safeguarded euthanasia is to begin to change the nonsensical notion that every life should be dragged out to the bitterest end regardless of the cost. An 80 year-old man with terminal cancer has a right to burn up resources, but he has a moral obligation to consider other paths as well.
If we can cut the nonsense about “playing God,” (Like we don’t play God every day) we could perhaps get more people to treat death as a natural part of existence, not some excuse for a futile, all-in, damn-the-cost battle. It’s long past time for us to grow up. You’d think a population that expects to go live in heaven would be more sanguine.
Drew,
I think it’s been like 5 or 6 times I’ve pointed out to you here and at OTB the CBO data on effective tax rates, which have nothing to do with GDP, and you’ve yet to reply. The fact is that federal taxes on the so-called “rich” (top 10%) are, at worst, about average for the last couple of decades and taxes on everyone else are way down. Effective rates on the super-rich (1%) are at or below the mid-1980’s rates. Once again, you can look at the data yourself.
Secondly, who are the “productive?” Just because someone receives a high income does not mean they are productive.
The device did not find every melanoma in the sample (“Since the device is not 100% sensitive, if use based on the device’s diagnostic performance reduces the number of biopsies taken, harm could ensue in the form of missed melanomas.â€)
Yeah, typical. Too bad the doctors can’t find cancer 100% of the time – even if it is pointed out to them. The fucking doctors have basically killed my mother by taking more than a year to run the appropriate tests to diagnose her medical condition, despite the fact that I begged them too, as did she. But instead they pussy-footed around, following “protocol” and refusing to go the extra millimeter. Here recently the asshole doctors wouldn’t even check her into the hospital when she was clearly starving to death because Medicare protocols would not allow her to be checked in for “fatigue” unless she was then released solely to a nursing home. They thought we wouldn’t like that. (Matter of fact, we wouldn’t.) But the fucking worthless doctors didn’t even tell us this was why they were foot-dragging until it didn’t matter.
No, they told me that shortly before putting Mom in the hospital for dehydration. Once she was in, they started running the tests. The asshole doctors then found a big fucking tumor in her chest. The fucking worthless doctors then acted surprised when we informed them that Mom had been having chest & shoulder pain for over a year. This despite the fact that she had been complaining about it for the whole goddamned time to those same fucking doctors.
Turns out it is probably thymic carcinoma. If they had found it earlier it could have been removed surgically. But that doesn’t seem to be possible now that it has wrapped itself around her aorta, pulmonary artery, and other extremely valuable bits of whatnot near her heart. Now if they had found it a year ago….
(They have also found a kidney problem. Mom has been complaining about lower back pain for over two years. None of them bothered to figure that out either. Turns out she has an obstruction leading out of her right kidney. Two years of pain meant nothing to those fucking twats – it was probably just a twisted colon because she didn’t eat enough fiber.)
Of course, time is of the essence now for any treatment. Which is why it has been over three weeks since the cancer was discovered and the fucking doctors still have their collective thumbs up their asses. We’re SUPPOSED to start radiation therapy on Wednesday, but I imagine that will get screwed up somehow. For that matter, they still haven’t told us if the tumor board that decides which cases are operable has even discussed her case yet. We have called three of the fucking doctors involved, and none of them have contacted us yet. Her case was supposed to be reviewed on the Wednesday before last. It wasn’t. Then it was supposed to be reviewed this last Wednesday. No idea if it was or not. Of the three fucking doctors that are on her case and that actually sit on the tumor board, one has told us he has no idea because he missed this week’s meeting, one has been unavailable because he has been doing nothing but heart and lung surgery since Wednesday (apparently non-stop, as he hasn’t even been able to inform his staff of anything), and the third has just been unavailable.
Fucking doctors have fucked us but good. The worst isn’t that my mother is dying. At 83 that is not unexpected. The worst is that she is dying a needlessly painful death because of their fucking vacillations and protocols.
No, that isn’t the worst. The worst is that we’ve seen this before, when the VA fucked over my father-in-law in the same manner over a decade ago. (Three cheers for government run healthcare! {crickets} ) The same needless vacillations over protocols and indifference that are killing Mom now killed him then, and at the ripe old age of 58. They did it to my brother too a few years later, though in his case there was probably nothing they could have done even if they had hurried up and done their jobs.
No, that isn’t the worst of it either. The worst of it is that Mom has been out of the hospital a mere 14 days and the bills from the doctors have already started to come in. How’s that for efficiency? My favorite is (one of the many) $85 charge(s) from Mom’s primary for visiting the patient in her hospital room. Get this – he had to travel a couple of hundred feet to an elevator, take the elevator up one floor, and then travel another couple of hundred feet to get to her from his one and only office. No wonder he wants compensation. But this one particular visit itself is the beautiful part of the story. He breezes into her room on a Friday evening at 6 pm, says “I can’t take any questions because I have to go pack for my vacation†and then tells my mother, sister and brother-in-law that Mom has inoperable stage 4 lung cancer. “Goodbye.â€
Apparently his trip got delayed for a couple of days because he showed up again at 6:40 am on Monday morning. Same story, similar bedside manner. But 90 minutes later the oncologist comes in and tells us another story entirely – thymic carcinoma, probably stage 2 or 3, probably operable, decent prospects for five year survival. “But we need to get her into surgery by the end of this week!” (That was nearly three weeks ago.) Holy fucking shit. The two of them had been looking at the same reports and scans.
But the surgeon thinks the cancer is more advanced than that, as he doesn’t see the delineations he would see in an earlier stage. And the radiation oncologist doesn’t think any of those diagnoses are correct, but what the fuck, let’s zap the fucker ten times anyway. It’s a living, for him anyway.
Taking care of Mom out of the hospital has been fun too. Orlando is a test market for new Medicare procedures. Apparently this is part of the new Obama-care reforms. Outstanding. There is now a competitive bidding process for vendors – only those that win bids from Medicare can be reimbursed by Medicare for supplying a given item. So, we’re getting the enteral feeding stuff (that’s Jevity for those keeping score at home) from Binson’s. But they can’t supply the walker, wheelchair or oxygen. Nope. We got the wheelchair from some outfit called Apria, IIRC, and I probably don’t. And they, of course, couldn’t supply the walker or oxygen. We needed a third outfit (Sunbelt) for the oxygen. The walker is the best part. We can get one from Colonial Medical Supply. The basic model would end up costing us $9.95 plus tax after the Medicare reimbursement. My sister thought we should go with another model. Now that walker would end up costing us $68.95 plus tax after Medicare reimbursements. Or we can get it for $75 at Binson’s and not have to drive to Colonial Medical Supply. Yep, the winning bidder is actually selling it for substantially more than the losing bidder, if you factor in Medicare’s part too. Thank God for healthcare reform. Maybe we’ll get some someday.
So now we wait and see if Mom can even survive to the first radiation treatment. The fucking doctors have diddled for over a year on the diagnosis, and they continue to diddle on whether or not to tell us which (if any) treatment from which (if any) fucking doctor she should get.
But it is good to know that the FDA is protecting that noble profession from any possible challenges from technology. If only the buggy-whip manufacturers had as good a lobby over 100 years ago we could have avoided the entire GM/Chrysler bail-out mess.
So if you want to know why I haven’t been around much, and why I have been extremely pissed off (even by my standards) when I am around, that’s it. My mother is getting fucked by Drew’s hated government regulations and intrusions, Michael’s hated private sector, and steve’s “noble†profession. (“You’re dead. Now where’s my $85?â€) So I say once again, the three of you can fuck off and die with all your bullshit about how much the three of you rich bastards care about all us prols. You’re all just looking to suck the world dry for your own team and fuck the rest of us. I just hope I live long enough to see the world burn. The looks of surprise will be fucking priceless.
* I don’t believe Cassandra realized the one advantage she did have – that is, she should have known where the best seats would have been to view any given comeuppance. Come on, C, we’s gots to get our jollies whence we can!
I am one who has “redheads skin” (and agent Orange) and have had literally hundreds of basal cell and squamous cell carcinomas, one melenoma. I have seem many dermatoligists and can vouch for the quite extensive varibility of dermatoligists abilities to diagnos and remove. . .
I believe a device would be of great help and am sorry the FDA is so $ oriented and is picking winners and losers based on politics and corruption. . . . .