In The News

The Cost of Healthcare in Rural Kenya

Nov 28 2011

Matt Landman
Resident
Kijabe, Kenya
Vanderbilt International Surgery

matt landman kijabe 1

(Photo: Matt Landman at left)

It’s now been one full week since my arrival in Kijabe, Kenya.  Simply speaking, to understand everything I’ve seen and experienced in the past week will take months of careful thought and reflection.   I’ve seen the shackling consequences of poverty, the natural history of surgical disease more advanced than I’d ever seen before, a lack of medical resources, and the list goes on; but, overshadowing all of this, I’ve seen the good several committed people can do at one place in time to positively affect patients and their families for a lifetime. 

My first full day in the hospital was spent in the general surgery clinic.  I use the description “general surgery” but in reality, if forced to label it back at my home institution in the U.S. it would be better described as the general surgery - urologic surgery- otolaryngology -surgical oncology -endocrine surgery -thoracic surgery –vascular surgery-wound care-palliative care clinic. 

I never imagined a more unique conglomeration of surgical diseases coming through the door in a single day.  While the pathology was interesting (and inspiring to hit the books to expand my surgical knowledge) I was most struck by what each procedure meant for the patient—particularly the financial toll.  Instead of flashing an insurance card and putting down a small copayment, each patient (and many times their family) was required to produce a down payment for the recommended procedure.  If they required a cholecystectomy it would be x-amount of Kenyan shillings.  If they required a colonoscopy it would be y-shillings.  Quite foreign to me (and most in the US) was the readily available price tag, if you will, for each procedure (I should note that the payment system was different for emergency cases).  That price tag allowed me to clearly see the financial sacrifice, relatively extreme in some cases, made by patients and their families to improve (or simply maintain) their health. 

I often wonder what would happen to Americans if we were put in a similar situation.  Would we still spend most of our healthcare dollars at the end of life?  Would we be doing radical resections with small chances of cure?  Would emergency rooms still be overcrowded?  What would I give up in order to pay for me or my family’s medical care?  While I’m not sure of the answers, I know that many Americans, as I’ve seen these Kenyans do countless times this week, would step back and evaluate their priorities and healthcare need. 

The knowledge of these costs has another effect.  Physicians are forced to understand their healthcare consumption.   I certainly have been more cognizant here of what each laboratory test, imaging procedure or recommended operation would mean for my patients and have tapered my practice and recommendations to be cost-conscious while maintaining medical effectiveness.   Seeing the results of our operations and care here, I’m confronted with excellent results that don’t necessarily correspond to the amount spent on each case. 

It’s been a week and I’ve learned quite a bit, both medically and professionally.  I look forward to the coming weeks for more experiences in which I can look back and evaluate my role in this place and in surgery as a whole globally and in the U.S.

 

Russian Delegation's Visit Builds Knowledge, Trust

Nov 14 2011

The Tennessean

by Bill Frist

Russian-U.S. relations are complicated and, at times, trying. But since we share a commitment to improve the health of our citizens, there is much we can learn through dialogue and collaboration. And there is no better place to do so than Tennessee, the heart of health-service delivery innovation.

Even at the height of the Cold War, U.S. and Russian scientists collaborated closely to eradicate polio and smallpox. Similar collaboration can lead to mutual benefit for today’s shared challenges, chronic disease and obesity, with a byproduct of improved diplomacy. Collaborations on health-service delivery in Tennessee between Russian and U.S. doctors are a powerful example of health diplomacy and a valuable currency for trust and understanding.

Russia has more doctors, health-care workers and hospitals than most countries, but standards remain variable. Prime Minister Vladimir Putin has committed $16 billion over two years to bolster working conditions, training, and national electronic health records with a promise to trim bureaucracy.

The Washington-based Open World Leadership Center invited 30 health professionals from Kirov State, Russia, to come to the U. S., specifically to Tennessee, to study and explore financing, organization and delivery of health infrastructure and services.

The Russian delegation spent a day in Washington to better understand how health policy is formulated at the federal level and to visit the National Institutes of Health. They then came to Tennessee for a week, spending time in Memphis, focusing on research, and in Knoxville, focusing on rural health delivery.

The visit culminated in Nashville, where they observed firsthand our $70 billion global health-care industry. Hosts Nashville Health Care Council and Hope Through Healing Hands welcomed the travelers to the “Silicon Valley” of health care.

Industry leaders citywide opened their doors with sessions on medical simulation at Vanderbilt and HIV research by Meharry. The group also received an inside look at the public health sector’s progress on making communities healthier from state Health Commissioner Dr. John Dreyzehner, Nashville Mayor Karl Dean and Metro Public Health Director Dr. Bill Paul. The day concluded with global disease-management leader Healthways, and focused on the company’s work to improve well-being through prevention.

Most valuable, however, was the opportunity to hear what the delegates found most applicable to their home. Among them were the development of IT for unified e-records, logistics for emergency services, and the great benefit of community volunteerism.

As the U.S. and Russia attempt to address growing health demands, we have much to learn from each other. Collaboration, using health as a currency for peace, will mean healthier societies, better diplomacy and improved bilateral relationships between our nations.

Sen. William H. Frist is a nationally recognized heart and lung transplant surgeon and former majority leader in the U.S. Senate.

Frist Hosts Russian Health Delegates

Nov 04 2011

Nashville Business Journal
by Chris Silva, Staff Reporter

Former Tennessee Sen. Bill Frist was at the Hermitage Hotel this morning with about 30 Russian physicians and a cadre of Nashville’s health care and business leaders to promote global unity and attempt to solve public health and behavioral issues that lead to chronic diseases.

Frist said Russia faces many of the same health care dilemmas as Middle Tennessee.

“We do have the best health service infrastructure here in Middle Tennessee, so why not share it with the global community – a oneness of mankind?” said Frist, who prompted Sen. Lamar Alexander to send a request to Open World Leadership Center to host the health exchange. “Out of our commitment to global health, democracy, being the best in the health service delivery and using health as a currency for peace, we had the conference today. It will be a foundation for future exchanges.”

The Russian visitors started out with a tour of Vanderbilt University Medical Center this morning and listened to a presentation from an expert from Meharry Medical College on HIV/AIDS research.

Ralph Schulz, president of the Nashville Area Chamber of Commerce, was on hand, as was Mayor Karl Dean.

“I am concerned most about this issue of obesity,” Dean said. “It’s going to be a battle that will be won or lost in the Southeast.”

Today’s events were hosted by the Nashville Health Care Council and Hope Through Healing Hands.

Pediatric Anesthesia in Kijabe Hospital

Nov 04 2011

by Allison Greening

Vanderbilt International Anesthesia

Kibaje, Kenya

anesthesia

I arrived in Kijabe, Kenya with two other senior anesthesia residents from Vanderbilt midday Sat Oct 29th, after departing Nashville Thursday Oct 27th, flying overnight to London, and then all day to Nairobi. We spent the night in the Mennonite Guest House in Nairobi, where we met several missionaries coming and going to and from various parts of east Africa, and then were driven up to Kijabe the next morning.

We had been scheduled to travel Monday Oct 24th, but were delayed with security concerns due to the Kenyan army invading Somalia in response to recent kidnappings in northern Kenya, and threats of Al-Shabaab retaliation in Nairobi for a few days. Effectively this means we’ve missed a week, but three weeks are better than none! One of the first things we noticed about the place is its utopian feel. Justin, one of the other residents, referred to it as a “summer camp” feel.  It seems funny to think of any sort of terror attack happening here, in an idyllic small town mostly made up of missionaries who either work at the hospital or international school, but evidently someone has thought of it, as it’s surprisingly secure.

We spent the weekend getting settled in, and then started in the operating rooms on Monday. I have an interest in pediatric anesthesia, so have been running the pediatric room, though my compadres have been doing lots of regional anesthesia with the new ultrasound donated to the hospital recently from Vanderbilt and Dr. Randy Malchow. (1st photo) We’ve also been involved in a couple of airway cases, using the brand new glidescope, all of which has drawn quite an audience! (2nd photo below) I’ve done some amazing pediatric cases; the two that stand out the most were an open thoracotomy to repair a patent ductus arteriosus (PDA) in a 15 kg, 7 year old boy who was an achondroplastic dwarf, and a debridement of a severe, 48 hour old burn to the face of a 3year old boy. 

jace perkerson

The first case was a pretty big deal, basically minor heart surgery in a third world country, and I was the experienced one in the room, with both a Kenyan nurse anesthetist and a Kenyan nurse anesthetist student helping. A few aspects of the case amazed me, especially how well we did with so much less than we do in the states, and even more so, how well the boy did after having such a major, and painful, surgery. Kenyans are tough!

The burn case was very memorable as well, and also good teaching for the nurse anesthetist and student. The boy also happened to have muscular dystrophy, which presented its own anesthetic challenges, on top of those unique to burns, such as not being able to use certain drugs, and potentially having trouble breathing for the patient after putting him to sleep. The burn patient, like the PDA patient, looked great the next day. There’s even quite a lot to be learned from a fairly basic case like we did today, when just a few minor speed bumps along the way became important teaching points! I should be clear though, that I am not the only one doing the teaching!! I have learned quite a bit, and already in the first week had experiences that will rival any that I’ll get during my pediatric anesthesia fellowship next year!

 

TASO Launches House of Hope! Funding by World of Hope

Nov 02 2011

TASO sets another milestone: Launches a House of Hope for persons affected by HIV and AIDS in Uganda.  

house of hope

As 2011 draws to an end, The AIDS Support Organisation (TASO) is elated to record yet another milestone in restoring hope to people affected by HIV and AIDs pandemic in Uganda.  The organization, with support from her development partners and friends, has completed the construction of a multi-million complex, named House of Hope.

The attractive building, located at Plot 10 Windsor Loop, Kampala, was officially opened on 16th of September 2011 in a grand ceremony presided by Hon. Princess Kabakumba Masiko, Minister of Presidency, who represented H.E Yoweri Kaguta Museveni, President of the Republic of Uganda.  

The colorful event was attended by over 400 guests including members of the diplomatic community, representatives of development partners, Ministry of Health, Uganda AIDS Commission, leaders of various local and international AIDs Support Organisations and other civil society organizations, TASO governance bodies, TASO founder members, management and staff and above all, the gallant clients living with HIV.

In her remarks to launch the House of Hope, Hon. Masiko appreciated TASO for the innovativeness in the fight against the AIDS pandemic and for standing tall in the country and the world over in providing hope to people living with HIV. She pledged continued support to TASO and other stakeholders from the Government of Uganda.

The vision of the House of Hope was conceived as one of those strategies of sustaining provision and quality of HIV prevention, care support and treatment services to the TASO clients. Faced with the challenge of a growing number of clients seeking services especially following the initiation of ART programme, the available physical space and related resources at the Mulago Service Centre, which also housed the TASO Headquarters, were increasingly becoming inadequate. Therefore a need to decongest the facility at Mulago became more apparent and had to be addressed.

The management of TASO, with the approval of the Board of Trustees (BOT) then decided to construct a building to house the TASO Headquarters with additional space for generating resources for continued innovations and work in the provision of services to the clients and HIV prevention interventions.

The construction of the building commenced in November 2005 with the laying of the foundation stone in a ceremony officiated by Dr. Sam Okware, a prominent HIV activists and then a Director at the Ministry of Health.

The initial funding for the House of Hope project was provided by the World of Hope Foundation, USA. This funding followed a visit to TASO by a US Senator Bill Frist in 2005. During that visit, Senator Frist, a medical doctor, was taken around and briefed about TASOs work by the then TASO Executive Director(ED), Dr. Alex Coutinho and Dr. Matovu, then BOT Chairperson and Member of Parliament. Senator Frist was deeply touched by the great work TASO was doing in preventing HIV infection, restoring hope and improving the quality of life of individuals, families and communities affected by HIV infection and disease.

On going back to the US, Senator Bill Frist, M.D. nominated TASO to The World of Hope Foundation to be considered as one of the recipients of funds left over from former US President Bush’s election campaign. His nomination of TASO was accepted and gratefully, a generous contribution of US $500,000 was given to TASO, out of which about US $ 350,000 went into the House of Hope project.

The House of Hope project is one of the biggest projects that the current ED, Mr. Robert Ochai inherited when he assumed office. Together with his team, he raised additional funding from TASO friends from near and far, including the Board of Trustees, Staff, Subscriber Members and Clients, to complete this dream of a symbol of hope for TASO clients and friends. TASO pays great tribute to all the friends who contributed to make this big dream a reality.

Speaking at the opening ceremony, Mr. Micheal A Strong, the PEPFAR Coordinator, US Mission Kampala, Uganda, noted that the House of Hope is an investment for people living with HIV and will generate revenue for TASO for years to come to sustain the excellent work on HIV and AIDS prevention, care and support. He urged all organizations to emulate TASOs example of looking outside our narrow boxes to find creative ways to fund and sustain the efforts to improve the health of all Ugandans.  On their part, the ED, Mr. Robert Ochai and the Immediate former ED, Dr Alex Coutinho, noted that TASO‘s commitment to preventing HIV infection, restoring hope and improving the quality of life of persons, families and communities affected by HIV infection and disease, has resulted into the organization taking up a pioneering pace setter role in the fight against HIV and AIDS in the country and the region.  From the enviable milestones recorded over the years, the name TASO has now come to be synonymous with any initiatives in HIV prevention, care, support and treatment in Uganda.

The House of Hope is a modern facility, complete with a 400 seater conference facility/board room and a parking yard of over 30 vehicles. The facility also has a wall of memory of over 100,000 departed TASO clients. TASO is pleased to posses this facility on behalf of everybody involved in the fight against the HIV pandemic and especially the gallant clients who have given HIV a face. There is hope and together we shall fight on to defeat HIV so we can, one day, reach our vision of “A world without HIV”.

Russian Delegation in Knoxville and Memphis: November 2

Nov 02 2011

by Jenny Eaton Dyer, Ph.D.

Both Friend Force of Knoxville and Friend Force of Memphis are hosting the Russian delegates this week, including today. 

The Russian delegates in Knoxville will be meeting with governmental officials Mayor Daniel Brown as well as Judge Tom Varlan today. They will be briefed on the bluegrass music of Appalachia at the Knoxville Visitor's Center, and their afternoon will be spent visiting with Cherokee Health Systems. This evening, the North Rotary Club of Knoxville will host the Russian delegates for dinner.

In Memphis, the delegates will meet with the Memphis Medical Society as well as with the University of Memphis. At the University, there will be round table discussions regarding healthcare delivery in Russia and the United States among other presentations.

Russian Delegation in Knoxville and Memphis: November 1

Nov 01 2011

by Jenny Eaton Dyer, Ph.D.

In following the meetings and events of the Russian delegation learning from Tennessee's wealth of health care corporations, universities, and institutions, we will share their schedule throughout the week.

Today, Tuesday, November 1, the delegates visiting Knoxville have spent the morning at Pellissippi State Community College touring the Nursing Department. This afternoon, they toured the UT Hospital and had a quick photo at the Rachmaninoff statue in World’s Fair Park. Afterwards, they will visit the Knoxville Museum of Art and learn about their Mobile Meals program for the elderly.

In Memphis, the other delegates met this morning at the Christ Community Health Services. This organization is a faith-based network of medical and dental clinics supplemented by a range of community outreach activities.  CCHS serves a primarily low-income minority population that does not have the resources to obtain care elsewhere. For lunch, they visited the Caritas Village. And, this afternoon, they visited the Assisi Foundation of Memphis for a presentation and discussion on current health care reform initiatives and then the Hope and Healing Center to learn about their wellness and fitness program for a low-income population.

Kijabe: An Island of Hope in a Country of Medical Need

Nov 01 2011

by Walter Schratt
Vanderbilt Department of Surgery
Kijabe, Kenya

I arrived at the beginning of September for my first time in Africa. I really did not know what to expect but after 2 weeks I am really deeply impressed. Kijabe hospital is a medical center in Kenya where people get medical treatment at a high level for a reasonable price. The doctors are well trained – mostly in America and Australia, the residents, house and medical officers are highly motivated, have abundant basic medical knowledge, and, on top of that, they receive a detailed and profound training in their specialties that will prepare them for their challenges in the smaller community hospitals. Politics just has to make sure that they stay here in Africa to serve their countries and their people after they are finished with their training.

Same for the nursing staff. The nurses are competent, helpful, motivated.  A substantial number of nurses who are trained here are hired at the big and prestigious hospitals in Nairobi – unfortunately for the Kijabe hospital but also an expression of the quality of training they receive at Kijabe hospital.

The African people are friendly, open and very patient and generally happy.  Imagine 100 people in surgical clinic, first come  first serve, waiting from 9 am to be seen at 3 pm – no complaints, still happy to be seen after a 6 h wait. Those people deserve our help despite political uncertainties. The fellow doctors who work here full time on their missionary dedication deserve our full recognition and support. I am lucky to be here. I am looking forward to the rest of my stay and hopefully I will be back some time.

Open World Program Hosts Russian Delegates: D.C. and Tennessee

Oct 31 2011

In May 2007, Dr. William H. Frist co-led a Center for Strategic and International Studies (CSIS) delegation to Russia to participate in the first St. Petersburg State University Forum on Global Health. The forum explored bi-national cooperation in health and health care delivery, including the exploration of establishing a public health initiative in Russia.

At the conclusion of the trip, Senator Frist published the paper: “Improving Russian-U.S. Collaboration on Health” (Washington Quarterly, 30:4, 2007, pp. 7-17) which focused on how Russia and the U.S., in a time fraught with tension, could work together to solve public health issues in terms of policy, behavioral change, and chronic disease. Both could emerge as better, healthier, more viable countries, with health partnerships strengthening diplomatic relations. 

Senator Frist, a trustee at CSIS, was instrumental in establishing the Global Health Policy Center, and he served on the advisory board of the Commission for Smart Global Health Policy. This commission created the report, “A Healthier, Safer, and More Prosperous World,” as the product of a year’s worth of study of the long-term U.S. strategic approach to global health. Dr. Frist, in addition, serves as a co-chair of the Eurasia Health Project as a part of the CSIS Russia and Eurasia Program. 

Initiation of the idea of receiving a Russian delegation of high level physicians in Tennessee began with a discussion among Russian and American experts in global health at CSIS in May 2009.  Co-chaired by Senator William Frist, former Majority Leader of the U.S. Senate and CSIS Trustee, and Dr. Nikolai Gerasimenko, First Vice Chair of the Russian Duma’s Committee on Health Protection, the panel weighed new ideas for future Russian-U.S. joint initiatives and generated considerable shared excitement.  CSIS Senior Associate Judyth Twigg played the lead role in conceptualizing and coordinating the session. Approximately twenty additional experts on U.S.-Russian collaboration on health, representing government, academia, and the private sector, contributed significantly to these discussions, which amounted to a brainstorming session for a blueprint for strategic bi-national collaboration on health. 

Dr. Andrew C. Kuchins, Director and Senior Fellow, CSIS Russia and Eurasia Program, and Dr. Judyth Twygg have been part of this effort to bring Russians to the U.S. from the beginning. On January 31, 2011 the CSIS Russia and Eurasia Program hosted a conference as part of the Eurasia Health Project entitled, "Sharing Health: U.S.-Russian Collaboration in the Health Sector.” Dr. Nikolai Gerasimenko, a long-standing member of the Russian parliament and former chair of its health committee, served as the Russian Co-Chair along with Senator Bill Frist from the U.S. This meeting, which discussed U.S. and Russian efforts in health sector reform, promotion of healthy lifestyles, and regional-level efforts at health reform, was intended to generate momentum toward meaningful communication and collaboration between the two countries at both the governmental and non-governmental levels. Senator Frist’s article, “What the Doctor Orders” (Foreign Policy, 9/11/09) highlights the key findings and conclusions of this conference. 

While serving in the U.S. Senate, Dr. Frist worked alongside Alaska Senator Ted Stevens and Librarian of Congress James H. Billington to establish the Open World Program by an act of Congress in 2000. The Open World Leadership Center conducts the first and only international exchange agency in the U.S. Legislative Branch and, as such, has enabled more than 16,500 current and future leaders from Azerbaijan, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia, Ukraine, Tajikistan, and Turkmenistan to meaningfully engage and interact with Members of Congress, Congressional staff, and thousands of other Americans, many of whom are the delegates’ direct professional counterparts. Senator Frist served on the board of Open World from 2003 to 2010. 

Prompted by Senator Bill Frist, M.D., Senator Lamar Alexander sent a request to James Billington, Chairman of the Board of Open World Leadership Center, to host a health exchange with Russian health professionals in the state of Tennessee. Dr. Billington responded in a Letter to Senator Alexander with enthusiasm: 

     “Having hosted nearly 400 Georgian, Kyrgyzstani, Russian, Ukrainian, and Uzbekistani participants—including health leaders—in Tennessee, Open World has an excellent statewide network of local host organizations and host families there. I am confident that, working with Senator Frist and his staff, you and your staff, and CSIS, Open World can carry out an exceptionally strong program on health care that will benefit both the Russian delegates and the participating Tennesseans.” 

Open World agreed to provide nominations for the Russian delegates, and the Open World Moscow staff worked with the Administration of Kirov Region with approval of Governor Nikita Belykh.

High rates of communicable and chronic diseases, outdated medical equipment and facilities, and inadequate health care financing have contributed to a health care crisis in Russia. Open World provides grants for a Health Care Provision to address the issues relating to the delivery of services for patients with communicable or non-communicable diseases as well as at-risk individuals. Open World hopes that the outcome of this exchange is a medical partnership between the State of Tennessee and the Kirov Region. 

Senator Frist has assisted directly in the organization of the statewide effort to place the Russian physicians in programs across Tennessee consistent with their interests in rural health, academic medicine, information technology, and health service delivery. 

Senator Frist has had a longstanding commitment to “using health as a currency for peace.” Health care partnerships and exchanges of information provide powerful and robust contributions to diplomatic relations between the peoples of two countries. Such health diplomacy contributes to better understanding among nations and leads to dialogue in other spheres of human and government interaction. “Health as a currency for peace” allows individuals to be a part of missions greater than themselves and provides a way for America to begin to think about a long-term vision for building bridges of trust around the world, in both G8 nations as well as developing ones. Building Russian-U.S. collaboration in health care will benefit the foreign and public diplomacy of our nations and a better quality of life for the citizens of both nations.

Last week, the Russian delegates arrived and spent time with the Center for Strategic and International Studies, Kaiser Family Foundation, and National Institutes for Health in Washington, D.C. For the weekend, the delegates separated into two groups to tour both Knoxville and Memphis, Tennessee. In Knoxville, the delegates enjoyed a football game and other festivities and today they will visit De Royal Industries. In Memphis, the delegates visited St. Jude Children's Hospital, the National Civil Rights Museum and Beale Street over the weekend. Today, they will tour the Shelby County Health Department and Le Bonheur Children's Hospital. We are excited to host these health professionals in the State of Tennessee!

We will keep you apprised daily of their activities this week.

Lessons Learned in Kijabe

Oct 12 2011

by Sina Iranmanesh
Vanderbilt Department of Surgery, Resident
Kijabe, Kenya

sina iranmesh blog

No doubt, working at Kijabe is a once-in-a-lifetime experience.  Upon setting foot on the dirt road leading to the hospital, I knew I would face many hurdles over the next four weeks as a general surgery resident.   Over time, I appreciated subtle clues and changes in each patient’s physical exam to help guide the management of their care without relying on further information.

Lesson number two: I could no longer practice medicine ignoring the financial burden of my treatment plan.  Practicing cost-conscious medicine was not just beneficial on a global sense, but specifically affected each family suffering from an economic crisis.  Even worse, many treatment options (i.e., chemotherapy, radiation therapy, referrals to specialists) were physically or financially inaccessible by our patient population.  For example, unlike women in the U.S. who had the option of a lumpectomy with radiation for breast cancer, our patients in Kijabe underwent a mastectomy because they could not afford radiation. I spent time counseling a young woman on her treatment options after removal of a large tumor from her thigh. I recommended radiation therapy to reduce the chance of the tumor returning, though she decided against it after discovering how much it would cost her.  Such encounters were unfortunately fairly common.

In contrast to the philosophy of utilizing single-use, individually wrapped, and disposable equipment in Western operating rooms, Kijabe’s mantra of maximizing its very limited resources proved surprisingly effective. With the exception of our gloves, every piece of equipment used in the operating room (especially those labeled as ‘single-use’) had been routinely sterilized over and over again. I can only wonder what impact we can have on the US Healthcare Crisis if we learned a few lessons from Kijabe...

Kijabe is renowned for its level of care and medical education. As such, it is home to a number of visiting physicians of all levels of training. I felt fortunate to have encountered a number of these missionary physicians.  My one-month commitment to work in an African hospital paled in comparison to individuals (and their families) who offered years of devotion. Working alongside such individuals was inspiring to say the least.  I am grateful for the opportunity to experience medicine from a different angle, and the lessons I learned along the way.

 

« First < Prev Next > Last »

Subscribe to our newsletter to recieve the latest updates.