Public health 🤝 Healthcare

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A new study sheds light on the mechanisms of H5N1 spread in cattle. A link between semaglutide and a rare form of vision loss emerges. Fourth of July fireworks are still dangerous, in more ways than you think. This is America Dissected, I'm your host, Dr. Abdul-El-Sayed.

Everyone, okay, almost everyone has been to a doctor. You have a sense of what doctors do, the gigantic institutions behind the provision of healthcare, and where you would go should the worst happen, and you need emergent medical services. Doctors, hospitals, even health insurance companies, they're all an indelible part of most people's lives. Public health, well, not so much, at least not in ways they know. Most folks just think that public health is the same as healthcare.

And when the difference is explained, they can't really identify what public health institutions actually do. I run a local health department and I find myself having to explain what we do to most doctors I meet, let alone folks with no background in health at all. What's worse is that, after COVID, what folks now think about public health probably isn't the best. A Harvard study about the public's assessment of the public health system, done in March of 2021, a year into the pandemic, found that public approval for the nation's public health system fell from 43% in 2009 to 34% in 2021. And it's not hard to understand why.

Most people probably went from not knowing what public health is and does to believing that whatever we were supposed to do, we didn't, which ultimately led to the pandemic. And that's the best case scenario. Spinmeisters on the right have worked to paint public health as the antithesis to personal freedom. So, beyond being the folks who failed to keep us safe, a swath of the public thinks of public health as the folks who tried to take your rights away. Not a great look.

On the other hand, the same survey found that the approval of our nation's health care system in the same period went from 36% in 2009 to 51% in 2021.

. That also tracks. After all, we were all rightly lauding our health care heroes who were showing up to care for Americans in our darkest hour. But those health care heroes, the individual nurses and doctors caring for patients, they're not the institutions they work for, which is a critical difference. All of this highlights the way that our narrative always tilts towards health care.

In the first place, public health traditionally operates in the background, keeping folks healthy in ways they don't even see. But we don't deal in specifics. We deal in probabilities. We're the folks who can tell you that some proportion will die of X, Y, or Z disease, but not who, specifically, will die of what disease and when. But health care whirs into action only after a specific person has gotten a specific disease at a specific time.

And because none of us are a population and each of us is an individual, we have our own unique stories about our interactions with health care, while few of us can identify specifically how public health helped us. That fact is called the prevention paradox. And it really is a paradox. See, if I asked you if you'd rather never get cancer at all, or get cancer and have the best health care money can buy, you'd probably pick the former. But because we're all essential optimists, and none of us believe we're going to be the ones on the wrong side of the probabilities, and prevention is a collective action problem that requires all of us to believe we're all at risk, we almost never invest enough in prevention.

That's also because health care can be sold. And because it can be sold, there's a lot of money to be made providing people health care. It's why it accounts for nearly one in every five dollars spent in our entire economy. It also accounts for some of our country's biggest industries. Beyond doctors and hospitals, which are behemoths unto themselves, you have the pharmaceutical industry, which is one of the biggest in the country, and the insurance industry.

That's not to mention medical devices, skilled nursing facilities, and so many others. But those industries get to hide behind the individuals who make them go. We love our nurses and doctors. We don't love our hospitals, and certainly not our health insurance companies, who too often underpay and overwork them. And yet, those hospitals and health insurers, they take credit for the heroes they employ, all the while raising our health care costs and feeding their bottom lines.

And all of that cost, it doesn't leave much room for investments in public health, which have become anemic over time. Never mind the fact that the people who have the ability to invest in public health tend to think it's just an extension of health care, taking us right back to where we started. But if anything showed the fundamental need for public health, especially to health care companies, it was the pandemic. As hospitals filled up in the midst of a failing public health system. at the outset of the pandemic, it became clear just how interconnected, and not the same, these systems are.

Dr. Dave Chokshi is a friend and former health commissioner of New York City. He's a veteran of the pandemic, serving New York through some of its worst days. Before that, he worked in New York's public health care system, New York Health and Hospitals. Now, he's using his experience at the edge of public health and health care to try and bring them together through a project called the Common Health Coalition.

While I do have my skepticism, and you'll hear it in the interview, about whether or not health care companies are coming to this coalition with the right intentions, one set of intentions I never question are Dave's. I wanted to have him on the show to share more about their work, the opportunities and pitfalls, and the vision he has for unity. My conversation with Dr. Dave Chokshi after this break.

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Okay, can you introduce yourself with the tape?

So, you know, you've alighted upon, in this work, this sort of central disconnect between these two things that, in most people's minds, who haven't spent a lot of time thinking about these things, should kind of be one and the same, right? When you talk to people about public health versus healthcare, oftentimes what seems to be a gigantic difference for all of us in this world is just, you know, all of it kind of centers around health, and they're like, oh, we all do the same thing, and we take great pains to explain that we don't. Which highlights, right, the fact that we probably should come to know each other a little bit better. So, I'd love to hear a little bit from you about what you think that disconnect is and why you think it exists.

You know, why aren't you guys already seamlessly figuring out, you know, how to improve my health? And I think there's actually a North Star, you know, in there for those of us who are passionate about improving health, which is to figure out how to, behind the scenes, in a way that is seamless, you know, for the people we serve, figure out how to knit together these different, you know, siloed parts of our health system. And, you know, you asked about a little bit of the lineage of this. You know, why do those silos exist in the first place? And, you know, I think so much of it is rooted in the history of how healthcare and public health sort of came up, particularly in the United States, where, you know, health departments and healthcare systems, and then eventually health insurance companies, particularly employer-sponsored health insurance, they all sort of evolved on parallel paths.

And whereas in many places around the world, there were opportunities for there to be a convergence across those things, we haven't quite seen that in the United States. And it's not for lack of trying. You know, many people have tried to bridge these sectors over the decades. But, you know, but we haven't seen that happen nearly as much as we should have. And fundamentally, that's what we're trying to change with the Common Health Coalition.

But healthcare is really easy to sell. People usually buy healthcare at the end of knowing exactly what kind of care they need, not just want, right? And what has happened in this country in a way that hasn't really happened in a lot of other countries, or at least has been bridled in a lot of other countries, is that our healthcare system has developed largely on profit-maximizing terms. In a lot of ways, even the language we use in healthcare in this country is less about trying to take care of sick people and more about trying to understand a bottom line for a large set of institutions, be that payers or providers. And the way that large corporate capitalism has sort of wrapped itself around healthcare, I think, has been part of the challenge.

And I'd love to get a sense of how you think about that problem and the ways that we can start to address it. Because I think, you know, I know a lot of public health folks, and they'll say, well, the problem, the reason that we don't have a seamless system, is because those folks tend to be a lot more focused on making money. And of course, you don't make money taking care of the sickest or the poorest people. And herein lies the divide. So I'd love to get a sense from you about that part of the challenge and how you've thought about that.

You know, historically, the sort of simple way of describing the difference between health care and public health is that health care is particularly focused on individuals, on service delivery, you know, on making sure that when someone gets sick, there is, you know, a group of people and, you know, a set of services available to help them. Whereas public health is more focused on populations. It's more focused on some of the structural drivers of health and doing things like ensuring that we have rigorous data and analysis, you know, for us to understand trends when it comes to illness and health. And the Common Health Coalition is really trying to bridge those two things, recognizing that we need both. You know, we need an apparatus that is set up to be able to respond to the needs of individuals while, at the same time, concerning ourselves with the health of populations.

And, you know, I think the other thing that's important to say is that timeframes really matter with respect to how we think about, you know, prioritizing what the various parts of a health system can do. Much of what we're focused on is the things that we can do in the near term, you know, particularly in the wake of the pandemic. And I hope we'll have a chance to talk a little bit more about how this worked and sometimes didn't work during COVID-19.. But in the wake of the devastation and the suffering that we saw during COVID-19, what is it that we can do in the here and now in a one to two year timeframe? Even as we think about, you know, how those broader parameters of our systems need to be changed, what can we do right now to improve our fellow neighbors and family members' health?

You know, in the health care system, I was the person who was asking about denominators. You know, like, well, how, when we're talking about quality measures, when we're talking about blood pressure control for our patients, you know, out of what denominator are we actually measuring that? And vice versa, you know, on the health department side, I was often the one asking what more could we do to reach across and partner with those aspects of our health system where people were coming across the threshold every day, whether in a hospital or a pharmacy, and figure out how we could be more effective, you know, in our public health goals by partnering with those other sectors of the health system. And the pandemic hit in 2020.. And, I mean, the memories of that time will be seared in my brain, you know, for as long as I live.

And there was so much tragedy, there was so much, you know, that reflected the cracks, you know, that exist in our system. But there were also bright spots, you know, it was a chance for us to finally work in concert, because the moment demanded it of us. So, for example, you know, we had a massive testing apparatus, we were doing tens of thousands or, at one point, you know, hundreds of thousands of tests each day in New York City. Our vaccination campaign was the largest in New York City's history, as it was for so many places, you know, across the nation. We vaccinated over 6 million New Yorkers in a little bit over a year against COVID-19..

And when it comes to, you know, trying to deliver services and improve health at that scale, there's simply no way that a public health department or any other isolated part of the health system can do that on its own. It took everything, working together, in concert, you know, for us to be able to accomplish that. So, I hope, you know, as we think about not just the lessons that we need to learn from the pandemic, but the lessons that we actually need to mobilize, that this collaboration, you know, this partnership across healthcare and public health is a key one because we saw its effectiveness in a time of crisis.

It's disconnected from what we do. And, you know, there's a bunch of box-ticking exercises that happen that healthcare has to do as a function of its funding, that every once in a while they give you a call and ask you to sit on an advisory board for their thing, and then that's the rest of it. And what you're trying to do with common health is to think beyond that. Can you tell us a little bit about the ethos of what you're building here, who the players are and the early wins that you've been able to see forward?

It's the American Hospital Association, the American Medical Association, AHIP, formerly known as America's Health Insurance Plans, ACHP, which is the Alliance for Community Health Plans, and Kaiser Permanente. So those five founding members got together and said, what can we do in the wake of the pandemic to build a better health system, one that is focused on strengthening partnership between healthcare and public health? I had the privilege of, you know, joining as chair a little bit less than a year ago, and we quickly got to work. One of the things that I really appreciate about those five founding members was that when we started out, you know, the push was that we don't want this to be a group that is just issuing recommendations or writing another report that, frankly, might sit on a shelf and, you know, go unread by anyone. Instead, we want to try to lead by example.

And so those five founding members decided to focus on a handful of specific areas of partnership between healthcare and public health and articulated a set of commitments and actions. So we have 33 concrete actions spanning four of those specific areas, as I mentioned, that, the five founding organizations issued in March of this year. I can say a little bit more about the substance of those, but since we've done that, we have opened up the coalition to any organization in healthcare and public health that wants to join. And I'm really pleased that we've had a great response to that. We've grown from those five initial members to now over 50 organizations, you know, across the country, spanning health systems, hospitals, physician groups, health plans, and, of course, public health organizations as well.

And so our aim is to create this big tent, you know, of folks who are working together, in many cases, who are already doing some form of this work, so that we can learn from one another, identify what's working, and then replicate and amplify it across the country.

Now, with that said, Abdul, there's no way for this, for partnership to work, if it's not, you know, a partnership that intimately involves public health and has those voices represented. So we have an advisory council set up that is co-chaired by two wonderful public health leaders, Dr. Georges Benjamin, the head of the American Public Health Association, and Dr. Nadine Gracia, who represents Trust for America's Health. We set up this advisory council under their leadership, with a range of public health leaders, as well as some additional healthcare leaders as well.

And my charge to that council was specifically around accountability to public health. How do we make sure that the work of the coalition, the commitments and the actions that we're undertaking are responsive to, and ultimately accountable to, public health? This is rooted in, you know, the history of what public health departments have done, have tried to organize, you know, at this intersection spanning decades. And I really want us to be informed by that and, you know, ultimately accountable to public health colleagues.

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I want to hear a little bit more about some of those initial actions and the ways that those manifested on the ground.

We're talking about things like memoranda of understanding, data sharing agreements,

frameworks and structures that allow for clear alignment of goals, roles and responsibilities across the different parts of the health system. So that's the C. The A in CARE stands for always on emergency preparedness. This is about having shared plans, optimally in advance of a crisis, you know, in relative peacetime, like what we're in right now. But then, importantly, for those plans to be similar across different institutions.

Right now, you probably know this in your own experience, there may be an emergency preparedness plan that a hospital has and a different one that a health department has. And we don't actually align, you know, and read off of the same sheet of music when it comes to that emergency preparedness planning. So this is about, you know, trying to forge that in a different way. The R in CARE stands for real-time disease detection. This is about ensuring that, you know, we have swift mechanisms for us to be able to find cases and figure out, you know, whether or not they are linked.

For example, to be able to declare an outbreak and marshal the resources that we need, you know, for a public health response. And then the E is also related to data. It's about exchanging data, particularly to advance health equity. So those are, you know, the four areas that we were spanning. And I mentioned.

we have, you know, 33 concrete actions across those areas. I'll just give you a couple of examples so you can get a sense for them. You know, under Always On Emergency Preparedness, we have the AHA, AMA, and Kaiser Permanente, all of whom have healthcare staff, you know, under their purview. And we saw during the COVID-19 pandemic how important it was for us to have mechanisms in place to share staffing so that they can get to places that are in dire need of them during a time of crisis. You know, in March and April of 2020, from New York City, I remember frantically calling everyone I could across the country, knowing that we needed staff for our intensive care units.

So this is about, you know, lowering barriers for staff who are already, you know, part of those organizations to be able to participate in disaster staffing programs. And then for us to set up other mechanisms to be able to share staff across institutional or, optimally, across geographic boundaries as well. Another example under exchanging data, particularly to advance health equity, is about exchanging data around immunization rates. Right now, you know, health plans often have a lot of up-to-the-minute information about who is vaccinated and who is not. In New York City, again, you know, I remember from COVID-19, we set up a program very quickly with seven health insurers in the New York City region for us to be able to have the, you know, sort of the real-time communication about who was still unvaccinated for COVID-19..

So that we could reach out to them, you know, and use our partnerships with community-based organizations and community health workers to actually get as many people vaccinated as possible. So those are, you know, a couple of examples of the actions under those four areas.

Early on in the pandemic, a lot of folks were in situations where, even if you had insurance, you couldn't necessarily get the health care you needed, because hospitals were on high alert for COVID. And so money that would have been spent for, you name it, a hip replacement or a knee replacement. or, you know, routine care didn't get spent. And the health insurance organizations ended up making huge amounts of money those years. And I would have loved to see a situation where we said, OK, well, you know, this is how much we're going to make and we're going to commit a certain amount of our profits to the overall response.

That didn't really happen. The other side of it is, you know, similarly, one of the biggest public health challenges we have in our country is that a large proportion of our population is either under or on or precariously insured. And that's a lot a function of the way that we provide health insurance in this country, rising costs of out-of-pocket care. You know, as we think about those structural features inside our health care system that need to change, if we were serious about having the kind of health care system that offered the kind of wraparound from public health to health care, how often or do you believe that there's an opportunity we have to actually start penetrating some of these big structural challenges? Because I think one of the worries I have is that it's nice to sit at a coalition and a table and be a part of a set of conversations.

And all of the things you talked about are really important. But part of me also says, you know, it's kind of similar to the conversation we have about health care costs. Everybody talks about accountable care organizations and these other, you know, niche opportunities, but nobody actually wants to speak to the structural reality that in this country, our costs are increasing because there's no real incentive to keep them down, right? Neither for insurers or providers, in large part because everybody's interested in making more money. So I wanted to ask about those structural features and the ability to speak truth on some of those issues, because I worry that, you know, in some respects, there's a space where we.

sometimes we have this competitive or competitive inhibition approach to thinking about big problems, where we take on a small piece of the problem, right, to avoid taking on the big piece of the problem. So I wanted to get your sense on that.

And what the coalition is focused on is really, you know, taking. what can we do in the here and now, in the one to two year timeframe, things that we know, you know, should be happening but are not, particularly in the wake of COVID-19..

And that meeting opened up with a panel on public health. You know, there's a conversation involving Dr. Mandy Cohen, the current CDC director, myself, a representative from the White House Office of Pandemic Preparedness and Response. And, you know, there's genuine interest in this type of partnership with public health. that, I think, is categorically different than, you know, what we've seen in prior times.

So I think we have to focus on, you know, the areas of consensus that we have right now, because so much of this work historically has suffered from a poverty of implementation and not of ideas. So let us focus on, you know, the actions, where, you know, where we know we can make a difference, where we know there are things that would benefit the people that we aim to serve in terms of lives saved and suffering prevented. And, frankly, build, you know, the muscle of partnership and relationships so that we can take on some of those deeper seated issues for which we still have to build consensus about the right way to approach them going forward. I just have to say one more word about this, which is that, you know, as I'm sure is true, where you sit in your day job as well, relationships are the foundation of all accomplishment. And too often we have not invested the time and the energy to build relationships across all of these different parts of the health system, hospitals and health plans, and, you know, pharmaceutical manufacturers and public health.

Too often we're inhabiting all of our own worlds, you know, in silos and not seeking to build bridges, learn one another's language and, you know, actually have relationships that we can call upon to be able to take on, you know, some of those more entrenched problems together. So my hope, with the coalition, is that we build some momentum, you know, taking on the things that we know will make a difference in the here and now and get bolder and bolder with respect to the problems that we're willing to take on going forward.

Right. And I think, as those of us who sit on the less conflicted side of the public health healthcare debate, right, where there's not as much of a profit motive, it's really important to keep in mind the responsibility to be speaking about the larger, bigger picture questions, even as we work at trying to implement, to your point, right, the structural solutions that help us in the short run. Right. And I think that can sometimes be the issue that, you know, you might find some points of opportunity to build. And the exchange is such that you are creating a system by which an organization that sits largely on the wrong side of the issues that you care a lot about can decorate itself or launder itself with the prestige of working with you.

And that is the, I guess, the one challenge that I often think about. Because when I think about a fight for Medicare for all, universal healthcare in this country, go all the way back to the ACA. Right. Whether you're talking about the AMA or the American Hospital Association or AHIP, they were all on the wrong side of this debate every single time. And they always have been.

And so I think it's important for us to always remember that, while there are short term structural solutions that I think sit very squarely within everyone's incentive set, trying to capture those wins cannot dissuade us from being willing to leverage a relationship, to speak truth to power and to continue to talk about some of the structural features of our health care system that rob people of access to affordable, quality, consistent health care, that often public health ends up on the other side of trying to clean up. Right. I think about a lot of the programs we run out of, out of our department. You know, a lot of them exist in large part as a bandaid on a structural set of problems. because, you know, big health care, be it the insurance industry or the provider industry, don't see it as profitable to be able to provide care for these folks.

And, you know, I know that, having worked with you, I know your heart and your mind are always on the right side of this conversation. And so, you know, I appreciate the way you're thinking about it and certainly trust that you're not one who would ever forget those bigger picture challenges.

Well, that's that's a great segue, because I do want to, you know, just just touch on on the prior comment that you made, which is which is thoughtful, as usual, Abdul. And, you know, this is an instance where we have these leading national organizations, you know, AMA, AHA, AHIP, ACHP and Kaiser Permanente, really creating a space, you know, for this conversation. that was not otherwise, you know, happening at a national level when it comes to strengthening partnership between health care and public health. And so, you know, I do think that there is something really powerful and novel about, you know, about the fact that those national organizations have stepped up in that way.

And, you know, you and I are perhaps somewhat biased in this respect. You know, you lead a county health department. I had the privilege of leading a city health department. And we've seen with our own eyes the way that the rubber meets the road, you know, when it comes to how partnership actually results in improvements in health, you know, for the people that we aim to serve.

at the local and the state level. For example, in Dallas, Texas, you know, where Parkland Health, the safety net hospital system down there, worked with the Dallas County of Health and Human Services. First, during COVID-19, you know, in kind of a hyper-local approach, sharing data to identify where testing sites needed to be placed. And then now, you know, in the wake of the pandemic, leveraging that same infrastructure to address asthma or unmet social needs, you know, for the same groups of people that were being served by that partnership during the pandemic. Indiana is another example where the governor and the legislature there have made a $225 million commitment to local public health.

And the local public health departments are working, through the Indiana Hospital Association with, you know, their local hospitals, on a handful of specific public health priorities, like smoking cessation or maternal health, you know, or obesity. So these are just, you know, some of the examples of how this work is already happening. What the coalition aims to do is, one, to identify those bright spots, because, you know, so many of them are already in existence right now. Stay tuned for a special issue of this journal called New England Journal of Medicine Catalyst, which will highlight, you know, even more of those specific examples, in part, because the coalition believes that part of our role is to amplify these things across the country. Because in many cases, people are not aware of, you know, the work that's already happening in specific jurisdictions.

There's a lot of inspiration to be derived from what's already being led, you know, at the local and the state level. The other aspect of this is, you know, we're working to sort of, you know, identify a number of leaders who really care about this work, either by their joining as members of the coalition or getting together, you know, in communities to be able to exchange lessons about not just the very tangible interventions, but also how to build those relationships in the first place. We're highlighting those on something called the Common Health Compendium, which is on our website, commonhealthcoalition.org, along with a number of very, like, specific resources that help with that work, whether it's data sharing agreements or memoranda of understanding. And then, ultimately, you know, we want this to scale to all corners of the country. So we have, you know, sort of this national level leadership.

As I mentioned, we have over 50 organizations that have signed on as members of the coalition thus far. Right now, that represents about 15 states. But we want this to be in all 50 states and also, you know, territories and tribal nations across the country as well. And so we're going to work to do that over the second year of the coalition and get even deeper on, you know, some of the specific issues that we're working on, starting with those four areas that I mentioned, but then expanding into other issues as they emerge. And that leads me to the last thing that I'll just say on this, which is that we have to be nimble.

You know, we're facing H5N1.

. We're seeing a resurgence in congenital syphilis.

And, you know, we have a respiratory virus season each fall and winter. And so those are all, you know, very sort of specific areas where we can save lives and prevent suffering as well.

Dave, thank you so much for your time.

While the injected cows did get a classic upper respiratory infection, they did not pass the virus onto the healthy cows. Though the findings have yet to be peer-reviewed or published, taken together, they suggest that cows may not be infecting one another via traditional respiratory droplets, as we usually think about the flu. But rather, the infection may be being spread around through the milking process. The researchers hypothesized that milking machines, which are not sterilized between cows, may be acting as a nidus of infection, moving virus from infected to uninfected cows. The great news here is that, well, respiratory transmission is a lot harder to stop.

And if the infection really is being transmitted through milking machines, then disinfecting those machines could vastly reduce transmission. The bad news? We're talking about an industry built on efficiency, and disinfecting milking machines isn't an altogether easy process. Which really should force us to ask some questions about the sustainability of factory farms more generally. But I digress.

In other news, a new study in the journal JAMA Ophthalmology suggests a possible link between semaglutide, the scientific name for drugs like Ozempic and Mugovi, and a rare form of eye disease called non-arteritic ischemic optic neuropathy, or NION. NION is also referred to as an eye stroke, which can cause sudden vision loss, and in severe cases, lead to blindness. There is no available treatment. In a sample of 710 patients with type 2 diabetes on semaglutide, 17 of them, or about 9%, developed NION. That compares to only 1.8% in patients on other drugs.

In another 979 patients taking the medication for overweight or obesity, 6.

7% had NION, compared to less than 1% in those not on the medications. Because of the weak study design, being an observational study rather than a randomized trial, researchers are quick to point out that no causal relationship between semaglutide and NION can be deduced, but that further study is definitely warranted. Importantly, NION was not an observed side effect in clinical trials for these drugs, but as more people take the medications, we're observing a lot more about the consequences, good and bad, of semaglutide therapy. Finally, I hope you and your family had a safe and healthy 4th of July. last week.

Here in Michigan, Detroit recorded the worst air quality in the world just after the annual fireworks show. as a result. Annually, injuries resulting from fireworks lead to nearly 10,000 emergency room visits, mostly because of injuries to the eyes, ears, and face. And then there's the fact that celebrating with explosions likely means that you've never been worried for your life by one. And for the thousands and thousands who have, because of war or terrorism or gun violence, they can bring on terrible flashbacks.

Oh, and my kids just can't sleep through them. Here's to hoping that next year, we find a better way of celebrating our national birthday than blowing shit up. That's it for today. Thank you so much to Dave Chokshi for joining us. And if you have guest recommendations for the show, share them with us at info at incisionmedia.co.

On your way out, don't forget to rate and review the show. It really does go a long way. America Dissected is also on YouTube. Follow us on YouTube at Abdul El-Sayed, and that's also where you can follow me on Instagram, TikTok, and X. Finally, to check out more of my content and subscribe to our newsletter, head on over to incisionmedia.co.

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And me, Dr. Abdul El-Sayed, your host. Thanks for listening.

We do not necessarily present the views and opinions of Wayne County, Michigan, or its Department of Health, Human, and Veteran Services.