Logic, the First Casualty

It is a fundamental principle of risk management that the benefits of any decision should be weighed against the costs. What is less often appreciated is that risk is an interactive phenomenon. Perceptions of risk often lead to people adjusting their behaviour in ways that reduce (or increase) the chances of a hazard occurring. Risk does not equal a hazard plus some fixed probability of it occurring.

University College London Professor Emeritus John Adams captured this with his idea of a ‘risk thermostat’, whereby we balance our propensity to take risks, risk perceptions and costs and benefits. Aaron Wildavsky perhaps captured this most parsimoniously in his aphorism that ‘the secret of safety lies in danger.’

But overestimating risk can lead to costly responses. In one famous example the 1976 Swine Flu epidemic in the US resulted in the rushed development of a vaccine that was far worse than the disease, causing many cases of Gullain-Barré Syndrome, a rather nasty immune system disorder. This was described in detail by Robert Formaini in his excellent book The Myth of Scientific Public Policy. Unfortunately, all too often, governments do not understand that public policy cannot be decided solely by scientific experts, because human conduct frequently undermines the intentions of policy-makers by exhibiting behaviour scientists did not anticipate.

The appropriate medical field for responding to pandemics is epidemiology, not immunology. As Nobel Prize winning immunologist Peter Doherty put it in an interview on Sky News on March 26, he’s a ‘lab guy’, not an epidemiologist. Good epidemiology should, of course, include a good measure of social science to cover this eventuality, but I once attended a conference on climate change where a prominent epidemiologist disavowed any knowledge of human behaviour, stating ‘I am not a social scientist.’ He went on to argue that the health of future Aboriginal Australians would be seriously harmed by climate change — ignoring the rather obvious point that the impacts of future climates projected by models rested on emissions scenarios that assumed massive increases in wealth; apparently none of this would find its way to Aboriginal communities, which would continue to wallow in squalor.

Which brings us to the current pandemic with the novel coronavirus, or COVID-19. The government policy response has seen some sensible measures adopted, especially in shutting down borders and requiring a degree of ‘social distancing’ in an effort to flatten the curve of infections sufficiently to allow the health system to cope. But has the National Cabinet gone too far?

The measures announced on the evening of Sunday, March 22, went beyond the sensible maintenance of social distancing at cafes, restaurants, pubs and clubs while throwing many of their employees on the unemployment scrapheap, joining those already put there by the collapse in the tourism sector. Estimates of unemployment running at a million people have been floated.

In announcing these measures, Prime Minister Morrison specifically mentioned the flouting of the restrictions on social conduct by the thousands who flocked to Bondi Beach the day previously. Yet the functioning of a National Cabinet ensured that they were applied equally here in Tasmania, where there were then fewer than 20 cases — all contracted by those travelling overseas. Policy was decided on the basis of the activities of sybaritic Sydney sun worshippers.

The impact on the hospitality sector alone has been enormous, and has a human face. To give one example, a café I frequent is struggling to keep operating by offering a takeaway service, but it usually provides work for dozens of people. These people are long-term unemployed, many with disabilities, who gain the work experience and skills that are vital to getting a foothold on the employment ladder. They now have no work, and if the café folds, that situation will continue.

But, we have been assured by the medical experts, this is all necessary because we are on the same tragic trajectory as Italy, which very quickly overtook China in total fatalities. The Victorian state government has been pushing in the National Cabinet for tougher measure, and has indicated it was willing to go it alone. On March 26, Premier Daniel Andrews warned Victoria could not wait for everyone else to catch up. ‘If we did that . . . we will look like Italy,’ he said.

But is that inevitable? Indeed, is it even so?

The Italian Case

One of the very challenging problems for policy-makers has been the lack of reliable data. Not only did the autocratic Chinese regime assist the speed with which this virus spread from bats in the wet markets of Wuhan, arresting those doctors who tried to sound the alarm and exacerbating the global crisis, but it has inhibited the flow of reliable data. Early on, statisticians pointed to a co-efficient of determination (R2) of 99 per cent between two series of data the Chinese official were reporting. Epidemiologists quickly noted these were not credible, and the data were clearly made up. And in late March the South China Morning Post reported that they had found another 40,000 cases down the back of the sofa.

The failure to provide the rest of the world with reliable information on the genetic characteristics of the virus and data on its spread and mortality is a further stain on the reputation of the Chinese regime.

Italy has provided more accurate data, but it requires close examination, because it suggests Australia is unlikely to follow its trajectory.

The impact on Northern Italy has indeed been alarming, but it needs to analysed carefully. An aging population and substandard health system, with fewer acute care beds than the European Union average could explain the mortality rate — but what explains the infection rate?

In point of fact, those factors don’t explain the mortality rate, and neither do air pollution and a heavy incidence of cigarette smoking, though all these no doubt contribute. Former Israeli Health Minister, Professor Yoram Lass has pointed out that Italy has more than three times the morbidity from respiratory diseases than any other European country. The data indicate that COVID-19 is actually less dangerous than media reports suggest. Italian Professor Walter Riccardi has estimated that only 12 per cent of death certificates in Italy have shown a direct causality from coronavirus, in contrast to media reports where all the people who die in hospitals with the coronavirus are deemed to be dying of the coronavirus. (In fact, it is usually the secondary infection from pneumonia that causes death).

This arises from the relationship between the coronavirus and other ailments. Comorbidities are the key. Italian data show that only 1 per cent of those dying have no other ailments, and almost 50 per cent have three or more. In fact, data show that morbidities in the 65+ cohort have been lower than usual this winter, following two relatively mild influenza seasons which have left more of the vulnerable exposed to COVID-19. Riccardi’s point is that most Italians have died with COVID-19, not because of COVID-19. But why are there so many cases in Italy — an in Northern Italy at that?

The answer lies in the economics of the textile and fashion industry. As one writer for Bloomberg put it, “Today, in the textile towns of northern Italy, ‘made in Italy’ often means made by Chinese workers in Chinese-owned mills.” Northern Italy has a huge Chinese immigrant population, many of whom travelled from Wuhan. Chinese New Year was celebrated from January 25 to February 8, and many of these Chinese immigrants went home to Wuhan to celebrate the festival with their families.

Italy has direct flights from Wuhan. When they returned after their leave, the migrants were not tested in Italian airports and their movement was not restricted in any way. When Prime Minister Conte suggested stronger action, these measures were called ‘fascist’ by the Left. When the public displayed some hostility to Chinese migrants in February, the Mayor of Florence launched a ‘Hug a Chinese’ campaign, egged on by Chinese supported social media campaigns, which featured videos such as that of a man of Chinese extraction holding a sign reading ‘I am not a virus – I am a human being.’ (see the clip above)


The Comorbidity Issue

The hedge fund Rebellion Research has provided excellent research on this, and the Italian National Institute of Health has published extensive data, but it is not clear that it has been appreciated by policy-makers in Australia and elsewhere. Certainly, as far as the United Kingdom government is concerned, their lock-down was provoked by modelling from Imperial College London (based on the Wuhan data) that estimated the best case for the UK was 250,000 deaths and that it could rise to 500,000. What government wouldn’t react to such results? They decided to try to restrict the impact to 20,000 deaths.

Problem was, the modelling failed to account for comorbidity, and the fact that there are around 600,000 deaths each year in the UK. Many of the coronavirus deaths will be those harvested early that would occur this year regardless, those with very short life expectancies. There will probably be few excess deaths, as is the case in Italy. It is the case that they will be concentrated in a shorter time period, and that is the most urgent policy problem.

As noted above, the Wuhan data are also not reliable. Even if we could trust Chinese government statistics, infection rates are hard to determine accurately. About 80 per cent of those tested are asymptomatic, but then there are reports that testing kits can also yield false positives. The extra 40,000 Wuhan cases were apparently asymptomatic, but we have little guidance as to what the denominator is to calculate mortality. This uncertainty has contributed to the costly responses by governments and the fear panicking markets. (Thank you, President Xi and the CCP!)

Some better analysis has been provided by John Ionannidis, an epidemiologist and biostatistician at Stanford University. Ionannidis is something of an iconoclast, having published research showing that most published medical research later proves to be wrong (often because of noble cause or more venal corruption). Ionannidis observed that the Case Fatality Ratio (CFR) among passengers and crew on the Diamond Princess, the only example where an entire, closed population was tested, was 1 per cent. This, however, but was a largely elderly population, much more susceptible to mortality. Extrapolating this to the age structure of the US population, he estimated the death rate among people infected with Covid-19 would be a mere 0.125 per cent. But he acknowledged this was based on a small sample size of about 700 people, and that the real death rate could range from five times lower (0.025 per cent) to five times higher (0.625 per cent). And then there might be delayed deaths, so his ‘reasonable estimates’ for the CFR in the general U.S. population vary from 0.05 per cent to 1 per cent.

Ionannidis’ analysis was supported by the Japanese National Institute of Infectious Disease, which found that despite the high average age of passengers on the Diamond Princess, 48 per cent of all those testing positive remained completely symptom-free.  Even among the 80-89 year cohort, 48% remained asymptomatic, while in the 70-79 cohort 60% were asymptomatic.

There are obviously many who are infected but remain unsymptomatic. This is how the virus spreads so effectively, but it inflates morbidity rates based upon confirmed cases.


Is it a case of TINA?

Margaret Thatcher was fond of the saying ‘There is no alternative’ (TINA). Decision-makers certainly seem to have been advised by medical experts that COVID-19 is a case of TINA, and measures that have closed down businesses and thrown people out of work — one hopes only temporarily — have been added to the havoc wreaked by the markets.

Is this really the case? The real problem seems to be that, left unchecked, COVID-19 will overwhelm health care (and funeral) sectors, even if the excess deaths over the year are likely to be modest. There are experts who argue that an effective response could come at lower cost — both economic and social. One such is Dr David L. Katz, founding director of the Yale-Griffin Prevention Research Center.

Writing in the New York Times on 20 March, Katz posed the question few others have done in the media: ‘Is Our Fight Against Coronavirus Worse Than the Disease?’ He goes on to suggest another, less costly approach to flattening the curve. Employing the war analogy he suggests that there are two options: the inevitable carnage and collateral damage of diffuse hostilities, similar to trench warfare and massed attack used in World War I; and a precision ‘surgical strike’ targeting the sources of danger, like a special forces operation. He noted that ‘The latter, when executed well, minimizes resources and unintended consequences alike.’

Noting the characteristics of the disease (perhaps 80 per cent of infections asymptomatic, average age of those dying about 80, comorbidity, low death rate among the young), Katz recommended focusing isolation and resources (including testing) on the elderly and vulnerable. Rather than a lock down of the education system that would send the young (likely to be asymptomatic carriers) to be shut up at home with parents and grandparents at greater risk, he advocated keeping it open, along with business as much as possible. Those infected with mild symptoms would acquire immunity — limiting their ability to pass it to others. Limited resources would thus be devoted to those most at risk, and those who display serious symptoms or develop pneumonia.

Katz is hardly a voice in the wilderness. There are numerous other experts taking a different line to that of the experts advising governments.

German virologist Hendrik Streeck holds that Covid-19 is unlikely to increase total mortality in Germany (normally about 2500 people per day or 912,500 annually). Professor Sucharit Bhakdi, an expert in medical microbiology, says there are other important factors at play, notably pre-existing health conditions and poor air quality in Chinese and Northern Italian cities, describing the imposed measures as ‘grotesque’, ‘useless’, ‘self-destructive’ and a ‘collective suicide’ that will shorten the lifespan of the elderly and should not be accepted by society. Danish researcher Peter Gøtzsche believes that Corona is an ‘epidemic of mass panic’ and that ‘logic was one of the first victims.’ German Professor Karin Moelling has stated that Covid19 is ‘no killer virus’ and that ‘panic must end.’

Pietro Vernazza, a Swiss infectious disease specialist, argues that many of the responses are not based on science and should be reversed. Vernazza considers mass testing makes no sense because most of the population will be asymptomatic, and lockdowns and closing schools are even counterproductive. Like Katz, he recommends focusing on protecting at risk groups while keeping the economy and society at large undisturbed.

Former Israeli Health Minister, Professor Yoram Lass, maintains the new coronavirus is less dangerous than the flu and that lockdown measures are likely to kill more people than the virus. He added that ‘the numbers do not match the panic’ and that ‘psychology is prevailing over science’. Professor Stefan Hockertz, a German immunologist and toxicologist, has stated that COVID-19 is no more dangerous than influenza, and that the fear and panic created by the media and the reaction of many governments were greater dangers.  Argentinean virologist and biochemist Pablo Goldschmidt agrees.

Dr John Lee, a retired pathologist, presented an analysis similar to that here in The Spectator, as I was completing this essay, adding the important point that the many varying infection and mortality rates between countries are probably an artefact of the way in which statistics are collected. COVID-19, for example, is a notifiable disease in the UK, but influenza is not and respiratory deaths are usually simply reported as ‘pneumonia’ or ‘old age’. COVID-19 is thus more closely monitored and reported and is more likely to be found in hospitals than among the general public.

While COVID-19 is a notifiable illness and the reason for an extensive lockdown in the UK, however, on 19 March it was removed from the list of High Consequence Infectious Diseases on account of its more information was now available ‘about mortality rates (low)’, greater clinical awareness and wider availability of s specific and sensitive laboratory test. If we want to compare COVID-19 with other recent respiratory illnesses, it is instructive to consider thse disease still on the HCID list: Avian influenza A H7N9 and H5N1; Avian influenza A H5N6 and H7N7; Middle East respiratory syndrome (MERS); and Severe acute respiratory syndrome (SARS).


The Missing Social Science Perspective

As it happens, there were some social scientists involved in the development of advice to the National Cabinet, but their counsel was over-ruled by the natural scientists on the panel convened among Group of Eight universities at the request of the Chief Medical Officer. This panel advocated even more extreme measures, including the closing of schools, but it rejected the suggestion of a regional and staged response, tailored to the circumstances of each state (such as whether there was yet community transmission). The Go8 reported that

Those who argued for a more nuanced approach came at it not as epidemiologists and public health experts fearing an Italian situation but as social scientists deeply concerned about the financially and mentally vulnerable, the lonely, and those about to become much lonelier as the restrictions and lockdowns become speedier and more severe.

Again, the view that epidemiology should not contain social science! And the public health experts were ‘fearing an Italian situation’ that they clearly did not understand fully. And were only the ‘social scientists deeply concerned about the financially and mentally vulnerable’? It is uncharitable to take that interpretation, but that is the way the Go8 put it, and the majority of the group did reject that ‘more nuanced approach.’

It is a brave political leader who fails to follow scientific advice in the present climate, but by failing to consider critically that advice, seemingly coming through single, official channels, and to undertake a proper risk evaluation that includes social and economic factors, they have done more harm than they need have done. They have done well on the basics of hand washing, basic social isolation, and so on, but they have inflicted greater harm than they need have if they had followed the advice of Dr Katz.

In the US Donald Trump is being excoriated for daring to consider the costs by those who consider risk management to be solely a matter for natural scientists, and to be decided without regard to cost. He is one of the few leaders (if not the only one) who is including some consideration of the human and economic costs of the responses dictated by the medical experts who have no expertise in risk management as it should be practiced.

And regardless of our opinion of him, he deserves credit for that.

Aynsley Kellow is Professor Emeritus of Government at the University of Tasmania. He is the author of Science and Public Policy: The Virtuous Corruption of Virtual Environmental Science and Negotiating Climate Change

9 thoughts on “Logic, the First Casualty

  • Macspee says:

    Great article. No one seems to talk of the effects of ultra violet on the virus. If it kills it is why are people not all out on the beaches?

  • Citizen Kane says:

    Incisive and concise. When a crisis arises, as happens in our personal as well as public lives, running around like chickens with their heads cut off is no substitution for calm, considered leadership. It is yet another lesson in doomsday catstrophe as the new opium (née religion) of the masses.

  • Stephen Due says:

    Excellent article. Mass hysteria driven by the media is determining government action. The uniformity of measures being adopted around the globe, and the relentless escalation of similar restrictions on social interactions, confirms this. As with ‘climate change’, the inability of governments and the general public to understand basic concepts of risk, scale, proportion, and margins of error, is leading to costly mistakes.

  • ianl says:

    Unfortunately for this analysis, clinicians on the front line are reporting evidence that those who are infected and “recover” (an essential segment in Aynsley Kellow’s implied strategy of “isolating the elderly”) have some heart, liver and kidney damage caused by C19 which may persist. This information is coming from various US clinicians who are well credentialled and on the front line. The data is ongoing and Aynsley correctly categorises the existing databases as poor, or at least sketchy.

    At least this article attempts by suggestion to define the cohort to be isolated and incarcerated – 80+. This won’t hold, I suspect, but Aynsley is again correct in suggesting that comorbidities are a critical aspect of 80+ deaths.

    The essential point here, though, is that evidence emerging from the clinicians treating patients with C19 of all ages seems to show that significant health damage is caused to a much wider range of ages than thought until now. The 80+ cohort generally have comorbidities aggravated by C19 but incarcerating them in isolation to enable “herd immunity” to develop in the remainder of the population is not viable, although that notion may be attractive to large groups of people not in that cohort. It does not solve the economic issue because the health danger remains as pointed.

    • Aynsley Kellow says:

      ianl – the alternative strategy is not mine, but Dr Katz’s. I merely pointed out there were alternatives, something along the lines suggested by the social scientists on the Go8 panel that were overridden by the medical scientists.

      ‘It does not solve the economic issue because the health danger remains as pointed.’ No! Care for the cohorts at greatest risk does not impact the economy as overwhelmingly they are not working. It is the vast economic harm done by closing businesses that its the concern. Most of us are likely to get this sooner or later, but very few of us are likely to die from it – though many might die with it.

      The commonwealth government is doing a reasonable job, given the advice it has received (quite obviously in the face of pressure form NSW and – especially – Victoria), but the economy will take a long time to recover from the damage inflicted.

      Others have pointed out that the ‘stimulus’ is misnamed. There is no shortage of demand (look at the supermarket shelves!) It is a shortage of supply as producers of goods and services close down. ‘Stimulus’ would be better described as emergency welfare.

      The monitoring of incoming passengers is the most effective measure to slow this thing, but it should be noted that most countries are not recording any EXCESS deaths, thanks to a mild winter flu season.. With all its deaths, Italy is only now demonstrating excess deaths.

      Note also that one of the Imperial College team has now suggested that excess deaths in the UK are likely to be around 20,000. As this is the government target, they will doubtless claim success for their measures! He no longer thinks it will overwhelm UK ICU beds.

      The best lesson comes from Taiwan, which started monitoring passengers from Wuhan on 31 December – BEFORE China went public. A teacher returning from Wuhan was their Patient Zero, and they had heard reports of the Wuhan virus through such channels. (We forget about the level of contact). They currently have 2 deaths. (Pity Xi didn’t tell us all earlier).

      But recall that Morrison faced calls of racism for his first measures – as did Trump from Schumer and Pelosi. And Morrison also now faces explicit scaremongering from Albanese, previously only implicitly possible, and given the reductionist advice, he could have done a lot worse.

  • lloveday says:

    “Most of us are likely to get this sooner or later, but very few of us are likely to die from it – though many might die with it”.
    Indeed, and that is what I used to hear about prostate cancer – many die with it, not from it – but now it seems every second man I know has had a prostate operation.
    Professor Alan Coates who was the inaugural CEO of the Cancer Council Australia (1998 – 2006), and then arguably Australia’s foremost cancer expert, unarguably one of the top few foremost, wrote an article in the Australian Financial Review “Informed Refusal” in which he said men should not generally have the PSA test and he would sue any doctor who tested him.
    In an email to me he wrote “if you have a roomful of say 25 men who have undergone prostatectomy for screen detected prostate cancer it is a fair bet that all 25 will be convinced that it has saved their life. And at least 24 of them will be wrong”.

  • padraic says:

    I agree with the quote in the above article of Professor John Adams of the Geography Department of the University London College that “Perceptions of risk often lead to people adjusting their behaviour in ways that reduce (or increase) the chances of a hazard occurring. Risk does not equal a hazard plus some fixed probability of it occurring.” The probability has to be flexible. Most professions have to adapt the circumstances to their assessment of risk in decision making. For toxicologists, for example, the rule of thumb formula is Risk = Hazard + exposure level. They occasionally mock others, mainly politicians (the Greens, for example), some of whom adopt the formula Risk = Hazard + outrage, as we see in the case of the use of nuclear power. I don’t agree with Riccardi’s rather glib and facile comment that “most Italians have died with COVID-19, not because of COVID-19.” Those people would still be alive today, despite their underlying treatable conditions, if they had not contracted Corona Virus. Also viruses do not include logic in their CVs.
    The present Australian policy is not only aimed at saving the lives of at risk people and keeping the economy ticking over, albeit at a much reduced rate, but also aims at creating some immunity in a community never before exposed to this virus via some level of infection and recovery. A full lockdown, as recommended by some journalists might completely stop transmissions initially, but when the lockdown was over new cases would return with a vengeance within a month or so. That’s why the PM is advising us that an easing of restrictions may be 6 months away. A complete lockdown may work if there was a vaccine available within 3 months but in the absence of that occurring there is a need to develop a herd immunity in a population for this new infectious disease. Herd immunity subsequently will be maintained by vaccination each year which decreases transmission, as with seasonal influenza. I remember as a child when there were no vaccines for mumps, measles or chicken pox mothers would ask us to go and play with other children who had these infections, so we would catch it and get it over and done with, rather than get them as an adult when the health outcome could be catastrophic. Thankfully in those days people had more sense and there were no unemployed human rights lawyers poised to launch class actions. In the case of smallpox you could not take that approach because it killed everyone from babies to old people and the only way to achieve herd immunity was through the use of a vaccine for the whole population. In the mid 1800s there were outbreaks of smallpox in UK and Australia and UK passed a law requiring a lock down for all people and then mass vaccination. The Australian States followed suit and the problem went away. As an incentive to obey the legislation, jail time was prescribed for those who did not comply and it was strictly enforced. I know many of the “easily offended by words” people got lathered up when the UK CMO recently mentioned “herd immunity” but from a medical aspect we are all part of “the common herd” even if we live in Toorak or Palm Beach.

    Dealing with the health aspects of pandemics and associated socio-economic factors is best managed overall by the team of public health experts which includes public health physicians, nurses, pharmacists, medical research scientists, epidemiologists, toxicologists etc. They may access the expertise of other professions if the need arises as they did with engineers and economists in the late 1800s in Sydney and Melbourne when the “summer sickness” (typhoid) was wiping out large numbers of citizens in the poorer suburbs of those cities because their councils could not raise enough money through the Rates to provide running water and piped sewage to each dwelling. Ratepayers in those suburbs were digging two holes in their backyards – one as a well for water and the other as a pit latrine, with the result in summertime typhoid bugs in the pit latrine crossed over via the common water table into the drinking well, with predictable results. The answer was to create a “Water Board” in each city which raised a new Rate from each household based on the unimproved value of the land. That meant that money from the richer and poorer suburbs was pooled and used to provide running water and proper sewage infrastructure for the whole community, designed by the engineers, and the problem went away. So it’s best if all the professions exercise mutual respect and co-operate with each other in this pandemic but leave the medical profession and allied specialists to run the show. An example of this co-operation is when a doctor or other health expert may be called as “an expert witness” in a court case but the court process is run by the legal profession, not the medical profession, which only assists when called upon.

    Working together respectfully is the only way we are going to get through this satisfactorily. One of the big problems is that at the beginning people have difficulty in believing it is happening. This was clearly expressed in the following extract from the novel “La Peste”, by Albert Camus, one of the books recommended in Christopher Heathcote’s recent Quadrant article “Books to make us count our blessings” :-
    “While a pestilence impacts a whole community, people have difficulty in believing that it is actually happening. Worldwide, there have been just as many plagues as wars and plagues and wars always find people caught unawares. Dr Rieux was caught unawares, just as much as were his fellow citizens, and hence he ignored the signs, with his feelings torn between concern for the present and confidence in the future.
    When a war breaks out people say ”This won’t last – it’s beyond stupid”. And without doubt war is extremely stupid, but that does not stop its progress, because stupidity will still persist since people are only concerned about themselves. Our fellow citizens in this regard were like everybody else, and just like the humanist elite did not believe in pestilences, believing them to be a bad dream which is going to go away. But it does not go away, and one bad dream follows another until death strikes both the general population and the humanist elite, because they did not take adequate precautions. Our fellow citizens were just as guilty as one another – they forgot to be sensible and they thought that everything was still possible for them, based on the supposition that pestilences were impossible in this day and age. They continued with their businesses, they prepared for holiday trips and they freely expressed their opinions. They could not conceive of a plague that paralyses the future, travelling and debates. They believed themselves to be free individuals without realising that you can never be a free individual in a time of pestilence.”

  • talldad says:

    When Prime Minister Conte suggested stronger action, these measures were called ‘fascist’ by the Left.

    Well, there’s another whopper – the Left never stop, do they?

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