Eradicating Trachoma in Endemic Areas: Changing Priorities from a Social Perspective.-Zareen Lakhani
Transmission and Epidemiolgy of Trachoma
Trachoma, a bacterial infection of the eye, is the number one cause of preventable blindness in the world (The Carter Center, Health Programs, 2006). In trachoma, the bacterium Chlamydia trachomatis infects the eye and causes follicular conjunctivitis, which leads to conjunctival scarring. Repeated infections result in the inward turning of the eye lashes and irritation of the cornea. This condition known as trichiasis is extremely painful and will eventually lead to blindness as the corneal scarring intensifies (Center for Disease Control and Prevention, 2004.
Trachoma infected individuals release a contagious discharge. When the discharge comes in contact to a trachoma free person’s eye, he or she will also become infected. Trachoma usually affects people living in poverty and is associated with inadequate water supplies and unsanitary conditions. Populations in poor, dry areas often do not have sufficient water supplies to wash themselves or their clothes to prevent the spread of the disease. Trachoma is mainly spread via person to person contact, contact with contaminated clothing or bedding, and flies that carry the bacterium from individual to individual. Children become infected at a higher rate because they are less hygienic and touch their faces more often. Furthermore, two-thirds of those afflicted by blinding trachoma are women, who tend to be the main child care taker in most of the areas endemic with trachoma (Alene, 2000). Infrastructure that could help eliminate trachoma are limited or non-existent in many areas endemic with the disease, such as the Middle East, North and Sub-Saharan Africa, parts of the Indian sub-continent, Southern Asia, China, Latin America, Australia, and the Pacific Islands (World Health Organization, 2006) .
Our Current Mentality: Medicalization of the SAFE Strategy
The current public health approach to treat and prevent trachoma is referred to as the SAFE strategy. SAFE is based on four key components: surgery, antibiotics, facial cleansing, and environmental interventions (Kumaresan, 2003). Currently, public health professionals are implementing SAFE with a focus on the primary interventions of surgery and antibiotics (Conrad N. Hilton Foundation, 2006.
From a social science perspective, the current trachoma implementation strategy is not addressing the root cause of the problem to mitigate the efficient eradication of trachoma. Public health leaders should focus their attention on preventing trachoma through the implementation of programs that promote proper hygiene such as facial cleansing and environmental initiatives that deal with containment of human excreta, solid waste disposal, management of food, and issues related to overcrowding (Mariotti, 2000). Such intervention strategies can center on educational awareness that emphasize cultural and socially accepted programs, while at the same time empowering the community and creating trust between public health professionals and the local population. The use of surgery and antibiotics are and integral part of the SAFE strategy, however, implementing more programs that highlight the facial cleansing and environmental initiatives will give public health professionals a greater ability to take social and behavioral factors into consideration and help contextualize the problem of trachoma.
A simple 15 minute eye-lid surgery has been proven to effectively treat trichiasis, an eye condition found in people repeatedly struck by the trachoma infection. But, less than half of the people offered the surgery for free actually have the procedure done. One must look at the bigger social picture to identify why 50% of people suffering from a painful, debilitating disease do not seek treatment. Some of the main barriers that hinder much of the effected population from getting the surgery include, “constraint by duties such as child care, lack of time, perceived cost of surgery, lack of an escort, distance to travel to surgery, and fear of the operation” (Kuper, 2003). Local populations afflicted by trachoma likely fear the medicalization of SAFE because they see it as foreigners handing out what they consider unknown drugs, medical examinations and procedures. In addition, it does not take into account practicality and the main priorities of the communities such as feeding and taking care of themselves and their children. These primary interventions do not try to involve and build trust with the community via education that could lead to an increased numbers of local people involved in trachoma eradication.
Rather, the interventions feed into the history and special interest groups that have framed these types of interventions as the main priority in implementing the SAFE strategy. The medical treatments are heavily supported by donors and health groups due to the quantifiable outcomes that can be seen immediately (Conrad N. Hilton Foundation, 2006). Phizer, a pharmaceutical company, has donated over 5 million antibiotics treatment to countries endemic with trachoma (Phizer, 2006). The idea that one dose of a free pill, azithromycin, can stop someone from going blind is very attractive to both donors and public health professionals, whom without many interventions can not be run. The appeal of the drug is even greater when compared to what organizations see as the daunting task of changing a regions infrastructure and developing projects that involve behavioral changes of the target population. History has also played a major role in framing as an individual medical problem. In the early 20th century, the illness was treated in eye hospitals in the western world. With new medical and scientific findings, trachoma was found to be a bacterial infection best treated by antibiotics and not community based education interventions.
A New Path: Participatory and Education Based Interventions
However, education and prevention based interventions can work with the SAFE model. Educational projects involving facial cleansing and environmental initiatives allow for a greater opportunity to implement programs that are culturally sensitive and empower the community. The Carter Center has developed many programs based on these social and behavioral sensitive issues in areas such as Ethiopia, Ghana, and Niger. In Ghana, the Carter Center began a radio-listening club. The organization provides wind-up radios to the local people and then regularly broadcasts educational programs focused on hygiene and sanitation activities that are hosted by native language speakers from the indigenous population. In Niger, the hygiene initiative targeting trachoma used local resources and knowledge on soap production to help promote the initiative, while also, providing new financial resources to the women who were involved in the process (The Carter Center, Activities by country, 2006). In Ethiopia, people traditionally use open defecation fields, and women are only allowed to defecate in the open at night (The Carter Center, 2006). This has been very problematic for the Ethiopian, female population. Therefore, the women of the region promoted the use of latrines not only as a mechanism to control trachoma, but also, a means to liberate them from the confinement of only being able to go to the bathroom at night. With the help of the female population, the latrine project in Ethiopia has gained massive success and has set an example for other latrine initiatives around the globe (Bixler, 2005.
These initiatives clearly display the success of programs that allow for real community involvement. The participatory and education initiatives generate community empowerment and invest the local population in the project. Public health professionals are beginning to recognize “that communities need to gain control of the determinants of their own health for their health status to improve” as “powerlessness, or lack of control over destiny, has emerged as a broad based risk factor for disease”(Egger, 130).
A Need for Social Theory
By contextualizing the problem and looking at the population’s other needs, one can see that having the surgery is not considered a main priority. Maslow’s Hierarchy of Needs helps explain why the population struck by trachoma may not see the surgery, and therefore their health as a main concern. In Maslow’s model, and individual must fulfill their needs in an hierarchical manner. First, physiological needs must be met, followed by a need for safety, then belongingness and love, and finally self actualization (Egger, 32). The need for surgery is compromised in order to fulfill the individual’s physiological and safety needs. The population not seeking care is consumed with other concerns, such as providing food and shelter for their family and is not able to take time away from their daily activities to travel to an area that has the surgery available. Also, the idea of having an operation creates a sense of fear for many people, and therefore, makes them feel unsafe, especially in an area where people you do not know and trust are providing the care.
By contextualizing the problem and looking at the population’s other needs, one can see that having the surgery is not considered a main priority. Maslow’s Hierarchy of Needs helps explain why the population struck by trachoma may not see the surgery, and therefore their health as a main concern. In Maslow’s model, and individual must fulfill their needs in an hierarchical manner. First, physiological needs must be met, followed by a need for safety, then belongingness and love, and finally self actualization (Egger, 32). The need for surgery is compromised in order to fulfill the individual’s physiological and safety needs. The population not seeking care is consumed with other concerns, such as providing food and shelter for their family and is not able to take time away from their daily activities to travel to an area that has the surgery available. Also, the idea of having an operation creates a sense of fear for many people, and therefore, makes them feel unsafe, especially in an area where people you do not know and trust are providing the care.
The community and education based initiatives described earlier create a better opportunity for local people to fulfill their other, more basic needs while also combating trachoma by logistically bringing the program to them and not interfering with their daily routine. They also help alleviate people’s sense of fear by involving the local population as leaders and teachers of the initiative. This allows people to identify with the messenger and creates a sense of trust, which may allow the local population to feel safe in implementing the behavior change.
Furthermore, the initiatives also display the crucial need for a trachoma project to have social and cultural accessibility to have a successful project. If one does not make the program culturally and socially acceptable, it will likely fail because people will not partake in the activity (Medecins Sans Frontieres, 24).
In order for a program to be accepted by a group, it must be culturally and socially acceptable explained by the theory of reason and action and “a growing recognition that behaviour is greatly influenced by the environment in which people live” (Egger, 130). One’s culture and accepted social norms gives insight about the person’s attitude towards an issue and how they view other people’s attitudes towards that issue and how they will behave in regards to it. By allowing the community as a whole to see a project in effect and seeing their community members actively working on the project, one can begin to bring the initiatives into the social fabric of the local area and begin to change social norms.
Final Thoughts
The current implementation of SAFE is not living up to the strategy’s potential. By focusing on individual medical care, the public health professionals are missing out on the many upstream initiatives that could prevent this debilitating disease at its source. Furthermore, many current trachoma eradication initiatives are leaving out the people who know how to implement the program most effectively, the local populations endemic with the disease. One should help educate the indigenous people about the basic transmission mechanism of the disease and ways to prevent it, and then learn from the community on how to best run their program. If they do not see the initiative as practical and accepted by their community, they will likely reject it. The ones in control of the initiative should be the ones who are afflicted by the disease and supported by those who can help. Examples were provided earlier of how hygiene and environmental programs permit for the involvement of the entire community.
In order to gain donor support, donors should be educated on these success stories and the necessity of implementing socially conscious programs. To promote the comprehensive use of the SAFE strategy one can also try to make the use of surgery and antibiotics more culturally and socially acceptable by involving local medical professionals and training native people on the simple eye lid procedure and the distribution of antibiotics. In order to implement the SAFE strategy effectively, the influence of special interest groups such as the pharmaceutical companies need to be put aside and one must step back and look at trachoma not only as a medical condition but as a multifaceted issue with many social and cultural issues.
Work Cited
1) “1998 – Trachoma.” Exploring Our History. 2006. Pfizer. 08/08/06
2) Alene, G. D., Kebede, W., Kebede, B. Prevalence and associated risk factors of trachoma among women aged 15 to 49 years in North Western Ethiopia. 2000;14(3). The Ethiopian Journal of Health Development. 07/18/2006 <
http://www.cih.uib.no/journals/EJHD/ejhdv14-n3/ejhd-14-3-page-293.htm. >
3) Bixler, M. “Latrine Program a Hit.” News and Info, The Carter Center. 03/05/2006. Atlanta Journal Constitution Feature: Rural Ethiopia Latrine Program. 07/12/06 < http://www.cartercenter.org/doc2100.html>
4) Egger, G., Spark, R., & Donovan, R. Health Promotion Strategies and Methods. 2005. Australia: McGraw-Hill.
5) “Ethiopia.” Activities by Country. 2006. The Carter Center. 07/12/06. < http://www.cartercenter.org/activities/showdoc.asp?submenu=activities&countryID=31.>
6) Kumaresan, Jacob, Mecaskey, Jeffrey. The Global Elimination of Blinding Trachoma: Progress Promise. 69 (Suppl 5). 2003. The American Society of Tropical Medicine and hygiene. 06/16/2006.
7) Kuper, H., Soloman, A., Buchan, J. et al. “A Critical review of the SAFE strategy for the prevention of blinding trachoma.” Review: Trahoma Prevention. 06/2003;3. The Lancet Infectious Diseases. 07/12/09 < http://linkinghub.elsevier.com/retrieve/pii/S1473309903006595 >
8) Medicins San Frontieres. Refugee Health: An Approach to emergency situations. 1997. Oxford: Macmillan Education.
9) Mariotti, S.P., Pruss, A. The SAFE Strategy: Preventing trachoma: A guide for environmental sanitation and improved hygiene. 2001. World Health Organization; International Trachoma Initiative.
10) “Trachoma.” Department of Health and Human Services: Centers for Disease Control and Prevention. 10/24/2004. National Center for Infectious Diseases/Division of Bacterial Mycotic Diseases. 06/16/2006
11) “Trachoma Control and Prevention - Carter Center Trachoma Control Program.” Health Programs. 04/2006. The Carter Center. 07/12/06
12) “Trachoma Control and Prevention – Carter Center Trachoma Control Program.” The Carter Center. 04/2006. The Carter Center. 06/16/2006
13) “Water and sanitation related diseases fact sheets.” WHO. 2006. World Health Organization. 08/04/06
Trachoma, a bacterial infection of the eye, is the number one cause of preventable blindness in the world (The Carter Center, Health Programs, 2006). In trachoma, the bacterium Chlamydia trachomatis infects the eye and causes follicular conjunctivitis, which leads to conjunctival scarring. Repeated infections result in the inward turning of the eye lashes and irritation of the cornea. This condition known as trichiasis is extremely painful and will eventually lead to blindness as the corneal scarring intensifies (Center for Disease Control and Prevention, 2004.
Trachoma infected individuals release a contagious discharge. When the discharge comes in contact to a trachoma free person’s eye, he or she will also become infected. Trachoma usually affects people living in poverty and is associated with inadequate water supplies and unsanitary conditions. Populations in poor, dry areas often do not have sufficient water supplies to wash themselves or their clothes to prevent the spread of the disease. Trachoma is mainly spread via person to person contact, contact with contaminated clothing or bedding, and flies that carry the bacterium from individual to individual. Children become infected at a higher rate because they are less hygienic and touch their faces more often. Furthermore, two-thirds of those afflicted by blinding trachoma are women, who tend to be the main child care taker in most of the areas endemic with trachoma (Alene, 2000). Infrastructure that could help eliminate trachoma are limited or non-existent in many areas endemic with the disease, such as the Middle East, North and Sub-Saharan Africa, parts of the Indian sub-continent, Southern Asia, China, Latin America, Australia, and the Pacific Islands (World Health Organization, 2006) .
Our Current Mentality: Medicalization of the SAFE Strategy
The current public health approach to treat and prevent trachoma is referred to as the SAFE strategy. SAFE is based on four key components: surgery, antibiotics, facial cleansing, and environmental interventions (Kumaresan, 2003). Currently, public health professionals are implementing SAFE with a focus on the primary interventions of surgery and antibiotics (Conrad N. Hilton Foundation, 2006.
From a social science perspective, the current trachoma implementation strategy is not addressing the root cause of the problem to mitigate the efficient eradication of trachoma. Public health leaders should focus their attention on preventing trachoma through the implementation of programs that promote proper hygiene such as facial cleansing and environmental initiatives that deal with containment of human excreta, solid waste disposal, management of food, and issues related to overcrowding (Mariotti, 2000). Such intervention strategies can center on educational awareness that emphasize cultural and socially accepted programs, while at the same time empowering the community and creating trust between public health professionals and the local population. The use of surgery and antibiotics are and integral part of the SAFE strategy, however, implementing more programs that highlight the facial cleansing and environmental initiatives will give public health professionals a greater ability to take social and behavioral factors into consideration and help contextualize the problem of trachoma.
A simple 15 minute eye-lid surgery has been proven to effectively treat trichiasis, an eye condition found in people repeatedly struck by the trachoma infection. But, less than half of the people offered the surgery for free actually have the procedure done. One must look at the bigger social picture to identify why 50% of people suffering from a painful, debilitating disease do not seek treatment. Some of the main barriers that hinder much of the effected population from getting the surgery include, “constraint by duties such as child care, lack of time, perceived cost of surgery, lack of an escort, distance to travel to surgery, and fear of the operation” (Kuper, 2003). Local populations afflicted by trachoma likely fear the medicalization of SAFE because they see it as foreigners handing out what they consider unknown drugs, medical examinations and procedures. In addition, it does not take into account practicality and the main priorities of the communities such as feeding and taking care of themselves and their children. These primary interventions do not try to involve and build trust with the community via education that could lead to an increased numbers of local people involved in trachoma eradication.
Rather, the interventions feed into the history and special interest groups that have framed these types of interventions as the main priority in implementing the SAFE strategy. The medical treatments are heavily supported by donors and health groups due to the quantifiable outcomes that can be seen immediately (Conrad N. Hilton Foundation, 2006). Phizer, a pharmaceutical company, has donated over 5 million antibiotics treatment to countries endemic with trachoma (Phizer, 2006). The idea that one dose of a free pill, azithromycin, can stop someone from going blind is very attractive to both donors and public health professionals, whom without many interventions can not be run. The appeal of the drug is even greater when compared to what organizations see as the daunting task of changing a regions infrastructure and developing projects that involve behavioral changes of the target population. History has also played a major role in framing as an individual medical problem. In the early 20th century, the illness was treated in eye hospitals in the western world. With new medical and scientific findings, trachoma was found to be a bacterial infection best treated by antibiotics and not community based education interventions.
A New Path: Participatory and Education Based Interventions
However, education and prevention based interventions can work with the SAFE model. Educational projects involving facial cleansing and environmental initiatives allow for a greater opportunity to implement programs that are culturally sensitive and empower the community. The Carter Center has developed many programs based on these social and behavioral sensitive issues in areas such as Ethiopia, Ghana, and Niger. In Ghana, the Carter Center began a radio-listening club. The organization provides wind-up radios to the local people and then regularly broadcasts educational programs focused on hygiene and sanitation activities that are hosted by native language speakers from the indigenous population. In Niger, the hygiene initiative targeting trachoma used local resources and knowledge on soap production to help promote the initiative, while also, providing new financial resources to the women who were involved in the process (The Carter Center, Activities by country, 2006). In Ethiopia, people traditionally use open defecation fields, and women are only allowed to defecate in the open at night (The Carter Center, 2006). This has been very problematic for the Ethiopian, female population. Therefore, the women of the region promoted the use of latrines not only as a mechanism to control trachoma, but also, a means to liberate them from the confinement of only being able to go to the bathroom at night. With the help of the female population, the latrine project in Ethiopia has gained massive success and has set an example for other latrine initiatives around the globe (Bixler, 2005.
These initiatives clearly display the success of programs that allow for real community involvement. The participatory and education initiatives generate community empowerment and invest the local population in the project. Public health professionals are beginning to recognize “that communities need to gain control of the determinants of their own health for their health status to improve” as “powerlessness, or lack of control over destiny, has emerged as a broad based risk factor for disease”(Egger, 130).
A Need for Social Theory
By contextualizing the problem and looking at the population’s other needs, one can see that having the surgery is not considered a main priority. Maslow’s Hierarchy of Needs helps explain why the population struck by trachoma may not see the surgery, and therefore their health as a main concern. In Maslow’s model, and individual must fulfill their needs in an hierarchical manner. First, physiological needs must be met, followed by a need for safety, then belongingness and love, and finally self actualization (Egger, 32). The need for surgery is compromised in order to fulfill the individual’s physiological and safety needs. The population not seeking care is consumed with other concerns, such as providing food and shelter for their family and is not able to take time away from their daily activities to travel to an area that has the surgery available. Also, the idea of having an operation creates a sense of fear for many people, and therefore, makes them feel unsafe, especially in an area where people you do not know and trust are providing the care.
By contextualizing the problem and looking at the population’s other needs, one can see that having the surgery is not considered a main priority. Maslow’s Hierarchy of Needs helps explain why the population struck by trachoma may not see the surgery, and therefore their health as a main concern. In Maslow’s model, and individual must fulfill their needs in an hierarchical manner. First, physiological needs must be met, followed by a need for safety, then belongingness and love, and finally self actualization (Egger, 32). The need for surgery is compromised in order to fulfill the individual’s physiological and safety needs. The population not seeking care is consumed with other concerns, such as providing food and shelter for their family and is not able to take time away from their daily activities to travel to an area that has the surgery available. Also, the idea of having an operation creates a sense of fear for many people, and therefore, makes them feel unsafe, especially in an area where people you do not know and trust are providing the care.
The community and education based initiatives described earlier create a better opportunity for local people to fulfill their other, more basic needs while also combating trachoma by logistically bringing the program to them and not interfering with their daily routine. They also help alleviate people’s sense of fear by involving the local population as leaders and teachers of the initiative. This allows people to identify with the messenger and creates a sense of trust, which may allow the local population to feel safe in implementing the behavior change.
Furthermore, the initiatives also display the crucial need for a trachoma project to have social and cultural accessibility to have a successful project. If one does not make the program culturally and socially acceptable, it will likely fail because people will not partake in the activity (Medecins Sans Frontieres, 24).
In order for a program to be accepted by a group, it must be culturally and socially acceptable explained by the theory of reason and action and “a growing recognition that behaviour is greatly influenced by the environment in which people live” (Egger, 130). One’s culture and accepted social norms gives insight about the person’s attitude towards an issue and how they view other people’s attitudes towards that issue and how they will behave in regards to it. By allowing the community as a whole to see a project in effect and seeing their community members actively working on the project, one can begin to bring the initiatives into the social fabric of the local area and begin to change social norms.
Final Thoughts
The current implementation of SAFE is not living up to the strategy’s potential. By focusing on individual medical care, the public health professionals are missing out on the many upstream initiatives that could prevent this debilitating disease at its source. Furthermore, many current trachoma eradication initiatives are leaving out the people who know how to implement the program most effectively, the local populations endemic with the disease. One should help educate the indigenous people about the basic transmission mechanism of the disease and ways to prevent it, and then learn from the community on how to best run their program. If they do not see the initiative as practical and accepted by their community, they will likely reject it. The ones in control of the initiative should be the ones who are afflicted by the disease and supported by those who can help. Examples were provided earlier of how hygiene and environmental programs permit for the involvement of the entire community.
In order to gain donor support, donors should be educated on these success stories and the necessity of implementing socially conscious programs. To promote the comprehensive use of the SAFE strategy one can also try to make the use of surgery and antibiotics more culturally and socially acceptable by involving local medical professionals and training native people on the simple eye lid procedure and the distribution of antibiotics. In order to implement the SAFE strategy effectively, the influence of special interest groups such as the pharmaceutical companies need to be put aside and one must step back and look at trachoma not only as a medical condition but as a multifaceted issue with many social and cultural issues.
Work Cited
1) “1998 – Trachoma.” Exploring Our History. 2006. Pfizer. 08/08/06
2) Alene, G. D., Kebede, W., Kebede, B. Prevalence and associated risk factors of trachoma among women aged 15 to 49 years in North Western Ethiopia. 2000;14(3). The Ethiopian Journal of Health Development. 07/18/2006 <
http://www.cih.uib.no/journals/EJHD/ejhdv14-n3/ejhd-14-3-page-293.htm. >
3) Bixler, M. “Latrine Program a Hit.” News and Info, The Carter Center. 03/05/2006. Atlanta Journal Constitution Feature: Rural Ethiopia Latrine Program. 07/12/06 < http://www.cartercenter.org/doc2100.html>
4) Egger, G., Spark, R., & Donovan, R. Health Promotion Strategies and Methods. 2005. Australia: McGraw-Hill.
5) “Ethiopia.” Activities by Country. 2006. The Carter Center. 07/12/06. < http://www.cartercenter.org/activities/showdoc.asp?submenu=activities&countryID=31.>
6) Kumaresan, Jacob, Mecaskey, Jeffrey. The Global Elimination of Blinding Trachoma: Progress Promise. 69 (Suppl 5). 2003. The American Society of Tropical Medicine and hygiene. 06/16/2006
7) Kuper, H., Soloman, A., Buchan, J. et al. “A Critical review of the SAFE strategy for the prevention of blinding trachoma.” Review: Trahoma Prevention. 06/2003;3. The Lancet Infectious Diseases. 07/12/09 < http://linkinghub.elsevier.com/retrieve/pii/S1473309903006595 >
8) Medicins San Frontieres. Refugee Health: An Approach to emergency situations. 1997. Oxford: Macmillan Education.
9) Mariotti, S.P., Pruss, A. The SAFE Strategy: Preventing trachoma: A guide for environmental sanitation and improved hygiene. 2001. World Health Organization; International Trachoma Initiative.
10) “Trachoma.” Department of Health and Human Services: Centers for Disease Control and Prevention. 10/24/2004. National Center for Infectious Diseases/Division of Bacterial Mycotic Diseases. 06/16/2006
11) “Trachoma Control and Prevention - Carter Center Trachoma Control Program.” Health Programs. 04/2006. The Carter Center. 07/12/06
12) “Trachoma Control and Prevention – Carter Center Trachoma Control Program.” The Carter Center. 04/2006. The Carter Center. 06/16/2006
13) “Water and sanitation related diseases fact sheets.” WHO. 2006. World Health Organization. 08/04/06
posted by Christina at 10:49 AM
7 Comments:
Hi Zareen,
This is a great analysis of the SAFE strategy. You should send it to the Carter Center, they do a lot of work on Trachoma.
Hi Zareen,
Interesting topic! How did u come across it?
Looking forward to ur talk :)
Hang on! Or simply certainly not! I submitted to Tiffany’s e-mail handle originating from a various position and this time frame I didnrrrt receive an blunder sales message.
This means your dog probably got the info this individual wished from
us (account selection, etcetera) now obstructed this e-mail deal with using an error message that affirms “Eric’s e-mail target isn't valid anymore”, but it’s almost certainly ready to go all over again. Resistant is actually We delivered a note to the deal with from a several position (one of my own other e-mail addresses) we failed to receive an miscalculation message… darn…tghthgthgg Lawrence help us observe my curriculum vitae within your company. I've got presently delivered this resume in
your company mail, make sure you I need a person's critical response.
Visit my web-site :: Cure acne
I actually don’t have any idea generate income ended up listed here, even so feel this information is unexpected.
I actually don’t understand what you do however absolutely you'll be described as a well-known blog writer, if you are not witout a doubt.
Look at my web blog :: Genital Warts Treatments
Us along with my buddy had been disagreeing a superb matter along
these lines! At this point you know that we was correct. :
)! Thanks for the details somebody article.
My site - Treating Genital Warts
I actually do rely on most of the basics you’ve offered for your write-up.
There're incredibly convincing and may absolutely do the job. Even now, the particular blogposts are certainly limited for starters. May anyone you should extend these individuals a bit out of future time frame? Thanks for the publish.
Also visit my web-site ... Records Search
pοwiadaciе... - mruknął Arnold pгzycіśnięty Touristen nareszcie
aż do muгu. - Wіecie, ρаnie, ze smokiem
wydаje sіę kwestіa... Odρowiedzialnie,
był
κweѕtia. Oficjalnie straszydło nie istnіał.
Νiе wspоmіnano ο zanim,
o ѕtraty.
Post a Comment
<< Home