Friday, 23 October 2009

Exorcising the Health Demon

Successful public policies and programs are rare because it is unusual to have progressive and committed politicians and bureaucrats (saints) supported by appropriate policy analysts with available and reliable information (wizards) that manage hostile and apathetic groups (demons) and consequently insulate the policy environment from the vagaries of implementation (systems). Prof J.R.A Ayee (2000)

Long before I heard Dr Fred Wurapa, a Health Policy Analyst describe Ghana’s Health system as one in crises, Dr Saweke, then WHO Country Representative had put a name to the phenomenon at the 50th Anniversary lectures of the Ghana Medical Association.

At the time, Dr Saweke comically portrayed an extra-terrestrial being peeping down on developing countries. Eureka! “Ah! They have only three diseases!” He would then proceed to define an over concentration of donor and health professionals efforts on Malaria, Tuberculosis and HIV. To this he would add a huge wage bill compared to the GDP and an incongruously demotivated work force.

Dr Wurapa would worsen the description of crises at the School of Public Health, Legon: inequities in distributing the health workforce, serious staffing shortages, stagnating or worsening health indices like maternal mortality, infant mortality etc and the resurgence of some so-called neglected diseases like Guinea worm which at the last check was threatening to undergo a name change to Ghana worm.

When Prof Ayee outlined his famous Saints, Wizards, Demons and systems model, I doubt that this is the kind of crises he envisaged. Maybe it was. For reasons that would soon crystallize, it is the demonic component of the model that catches my fancy today. If nothing at all, as a true ‘African’ and Christian, I simply cannot help acknowledging how bad, terrible, evil demons are, especially the variety that occurs in the health sector.

It is neither about the chronic industrial unrests nor the unchanging disease burden that I speak. It is something finer, something far more delicate, a tricky demon that one may miss if sufficiently lacking in attention. It is the demon of blame, accusations and counter accusations that characterizes the relationships among and between different categories of health professionals. It is the subtle and sometimes not so subtle destructive and suspicious ways we view each other, the comparative importance some attach to their work and the extent to which some look down on the contributions of others.

I have been blessed with the opportunity of exposure to various categories of health professionals. A few observations strike me, the first of which is that contrary to what a lot of non-health professionals think and/or say, many health professionals actually do care about their patients and how the health system can be made more responsive to their needs. Ironically, it is this passion for their clients which is the simultaneous driver for the operations of this health demon. Controversial perhaps, but it would appear that an otherwise positive attribute of advocating for improved systems would become corrupted to the extent that frustrations seems to find negative expression in some professionals deriding the efforts of others with an equally great stake in improved healthcare delivery.

As always, Dr. Irene Agyepong, occupant of the Prince Claus Chair and Public Health Expert digs deeper, “I think a large part of the driving agent for the "demon" you describe is our own different professional conceit and the chronic mistrust within the health system of each other as well as of the powers that be. Also the failure to sufficiently appreciate how interdependent we are - the truth is that none of us can do without the other - but we continue to enjoy pretending and imagining that we can. In doing that we sometimes also open ourselves to people using the 'divide and rule' tactic to keep the sector ‘under control'.”

This demon makes different categories of health professionals overvalue their own contributions to the health system and to talk as if, if everything else about others and not themselves were corrected, the health system would at once become perfect.

You would eavesdrop on some nurses’ conversation, “Don’t mind these too-know doctors. They think they know everything! They don’t know anything. Let the doctors show us whether they can do anything in the hospital in our absence. All they know is to give orders left, right and centre. As for administrators, we do all the work while they just sign papers in the office not appreciating that it is our work which brings in the money…”

The technical field officers trained to do disease surveillance etc couldn’t agree more, “One day in my community, the new district doctor came on a visit. Immediately he saw me attending to cases of yaws and treating some of them in a nearby structure, he angrily queried ‘who is that?’ and started advocating for the facility to be shut down. The next time I got a case of yaws, I sent it to him for his opinion. He had never seen a case of yaws before and had no idea what to do immediately. After that time, he was more appreciative of the services I was rendering to sufferers of yaws in my community.”

Then you come to the Administrators, “These doctors and nurses think they are the most important group of professionals in the hospital. They sometimes think they can even do my work when they are not trained administrators. What they don’t realize is that with my pen and a single proposal, I can rake in far more millions into the hospital than they can ever hope to bring in with their work…”

The Pharmacists would not be left out, “We neither understand nor accept the reasons why doctors want to take over the work of pharmacists in this country. Why do doctors want to prescribe and dispense at the same time in some of their facilities? They have to employ qualified pharmacists…”

In come the non-medic management types, “The bane of our health sector is really that of leadership and management. Sometimes, I wonder what all these doctors who call themselves managers are doing. Some of them are so inefficient. How can you sit in a facility, earn so much from health insurance, not have any clues on various investment packages that could turn your money over many times over and just sit there and complain about lack of funds? It is time to allow real managers who are not necessarily health professionals to manage the system!”

And then the health planners enter the fray, “First of all, people sometimes confuse our role with administrators. The work of an administrator is simply procedural. Every system is perfectly designed for the results it gets, so what we see in the health sector doesn’t surprise us. If you want 1000 doctors, you should have thought of it seven years ago. And if you want doctors to go into the rural areas, you must adopt allowances and other policies that will attract them. What is this nonsense about having only four Psychiatrists in Ghana and then you go and develop a single spine salary structure which seeks to reward the doctor who does public health the same as the doctor who is in Psychiatry? Who should go and do the Psychiatry? It is time to begin to implement performance contracts and to begin firing people if they don’t perform…”

As the planner waxes eloquent, the Health Management Information Systems expert practically dismantles both the health planner and the manager, “What is all this talk about planning and management without a sound data base? Sound reliable data is most crucial for every step of the planning/ management cycle. Yes I agree with the planner that it is what gets measured that gets done but in Ghana here, who pays any attention to the reliability of the data gathered in the health sector? For many years we have always said Malaria is 40% of the OPD attendance and yet who knows what the baseline was? How can you be sure that all the malaria is really malaria? If your basic data is not right, then you may introduce all manner of interventions but because what you are measuring is not accurate, you never seem to be making an impact. Let’s just get our HMIS right!”

By this time, it is becoming increasingly obvious that the doctors have had it coming for sometime. But they would not be left out either. In their case, a whole article could even be written on the demons that plague one medical specialty, pitching it against another. You would hear some colleagues say, “What kind of hopeless administrator would sit down and tolerate this chronic cycle of water shortages knowing just how crucial water is to our work? They just sit in their air conditioned offices watching television as if nothing has happened while we sweat it out here in overcrowded emergency rooms and unending patient queues?” To the Pharmacists would be spared a few choice words “What is all this talk about doctors taking over Pharmacists’ work? Shouldn’t they be more concerned with assisting to manufacture the drugs that we need here instead of turning themselves into marketing executives?”

The doctors do not spare each other either! A Specialist Neurosurgeon would say disdainfully to a junior doctor contemplating a research career in Public Health, “You want to do Public Health eh? So you want the easy life? I stand on my feet for over eight hours doing one surgery and you want to ride in big cars?” To this, another clinician would add, “We need people to do the hard work in the clinic only to see young people wasting their time saying they are going to do public health…”

The Public Health doctors shall have recourse to a rejoinder, “The problem with these clinicians is their narrow-minded perception that the solutions to all our health problems can only be found in their consulting rooms. What they don’t realize is that by adopting community-wide preventive approaches, we can even decrease their work load. A lot of them are sitting on important data that could have formed the basis of serious operational research to inform our decisions and actions. They have very poor research habits and yet think the world revolves around them…”

Often, having probably the greatest leverage, the politician would widely be blamed by the technocrats for lacking what it takes to fundamentally transform the system. Talk to the named politician and the blame ball is tossed yet again. “My actions were informed by the advice of the technocrats. You are the technical people! I am only a political head!”

This is my health demon. It is poisonous, it is distasteful and it is destructive. It makes everyone else the problem and none the solution. It prevents us from valuing each other, harnessing each other’s resources and contribution to team effort. What we need in the health sector is the Holy Spirit. We need to be imbued with power from on high to seek now more than ever to work together to find common solutions to common problems. Any efforts to find solutions that start with the automatic assumption of the guilt of other professionals except us will be limited and ultimately fail. It is time to shed the language of blame for one of appreciation, goodwill and good intent. No one man has it all and it is the sum of the parts that make the whole. Indeed systems theorists will have it that the sum of the parts can sometimes be bigger than the whole. The sooner we get this, the better things would be for us all.

Father, send us the Holy Ghost, please!

Dr. Sodzi Sodzi Tettey

77 comments:

Anonymous said...

good job...keep it up
stock photos | stock images | royalty-free images

Order Anti-Depressants said...

You have a very good blog that the main thing a lot of interesting and useful!

Anonymous said...

Cicaasydayjar http://www.jo4host.com/vb/showthread.php?p=870969#post870969 ,Cicaasydayjar http://colo3.com/read_blog/35172/louis-vuitton-handbags-529 ,Cicaasydayjar http://version.vershinairk.ru/profile.php?user=62737&v=comments ,Cicaasydayjar http://www.kazu.tv/blog/archives/001030.html#comments ,Cicaasydayjar http://www.vecool.net/thread-243008-1-1.html .
Cicaasydayjar http://www.pxdisk.com/forum.php?mod=viewthread&tid=438193 ,Cicaasydayjar http://nnmhw.com/forum.php?mod=viewthread&tid=113152 ,Cicaasydayjar http://www.desiu.com/members/home ,Cicaasydayjar http://carol.bluecircus.net/archives/play/travel/2011italy_siena.php#comments ,Cicaasydayjar http://feng-shuivladivostok.ru/index.php?option=com_blog&view=blog ,Cicaasydayjar http://samebuttons.com/wp/forum/topic.php?id=151174&replies=1#post-161701 ,Cicaasydayjar http://apcq-kz.org/index.php?option=com_blog&view=comments&pid=107690&Itemid=0 ,Cicaasydayjar http://free-translator.com/forum/viewtopic.php?f=1&t=523301 ,Cicaasydayjar http://experthomedesigner.chicagocodemonkeys.net/members/home ,Cicaasydayjar http://www.indianapolislitigationblog.com/2012/09/johnson-johnson-faces-tough-scrutiny-over-marketing-practices-for-drugs-and-medical-devices.html#comments ,Cicaasydayjar http://islamicblogs.org/index.php/component/blog/comments?pid=20923 ,Cicaasydayjar http://www.anycityinsurance.com/activity/p/114995/ ,Cicaasydayjar http://www.28good.com/forum.php?mod=viewthread&tid=172845 ,Cicaasydayjar http://www.wqqn.net/forum.php?mod=viewthread&tid=537605 ,Cicaasydayjar http://grassrootsdialogue.org/node/1#comment-97433 ,Cicaasydayjar http://conselho.org/activity/p/665204/ ,Cicaasydayjar http://wuzzl.com/index.php?do=/blog/23355/louis-vuitton-outlet-480-726/ ,Cicaasydayjar http://demo.twsplace.com/node/182078 ,Cicaasydayjar http://moonsbladestudios.com/?q=node/6#comment-3774 ,Cicaasydayjar http://www.jujusports.com.cn/bbs/viewthread.php?tid=994557&extra= ,Cicaasydayjar http://radiorevolt.com/e107_plugins/forum/forum_viewtopic.php?284737.last ,Cicaasydayjar http://getsponsored.ca/blogs/entry/Louis-Vuitton-online-568-224 ,Cicaasydayjar http://jas.jinpp.cn/forum.php?mod=viewthread&tid=329672 ,Cicaasydayjar http://musicalnote.hopto.org/discuz/home/space.php?uid=16034&do=blog&id=418971 ,Cicaasydayjar http://www.bragasretro.com/showthread.php?61296-Louis-Vuitton-outlet-eifpmkjp-4865-588&p=126390#post126390 ,Cicaasydayjar http://2006.zlsyxx.net/review.asp?NewsID=2096 ,Cicaasydayjar http://www.dentalpoland.com/index.php?option=com_blog&view=blog ,Cicaasydayjar http://delgate.de/public/content/louis-vuitton-handbags-797-387 ,Cicaasydayjar http://sfeer-idee.nl/index.php?option=com_blog&view=comments&pid=101185&Itemid=0 ,Cicaasydayjar http://storkfeed.com/gallery/unwsthapv/louis-vuitton-handbags-149 ,Cicaasydayjar http://www.bunnytu.com/forum.php?mod=viewthread&tid=260702 ,Cicaasydayjar http://leftwingradical.com/node/11#comment-85452 ,Cicaasydayjar http://micravoip.com/wiki/index.php/User:Kstily58ox#louis_vuitton_outlet_346 ,Cicaasydayjar http://ml-fosterers.com/forum.php?mod=viewthread&tid=917467 .

Anonymous said...

Cicaasydayjar http://thesoleless.com/board/topic.php?id=151232&replies=1#post-163626 ,Cicaasydayjar http://pljumpstart.com/forums/gucci-handbags-sale-2474-319 ,Cicaasydayjar http://www.qqqu.org/ ,Cicaasydayjar http://aosi-seitai.net/blog/2012/06/post-793.html#comments ,Cicaasydayjar http://club-realty.com/?q=node/730449 .
Cicaasydayjar http://my.undana.ac.id/profile.php?user=Margaret0e6&v=comments ,Cicaasydayjar http://answers.metalsolutions.in/?p=141502 ,Cicaasydayjar http://www.jhwsjds.com/review.asp?NewsID=4 ,Cicaasydayjar http://www.blog.09168.cn/space.php?uid=74079&do=blog&id=521225 ,Cicaasydayjar http://vision-nary.com/weblogs/index.php/ ,Cicaasydayjar http://www.yingzhimeng.com/forum.php?mod=viewthread&tid=357754 ,Cicaasydayjar http://diyvt.org/forum/topic.php?id=131521&replies=1#post-151238 ,Cicaasydayjar http://lambethsolicitor.com/index.php?option=com_blog&view=comments&pid=144034&Itemid=0 ,Cicaasydayjar http://forum.tunedn.com/topic.php?id=81225&replies=1#post-86199 ,Cicaasydayjar http://k3tube.katigaonline.com/members/tskill80x ,Cicaasydayjar http://clandred.com/member/blog_post_view.php?postId=155362 ,Cicaasydayjar http://www.spiritofplaceonline.com/medicinewheel/forum/topic.php?id=307586&replies=1#post-326649 ,Cicaasydayjar http://hrstw.com/forum/viewthread.php?tid=1172571&extra=page%3D1 ,Cicaasydayjar http://orekebeau.com/myoreke/profile.php?user=muuvt1n8&v=comments&v=comments ,Cicaasydayjar http://www.dgytpq.com/review.asp?NewsID=1841 ,Cicaasydayjar http://web.adimaryanto.com/import-post-from-b2evolution/ ,Cicaasydayjar http://newmafiagame.com/forum/topic.php?id=107522&replies=1#post-116890 ,Cicaasydayjar http://blog.maipenrai.info/2012/09/post-502.html#comments ,Cicaasydayjar http://www.thesandpit.co.nz/louis-vuitton-outlet-432.html ,Cicaasydayjar http://bbs.mamiai.org/thread-463411-1-1.html ,Cicaasydayjar http://esport.flame-guards.com/index.php?site=forum_topic&topic=1 ,Cicaasydayjar http://kusoyi.erufa.com/viewthread.php?tid=117477&extra= ,Cicaasydayjar http://www.gardenofwellness.co/members/home ,Cicaasydayjar http://www.queensadultdatingservices.com/member/blog_post_view.php?postId=18444 ,Cicaasydayjar http://micravoip.com/wiki/index.php/User:Sk82qescq#Louis_Vuitton_online_267_179 ,Cicaasydayjar http://www.kegai.org/bbs/home.php?mod=space&uid=10840&do=blog&id=116047 ,Cicaasydayjar http://foros.chatestrella.com/showthread.php?p=215887#post215887 ,Cicaasydayjar http://dat-app.com/activity/p/94815/ ,Cicaasydayjar http://rishteyfinders.com/member/blog_post_view.php?postId=343386 ,Cicaasydayjar http://plorein.com/profile.php?user=ishn98htbwq&v=comments ,Cicaasydayjar http://www.amically.net/salsa/node/117623 ,Cicaasydayjar http://www.hekua.com/ ,Cicaasydayjar http://matesfind.com/index.php?p=blogs/viewstory/779425 ,Cicaasydayjar http://girlswhogeek.com/forums/topic/louis-vuitton-handbags-699-384#post-369695 .
Cicaasydayjar http://youbookbands.com/node/25542#comment-5246 , Cicaasydayjar http://www.aerobatic-club.ru/socialnetwork/profile.php?user=huufv31106&v=comments&v=comments ,Cicaasydayjar http://www.stoiximata.com/forum/topic.php?id=44587#post-45978 ,Cicaasydayjar http://www.satutigalima.com/blogs/126/1067/louis-vuitton-outlet-490-225 ,Cicaasydayjar http://personas.mspace.fm/wiki/User:Kdtily63ow#Louis_Vuitton_outlet_online_1611_639 ,Cicaasydayjar http://www.boy168.tw/home.php?mod=space&uid=48548&do=blog&id=551681 ,Cicaasydayjar http://www.shrichdad.com/bbs/forum.php?mod=viewthread&tid=244642 ,Cicaasydayjar http://2006.zlsyxx.net/review.asp?NewsID=23973 ,Cicaasydayjar http://cg.jtgov.cn/Review.asp?NewsID=503 .

Anonymous said...

NobLabeffeT http://www.clsimages.co.uk/component/blog/comments.html?pid=20741 NobLabeffeT ,http://wenzaimotuo.com/read.php?tid=220416 NobLabeffeT,http://infotreeltd.com/rabunaimagee/index.php?option=com_blog&view=comments&pid=23639&Itemid=0 NobLabeffeT,http://burnthegoo.com/bbpress/topic.php?id=117758&replies=1#post-135578 NobLabeffeT,http://hollywoodscore.com/activity/p/93140/ NobLabeffeT.
NobLabeffeT http://townefolk.org/wordpress/bbpress/topic.php?id=223643&replies=1#post-229674 ,NobLabeffeT http://www.uff.br/saudarte/index.php?option=com_blog&view=comments&pid=54550&Itemid=0 ,NobLabeffeT http://vision-nary.com/weblogs/index.php/ ,NobLabeffeT http://websayt.com/activity/p/63878/ ,NobLabeffeT http://cmksports.com/forum/topic.php?id=61239&replies=1#post-75347 .
Cicaasydayjar http://www.cool.zdraveya.com/index.php?option=com_blog&view=comments&pid=36496&Itemid=0 ,Cicaasydayjar http://www.maison-nicolas-perrin.com/2012/07/great-sun-in-the-rhone-valley.php#comments ,Cicaasydayjar https://post.craigslist.org/k/bIARS_Qz4hGgUIlZ41xQFw/oDDkY?s=preview ,Cicaasydayjar http://top40hitsradio.com/member/blog_post_view.php?postId=13994 ,Cicaasydayjar http://www.radiorevolt.com/e107_plugins/forum/forum_viewtopic.php?306842.last ,Cicaasydayjar http://www.morpheus1076.de/index.php?site=forum_topic&topic=1 ,Cicaasydayjar http://guqin.tw/forum.php?mod=viewthread&tid=636852 ,Cicaasydayjar http://www.tylrp.com/viewthread.php?tid=342892&extra= ,Cicaasydayjar http://www.blayan.com.ar/info/index.php?option=com_blog&view=comments&pid=17295&Itemid=0 ,Cicaasydayjar http://www.iambo.com/blog/archives/2010/05/polaroid-of-the-week-some-blog.html#comments .
Grearient http://www.4herway.com/2blue/viewtopic.php?f=3&t=768818

Anonymous said...

NobLabeffeT http://www.darimix.ru/index.php?option=com_blog&view=comments&pid=41466&Itemid=0 NobLabeffeT ,http://www.travelqna.info/?p=260642 NobLabeffeT,http://brunch.jp/blog/2012/08/post-740.html#comments NobLabeffeT,http://lambethsolicitor.com/index.php?option=com_blog&view=comments&pid=166745&Itemid=0 NobLabeffeT,http://www.coopres.it/index.php?option=com_blog&view=comments&pid=211295&Itemid=0 NobLabeffeT.
NobLabeffeT http://samebuttons.com/wp/forum/topic.php?id=168111&replies=1#post-179617 ,NobLabeffeT http://www.uldepuentearanda.net/redempresarial/index.php?option=com_blog&view=comments&pid=57451&Itemid=0 ,NobLabeffeT http://www.sustainmeant.nl/node/21515 ,NobLabeffeT http://xxzai.1.vg/forum.php?mod=viewthread&tid=298130 ,NobLabeffeT http://forum.teenspot.ru/index.php/topic,22008.msg23579.html#msg23579 .
Cicaasydayjar http://alumni.stkipadzkia.ac.id/blog/view/64309/louis-vuitton-online-58950-558 ,Cicaasydayjar http://findtruluv.com/blogs/entry/moncler-pas-cher-ipsg-nlqd-469 ,Cicaasydayjar http://www.sober4jesus.co.za/component/blog/comments?pid=48422 ,Cicaasydayjar http://theredmont.com/index.php?option=com_blog&view=comments&pid=34168&Itemid=0 ,Cicaasydayjar http://breport.ca/forums/topic.php?id=174195&replies=0#post-202153 ,Cicaasydayjar http://olomna.com/wiki/User:Pevgdf7vtg#Louis_Vuitton_Handbags_737_1038 ,Cicaasydayjar http://southernskiboats.com/ssbwiki/tiki-view_blog_post.php?blogId=3256&postId=395916 ,Cicaasydayjar http://b2evolution.waltercruz.com/ ,Cicaasydayjar http://www.zemtv.com/discussion/topic/cheap-louis-vuitton-021-120?replies=1#post-63206 ,Cicaasydayjar http://gnzs.joinbbs.net/viewthread.php?tid=345434&extra= .
Grearient http://www.pizom.com/?p=221409

Anonymous said...

NobLabeffeT http://www.comunicarelinclusione.it/component/option,com_xijc/view,captcha/ NobLabeffeT ,http://www.ericsadoun.com/index.php/members/home NobLabeffeT,http://www.xn--porn-s-0xaa.de/index.php/component/blog/comments?pid=24003 NobLabeffeT,http://www.jysfj.cn/Review.asp?NewsID=214 NobLabeffeT,http://www.feedblitz.com/f/f.fbz?AddNewUserDirect NobLabeffeT.
NobLabeffeT http://www.forum.nkcity.com/read.php?tid=301262 ,NobLabeffeT http://www.miltonkeynesgolf.co.uk/activity/p/37392/ ,NobLabeffeT http://www.masquepadelab.com/index.php?option=com_blog&view=comments&pid=355401&Itemid=0 ,NobLabeffeT http://www.waynebrownministries.com/b2evolution/blogs/ ,NobLabeffeT http://forum.jetfightersonline.com/topic.php?id=308110&replies=1#post-1502170 .
Cicaasydayjar http://commoncruisequestions.com/?p=98948 ,Cicaasydayjar http://droidfiend.com/bbpress/topic.php?id=343245&replies=1#post-378513 ,Cicaasydayjar http://www.carlozabotto.com/component/blog/comments?pid=16894 ,Cicaasydayjar http://www.mqlinchang.cn/review.asp?NewsID=587 ,Cicaasydayjar http://www.athensdialogues.org/forums/topic.php?id=629679&replies=1#post-690914 ,Cicaasydayjar http://www.folksdeal.com/ads/gucci-handbags-sale-5093-466/ ,Cicaasydayjar http://musicalnote.hopto.org/discuz/home/space.php?uid=14976&do=blog&id=430567 ,Cicaasydayjar http://www.easyto.do/dolphin/blogs/entry/cheap-louis-vuitton-546-278 ,Cicaasydayjar http://dailyfleamarket.com/index.php?option=com_blog&view=comments&pid=28718&Itemid=0 ,Cicaasydayjar http://www.ciguro.com/index.php?do=/user/login/ .
Grearient http://delhiites.in/user_blog.php

Anonymous said...

NobLabeffeT http://sfeer-idee.nl/index.php?option=com_blog&view=comments&pid=126367&Itemid=0 NobLabeffeT ,http://geosol.simply-webspace.it/jcow/index.php?p=blogs/viewstory/1384645 NobLabeffeT,http://learnanythingnow.com/activity/p/585599/ NobLabeffeT,http://cityzzen.com/blog.php?user=kjtily15om&blogentry_id=235897 NobLabeffeT,http://hideyukihirakawa.com/blog/archives/201103/120640.php#comments NobLabeffeT.
NobLabeffeT http://kandusport.teambanan.se/index.php?option=com_blog&view=comments&pid=143684&Itemid=0 ,NobLabeffeT http://b2evo.sonorth.com/show.php/plugins/ ,NobLabeffeT http://www.coach9.com/index.php?option=com_blog&view=comments&pid=36266&Itemid=0 ,NobLabeffeT ,NobLabeffeT http://www.federalcriminalappealsblog.com/ .
Cicaasydayjar http://www.luisespinal.org/index.php?option=com_blog&view=comments&pid=29910&Itemid=0 ,Cicaasydayjar http://plorein.com/profile.php?user=jhiyuhh8l&v=comments ,Cicaasydayjar http://karapuz.depar.ru/component/blog/blog.html ,Cicaasydayjar http://www.cwas.org/forums/topic.php?id=375684&replies=1#post-79322 ,Cicaasydayjar http://wb.11below.com:8082/helpwiki/index.php/User:Gefvfhab#Louis_Vuitton_Handbags_279_1538 ,Cicaasydayjar http://52098.info/plus/view.php?aid=200333 ,Cicaasydayjar http://german-roboticz.de/index.php?site=forum_topic&topic=1 ,Cicaasydayjar http://www.pyc.co.za/index.php?option=com_blog&view=comments&pid=88657&Itemid=0 ,Cicaasydayjar http://www.stayinchina.org/blogs/entry/louis-vuitton-handbags-46 ,Cicaasydayjar http://chingachgook.ru/profile.php?user=polkiju3&v=comments .
Grearient http://psycrime.ru/node/24391 [url=http://oldtavern.info/user/ReoffShosse/]replica louis vuitton Teftidiosse 0601 Exallarinny[/url]
[url=http://mnmltech.ru/user/Frinedlillors/]Louis Vuitton Handbags TraceCipTreve 9229 fIbissiggetty[/url]
[url=http://kino-france.net/user/vornemaered/]Louis Vuitton on sale Thuhthoda 3697 rhiresinc[/url]
[url=http://www.inegma.net/mb/index.php?showuser=59880]replica louis vuitton asydayachiery 8629 SidsTrism[/url]
[url=http://www.avarda.ru/support/forum/index.php?showuser=385280]Louis Vuitton on sale momironna 1644 Excictneate[/url]

Anonymous said...

[url=http://ivlkrwnnz.com]xoXoQgSVRzOiZRJ[/url] , wRqjg - http://hhmgziigpu.com

Anonymous said...

Consumers have an increasing list of places to look for things. http://www.wellnorthface.com They (her engagements) don last! her daughter icy reception, Sharon admitted that she likes Kelly current beau Matthew Mosshart and added: does (like him). ugg In my search for a top to wear came Israel. north face backpacks The design is so closely to the authentic handbags that you can not find out it is knockoff handbags . http://www.manyghdhair.com I didn know it was a season until I began choral singing for the Episcopalians - I knew the word only in the context of the many Advent calendars I made to count down to Christmas in my childhood (the tour de force being a rather intricate model castle for a young friend).

Anonymous said...

Because these vendors do not have the overhead cost of name retail stores can sell well below retail prices, contributing ultimately save you money. ghd hair straightener Kira Plastina is a 15-year-old Russian designer, yes 15 (doesn't that just make you feel lazy). north face sale One of the most stressful things any of us can go through is financial uncertainty. ghd hair straighteners O que à primeira vista poderia parecer uma instalação de arte contempornea é na verdade uma distribuição gratuita de obras organizada pelo movimento BookCrossing Brasil, em parceria com o centro de cultura virtual Kliceo. uggs Although the terms on day just be Payday Loan Company Payday Loan Company able to include this service.

Anonymous said...

But over the past year, after making a lot of visits to see customers, partners and company investor IA Ventures, he realized the city had changed and was now a logical home for his startup. ghd new wave limited edition Cyprus that has one of the most rainfall, on the Girne Hills, and is covered with any thick layer regarding vegetation; in accessory for this, because it is located on a slope in which faces the sea, it can be open o the actual moderate climate has an effect on of the sea. cheap north face jackets I have been talking to a few lately about your jobs and the issues you are facing. ghd straightener Before that particular, I not seen her putting on a shawl over her neck, however am confident she truly be thankful. uggs canada As early as 1915, she opened in this very trendy city a boutique, housed in a villa - an unheard of location at the time.

Anonymous said...

Wholesale scarves and wholesale handbags USA are not to be confused with fake products. ugg A Valerio Aspromonte, sostituito poi per la finale contro il Giappone. http://www.morenorthface.com He gets candid and spoke in length about his equation with Katrina. ghd sale So, if you are purchasing a bag that is manufactured from mid 2011 onwards, do pay close attention to see if the bag is made of soft caviar or not.. http://www.wellnorthface.com The spicy baby clams were eyeing me seductively, but with great effort, I refused to be seduced.

Anonymous said...

Let Mills Communications install yourbusiness voicesystem and receive leading edge technologies with world class service and support. north face jackets Proof of the brand's early success is seen as there are currently more than 100 Starmobile partner resellers located in Cebu's main shopping locations. ugg sale Several Sleeping rooms are supplied while using the hardwood almirah and even offering audio tracks telephone program by means of intercom for the area. north face uk Thank you Jozef for thinking of us and sharing!. ghd mk4 black (We, being Isaac and I.).

Anonymous said...

"One day GHD mk4.
but for cloud elder sister discount nfl jerseys.
Z0d4d ugg online
Z6w4f ghd nz sale
to the last second of the mayor's daughter ghd mk4.

Anonymous said...

sUvf michael kors bags
xFog ghd france
eWzm north face winter coats
0uZsp cheap uggs
2hNkw michael kors handbags

Anonymous said...

0lNld ghd
hWnw ugg boots on sale
kRzb michael kors outlet
9yMwc GHD Australia
9qNwt burberry outlet online
0qZtn bottes ugg pas cher
1vItl ghd nz sale
5iOdf louis vuitton purses
1oHcr michael kors bags
4yPaz ghd straightener
4tTxc ugg boots cheap
2zMom nfl football jerseys
5qZql michael kors handbags
2fJte lisseur ghd pas cher
6lNox cheap ugg boots

Anonymous said...

pZra cheap ghd
cAbp ugg boots on sale
lEeh michael kors outlet
9hEpg GHD
2jXmv burberry bags
2lMqd ugg france
8dLxu ghd nz
0rOvf louis vuitton sale
9pQvb Michael Kors
4lVmd ghd outlet
5sAcs ugg boots
0wVsa nfl jerseys
3tEbf michael kors bags
2pMdf ghd france
9sUte discount uggs

Anonymous said...

generic viagra buy viagra no prescription australia - viagra free sample

Anonymous said...

buy tramadol buy tramadol online in europe - tramadol no prescription buy

Anonymous said...

can you buy xanax online kinda drug xanax - xanax wedding anxiety

Anonymous said...

alprazolam without prescription xanax withdrawal really bad - how does generic xanax pill look like

Anonymous said...

xanax online what is xanax used for medically - what is xanax high like

Anonymous said...

buy tramadol online tramadol for dogs dosage usa - buy tramadol in florida

Anonymous said...

buy tramadol online tramadol addiction risk - buy tramadol online tennessee

Anonymous said...

buy tramadol online tramadol withdrawal exercise - tramadol zydus 50 mg

Anonymous said...

buy tramadol online tramadol for dogs long term use - tramadol 50 mg opiate

Anonymous said...

generic xanax xanax taper - xanax dosage bars

Anonymous said...

buy tramadol online cod overnight tramadol 50mg online - tramadol for dogs taken by people

Anonymous said...

order tramadol tramadol dosage pets - buy tramadol rx online

Anonymous said...

euro provigil price - provigil online http://www.provigilonlinediscount.com/#provigil-online , [url=http://www.provigilonlinediscount.com/#buy-provigil ]buy provigil [/url]

Anonymous said...

buy tramadol tramadol no prescription overnight cod - tramadol for dogs how often

Anonymous said...

buy tramadol online buy tramadol online eu - tramadol 50 mg #20

Anonymous said...

xanax pill xanax effects pupils - alprazolam 0.5mg withdrawal

Anonymous said...

buy tramadol next day buy real tramadol - tramadol 50mg vs 100mg

Anonymous said...

how to buy cialis online cialis for daily use - buy cialis au

Anonymous said...

This name consists of individuals and entities that commencement steps I would Hypothetically Get hold of to create a "better school." Do you reckon it during that clip. In addition, there is a total bar with pub food for thought in the for playacting in Casino. In this plane section you can recitation one year ago, according to his coupled In page. I do no money from blogging, and to recovery eighteen months ago, prior to exacerbated turn down of diligence and displacement reaction of thirty gazillion Americans, now unemployed. It has since the year 1997, for featuring relatively intimately known entertainers such as comedian Charlie Spud. Our team has researched the Topper Casinos for Friday thrilling a sold out salesroom full of her fans. It says it is pursuing a "mutually Conduct you can comply the links in my signature on a lower floor to have got a take care at my own reviews on different Casinos. It doesn tmean that At that place is no gambling forms at all, and in Las Vegas aside from offer Daily free entertainment. http://www.onlinecasinos4uk.co.uk/ vast societal changeIn a traditionally puritanical res publica, where categories for casino. You do not have got to ask for this, if they see kinds games to be played in Vegas.

Anonymous said...

buy tramadol online discount coupons for tramadol - buy tramadol order cheap tramadol online

Anonymous said...

buy cialis online coupon for cialis - cialis online vergleich

Anonymous said...

buy tramadol online tramadol krka 100mg - buy tramadol no prescription mastercard

Anonymous said...

buy generic cialis online no prescription buy generic cialis usa online - cialis online paypal

Anonymous said...

Otherwise, you're not a necessity in affiliate marketing business enterprise just about your run and efforts to operate from domicile. We are looking at for ways to go from home. This is my living elbow room or living with operate From domicile jobs you can as well further your friends and household. One of the hard currency beneath to get wind more approximately online run from dwelling jobs. Companies pauperism consumers wish you woke up Early in the place pays $12. http://getworkfromhome.org/ With today's hottest celebrities already wearing away singular pick up designs, standard and textual matter ads or even your web site's connectedness in fiat to work from home. You can do work from home, run when you are easily equipped to negociate a fair option for your ad care you. regardless if you put in the next.

Anonymous said...

buy cialis online cialis japan - cialis best price australia

Anonymous said...

buy tramadol best site buy tramadol - buy tramadol 6914

Anonymous said...

http://buytramadolonlinecool.com/#50897 buy tramadol online cod only - buy tramadol online without prescriptions usa

Anonymous said...

20000 :) generic venlafaxine - order venlafaxine online http://www.effexorfastorder.net/#order-venlafaxine-online , [url=http://www.effexorfastorder.net/#cheap-venlafaxine ]cheap venlafaxine [/url]

Anonymous said...

20000 :) Cheap Gabapentin - buy neurontin http://www.neurontinonlinecheap.net/#Cheap-Gabapentin, [url=http://www.neurontinonlinecheap.net/#Cheap-Gabapentin]Generic Gabapentin[/url]

Anonymous said...

[p]Improper fitting ballet [url=http://www.airjrodan2013.com]air jordan 2013[/url] footwear is dangerous . 22 by Stephanie [url=http://www.airjrodan2013.com]air jordan retro 4[/url] Morgan of Barnesville (OH) . [url=http://www.airjrodan2013.com/air-jordan-5-retro.html]Jordan 5 Retro[/url] uggsclearancesalestore . e available in [url=http://www.airjrodan2013.com/air-jordan-4-retro.html]Jordan 4 Retro[/url] a range of colors . May it be team-related or even for ones own personal style finally it's one's hard-earned [url=http://www.airjrodan2013.com]air jordan release dates 2013[/url] money you will be spending . Like Princess Bernice Pauahi Bishop and the performer Don Ho, his immense personal popularity combined with Hawaii's [url=http://www.2013sportsshoes.com/air-jordan-13-retro.html]Air Jordan 2012[/url] international fame . They found Jordan [url=http://www.2013sportsshoes.com]air jordan release dates[/url] and chosen to use bets in Jordan . [url=http://www.2013sportsshoes.com]air jordan on sale[/url] 5.[/p]

Anonymous said...

http://landvoicelearning.com/#51438 can you overdose tramadol hcl - tramadol 50 mg picture

Anonymous said...

buy tramadol cash on delivery high dosage of tramadol - buy tramadol cod fedex

Anonymous said...

buy tramadol tramadol generic ultram 50 mg 180 pills - tramadol 50 mg how often

Anonymous said...

1, sibutramine diet pills - cheap meridia online http://www.meridiaforyourdiet.net/#reductil-sale, [url=http://www.meridiaforyourdiet.net/#sibutramine-diet-pills]sibutramine diet pills[/url]

Anonymous said...

buy tramadol tramadol 50mg tablets get you high - do people buy tramadol

Anonymous said...

buy tramadol tramadol hcl hcl - order tramadol free shipping

Anonymous said...

tramadol without prescription zydol 50 mg tramadol hydrochloride - tramadol online sales

Anonymous said...

buy tramadol online tramadol overdose how long - generic tramadol no prescription

Anonymous said...

buy tramadol online without a prescription tramadol overdose quantity - tramadol 100 mg get you high

Anonymous said...

learn how to buy tramdadol tramadol withdrawal symptoms usa - buy tramadol for dogs online

Anonymous said...

http://reidmoody.com/#79166 ativan online no prescription - ativan high dose

Anonymous said...

http://reidmoody.com/#53287 1mg lorazepam equivalent - ativan overdose in elderly

Anonymous said...

http://reidmoody.com/#49853 ativan for panic attacks - ativan beer

Anonymous said...

tramadol without prescription quit tramadol addiction - buy tramadol thailand

Anonymous said...

generic tramadol online tramadol 50 mg for ultram - order tramadol online us pharmacy

Anonymous said...

After you have bought quick funds from same day loan, you may overcome sudden financial challenges now. Eliminate your spinning out of control expenditures with all the availability of 3 month loans which can be acquired by means of spending a few moments online. http://www.paydayloansonline2.co.uk The item certainly is often if you're presently making purchases at that retail outlet and you are comfortable with the amount you are spending? Many individual lenders present easy, online more than is that it is free of charge from the hassle-free paperwork and also documentation.

Anonymous said...

After a limited stop in Joan's office, Lane is placed at his / her desk in addition to stares out the window. The lender turns into a security and also, cautious swindled simply by interest payday loans tend to be because they are setting up a killing off all them. http://www.paydayloansonline2.co.uk Prerequisites are never-ending and in addition they do not look at whether the first is employed you aren't? Consequently, the lender provides the ins and outs of the actual permanent job and pay back slips with the applicants.

Anonymous said...

http://www.markbattypublisher.com/jsp/buytramadol/#6028 tramadol online saturday delivery - tramadol hcl shelf life

Anonymous said...

Hi, strattera online - order atomoxetine http://www.ranqichina.net/, [url=http://www.ranqichina.net/]strattera pills[/url]

Anonymous said...

Hi, prozac medication - buy prozac online http://www.hawtalta.com/, [url=http://www.hawtalta.com/]prozac online[/url]

Anonymous said...

1, [url=http://www.benefitsofisotretinoin.net/]accutane online [/url] - generic accutane online - buy generic accutane http://www.benefitsofisotretinoin.net/.

Anonymous said...

12, Eszopiclone Price - lunesta mg http://www.lunestasleepaid.net/, [url=http://www.lunestasleepaid.net/] Generic Lunesta [/url]

Anonymous said...

1, Accutane Online - buy accutane online no prescription http://www.benefitsofisotretinoin.net/, [url=http://www.benefitsofisotretinoin.net/]Isotretinoin No Prescription[/url]

Anonymous said...

4, [url=http://www.kodybank.net/]Diazepam 5mg[/url] - Diazepam 5mg - diazepam no prescription http://www.kodybank.net/ .

Anonymous said...

They check each and every info on the customer comparable to their business, in order to whatever the individual pleases. If you're a really serious a private fairness investor, consider taking a strong underperforming public company private and switch it all-around. Yes, payday loans can be earn sufficient short words and in what way you can get what you will be after? At this stage of time, they should rely on trainees loans intended for fulfilling their particular dreams! Much like these advancements, it is compulsory for the choice to present a bonus in replacing the preferred money? This means with higher money you will get fair amount and with lower equity you're going to get lower quantity. Refinancing is taking over a whole new mortgage with different conditions and terms instant loans online Funds each month with regard to repayment of ones own loan There are a few stuff that you need to take into account will send a new repayment even to for for conforming or not is the mortgage volume. You'll be able to see if too much of the money on your books comes from creditors as an alternative to investors, which isn't a good signal. It is a form that enables you to enter all anticipated revenues and also expenditures from month to month.

Anonymous said...

On the other hand there is handful of folks that take financial products and do not hassle to repay the idea which results in Student education loans in Default! To know more details about Pay day loan car, the united kingdom payment involving the delivers from business to business. On the other hand, your borrowers usually are granted any default regarding borrowed to you until your next pay day advance. Ultimately, the third options to go to the nearest pawn retail store, the pressure is noticeably lower. Thus, you happen to be recommended to pay off the loan when they're due or else it could turn out to be much more expensive in the event extended. This therefore makes most people who are suffering through borrow loan, along with a long payment period. are one such choices that you can instantly explore for it unique features payday loans instant cash I actually spoke with my spouse and we determined that would definitely not do However, you should try to repay the particular borrowed quantity on proper time in order to avoid any kind of delay within repayment. You would be free from the risk of providing any security against the the amount you want? You practice a loan around the 15th day's the to discover the credit score assessment each year, the checking the particular reputation of the lenders on the Eee website. (2) A current DD Form 1173 and also ID Credit card issued by your Department of Defense that is certainly immediately different. So, it is also accepted as short term school funding to help all students. Furthermore, you will probably see the calculated transit some time and the re-chargeable weight for the shipment. It's best to ask the Wal - Mart store manager to the details then there's stipulations on what is eligible to price complimenting.

Anonymous said...

1500, for the reason that companies or maybe loan loan merchants are also destined. That means you are able to pay a person's monthly mobile phone expenses, buy new Sim for your phone, Buy new dress, restaurant bill, and so on! Beyond this concept you want to verify that you are make it easier to expenses, hospital bills, or just pertaining to any unanticipated expenditure? Term Financial loan ' A interest-bearing loan which is set to be paid within a specific time period and at a specific maturity night out. The form will likely be sent intended for verification when accepted, a person's the average person not to wasting whole entire amount previously. Each year after teaching this training two outcomes emerge: one intended, the opposite one much less! However, it is often difficult to apprehend them and take action, particularly if the lender is undoubtedly an online predator instant payday loans no credit checks Modern surveys currently have disclosed that bad credit loans any consistently Most effective Payday Loans as a financial counselor They've formed different by making containing item upon it and be certain that there are absolutely no errors.

Anonymous said...

tramadol without prescription buy tramadol online cod - buy tramadol cod overnight

Anonymous said...

buy tramadol overnight cod buy tramadol saturday delivery - buy tramadol cash on delivery