A recent article in the British journal, The Lancet reported on a study by the UK Special Interest Group in Gastroenterology and Abdominal Radiology (SIGGAR….thank goodness another acronym) comparing virtual colonoscopy, also called computerized tomographic colonography (CTC) and colonoscopy. The study included 1580 patients considered high risk for colon cancer because of bleeding, pain or change in stool habits. (Although please remember that above the age of 50 we are all at risk… colon cancer is the third most prevalent cause of cancer deaths in women, after lung cancer and breast cancer.) Half of the patients were assigned to CTC and the other half to colonoscopy. The “yield” i.e., the finding of colon cancer or large polyps that are often precursors to colon cancer was nearly identical in the two groups (10.7% with CTC vs. 11.4 % with colonoscopy). The number of patients with pre-malignancies and malignancies seems high, but the individuals in the study had significant symptoms and were not simply being screened. The take home message (well perhaps polyps are not what we want to take home…) that was deemed important was the fact that both tests were comparable when it came to finding pathology. But before the Lancet commentators felt that all is well in the virtual realm of diagnosis they pointed out that 30 % of patients who underwent CTC were subsequently referred for colonoscopy and biopsy whereas “only”  8.2 % of patients in the colonoscopy group needed further investigation, mainly due to incomplete colonoscopies. Furthermore in the trial 7-10% of patients who had CTC had findings that were outside of the colon and these resulted in the need for additional testing. (CT scan surveys of large areas of the body often detail findings that may have no impact on a patient’s health. Once out there, the report mandates further work up. On the overall public health scale. this is not considered cost- effective.  Aside from cost, many of these patients who now have incidental or accidental findings will undergo unnecessary, stressful and perhaps invasive testing. A few will benefit with early diagnosis and treatment of a disorder that they and their physicians did not know they had. For those few, further testing was “worth it”. But insurance companies and health care organizations don’t think that a full body scan to search for an unknown and non symptomatic “something” is an appropriate use of health resources.)

Back to recommendations…CTC does not require anesthesia. It is less invasive than colonoscopy and will not cause complications such as perforation and bleeding. And, it is less expensive. The Lancet and other studies have shown that the “miss rates” with CTC for large polyps and cancer are low. CTC may, however, miss very small polyps. When considering the pros and cons of virtual vs. “in there” colonoscopy remember that if a polyp is found on CTC it mandates a referral (and another prep) for the full colonoscopy, so that a biopsy can be done. The current estimate is that during low risk screening, this will occur in 5 % of patients. Finally, CTC is currently not covered by insurance.

My preference for most of my patients is that their first screening procedure for colorectal cancer be done via actual colonoscopy at age 50 (earlier if there is a family history of early onset colon cancer, a history of inflammatory bowel disease or other factors that increase risk.) Once the absence of polyps is confirmed and there is no family history of colon cancer, repeat screening 10 years later with CTC is a reasonable option.  And who knows, by then there may be even simpler, non prep requiring tests such as DNA screening of stool for precancerous or cancer mutations.

I have to apologize for the fact that I did not summarize a very important article that appeared in the New England Journal of Medicine on April 4 before this. But better late than later… The article is titled “Primary Prevention of Cardiovascular Disease with a Mediterranean Diet.”

We know that the Mediterranean diet is supposed to be good for our hearts but this study honed in on two particular components of the diet, olive oil and nuts. It was conducted in Spain during a period of time when they probably had (or thought they had) the capital to fund research. A total of 7447 persons were enrolled in the study. Their age ranged from 55 to 80 years and 57% were women. They were considered to be at high cardiovascular risk but had no cardiovascular disease at enrollment. They were assigned to one of three diets: a Mediterranean diet supplemented with extra-virgin olive oil, a Mediterranean diet supplemented with mixed nuts, or a control diet with advice to reduce dietary fat. The participants were seen every four months and had both individual and group educational sessions. Depending on which group they were in, they were given free extra-virgin olive oil, mixed nuts or small nonfood gifts. No one was left giftless. The trial went on for 4.8 years but was stopped because two of the groups did so much better and were significantly less likely to have a major cardiovascular event (heart attack, stroke or death from cardiovascular causes) that it would not have been ethical to continue. Those on a Mediterranean diet with extra-virgin oil and those assigned to a Mediterranean diet with nuts had a hazard ratio for adverse cardiovascular events of 0.70. This means that they were 30% less likely to have suffered heart attack, stroke or death from these events in comparison to the control group.

So how much olive oil were they supposed to consume? (It had to be extra- virgin because this is a polyphenol-rich olive oil, whereas the ordinary refined variety is low in polyphenols. I bet you didn’t know that!) Those in the olive oil group were given 1 L per week; the goal was for them to consume 50 g or approximately 4 tablespoons or more a day. Those who were assigned to the nut group (no jokes here) were given 30 g of mixed nuts per day; 15 g of walnuts, 7.5 g of hazelnuts and 7.5 g of almonds. No calorie restriction was advised, nor was physical activity promoted.

Although most of us know more or less what is in a Mediterranean diet, here is a brief summary of what is included: three or more servings of fresh fruits per day, two or more servings of vegetables a day, three or more servings of fish (especially fatty fish) a week, three or more servings of legumes a week, white meat instead of red meat, and wine with meals (optional only, for habitual drinkers). Soda drinks, commercial bakery goods, fats and red and processed meats were all discouraged.

So there you have it. In this trial, an energy-unrestricted Mediterranean diet supplemented with either extra-virgin olive oil or nuts resulted in an absolute risk reduction of major cardiovascular disasters by approximately 30% in high-risk individuals. Although I don’t consider myself particularly high risk, I have to admit that I started adding the appropriate oil and am consuming many more nuts as a result of this study. Yes we should exercise, refrain from smoking, maintain normal blood pressure and weight, but this seems like a very tasteful way of to help promote heart health. Too oil and nuts!

I realize that many of my website articles deal with major health problems, but this week I want to write about a more superficial issue that so many of us (although we may not want to admit it) care deeply about: wrinkles. An article in this month’s issue of the Journal of the North American Menopause Society caught my attention and basically supplied corroborating evidence for the impact of a prescription I have given to many of my patients for years: topical estrogen. The article reports that locally applied estrogen can help prevent the formation of wrinkles in facial skin. The exact and esoteric title of the article was (it was published in a medical journal and not in Vogue) “Hyaluronic acid concentration in postmenopausal facial skin after topical estradiol and genistein treatment: a double-blind, randomized clinical trial of efficacy.”

The study comes from a country that is very aware of the importance of unblemished, unwrinkled skin … Brazil. Researchers from the departments of gynecology, molecular biology, biochemistry, dermatology, endocrinology, morphology and genetics at the Federal University of Sao Paulo-Escola Paulist de Medicna, Sao Paula, Brazil were involved. ( A lot of MDs and PhD’s received publishing credit on this one!) Thirty postmenopausal women were evaluated before and after applying a gel that contained 0.01% estradiol or 4% genistein gel to their faces. The treatment lasted for 24 consecutive weeks. These women agreed to have small skin biopsies taken from the area of their face just proximal to the front of the ear (preauricular) at baseline and after treatment; a pretty brave act in the name of cosmetic science! The biopsies were then evaluated to assess the concentration of hyaluronic acid in the tissue. Collagen, in the skin’s inner layer (the dermis) is associated with  hyaluronic acid (HA) ,which is responsible for moisturizing the skin. Basically HA fills the spaces around the cells and together with collagen is necessary to maintain the skin’s elasticity, thickness and quality…in medical terms, “skin tropism”. Loss of tropism is caused by multiple factors including our genes, age, exposure to ultraviolet radiation, and hormonal status.

The authors point out that research has demonstrated that estrogen stimulates HA synthesis by cells called fibroblasts. So they weren’t surprised to find that estrogen applied as a gel could increase HA. But they wanted to see if an alternative to estrogen, a soy isoflavone (a flavonoid found in plants) that binds to estrogen receptors would do the same. They opted for genistein  because it is one of the main active components of soy isoflavone with an affinity for a type of estrogen receptor known to predominate in the skin. The researchers explained that they used a gel rather than a cream because they wanted to make sure that moisturizing effects were not due to the emollient qualities of cream. They also measured serum estradiol levels before and after using the estrogen gel and found that there was no change in blood levels of this hormone, hence it would not be expected to affect other organs in the body.

After 24 weeks of treatment, HA concentration increased in both groups but the effect was greater for the estradiol treatment then for the gel containing genistein. Moreover, they found that estrogen gel also increased the number of blood vessels in the dermis which should also promotes “skin tropism”. Although the genistein gel caused some improvement, the action of estradiol gel was definitely greater.

Is this enough for an estrogen “takeover” of prescribed skin products? Probably not. Remember, the study was small and lasted just 24 weeks.  The authors point out that prolonged use might ultimately have systemic consequences. But this and other studies do plant a seed (or a source of  HA) for thought with regard to our facial skin’s health and tropism. Currently there are no FDA approved estrogen products for our faces. And we are sure to get wrinkles before approval is forthcoming. But a compounded cream or gel might help. (Please note this statement is not a comprehensive endorsement for all compounded products or labs…which, as you know have considerable supervision, purity and contamination issues.) This is where you should have that individual conversation with your doctor.   

East Africa Drought and Food Crisis: A dollar a day for 100 days can help us keep a child alive. Give online at www.savethechildren.org/food-crisis-6 or text “SURVIVE” to 20222 to donate $10 (Standard message rates apply). Legal disclosure:www.savethechildren.org/legaldisclosure

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One of the questions I ask each patient when she comes in for her check-up is whether she tales calcium and vitamin D. I know a lot of you have read media reports voicing concern about excess calcium intake. And indeed, many of my patients have simply stopped taking calcium supplements as a result of these reports, despite the fact that may not get adequate calcium in their diets. Unfortunately, the current typical answer that I seem to get regarding milk product consumption is “yes, I add milk to my coffee”…

I thought, therefore, it would be a good idea to summarize the recent article that appeared under the medical news and perspectives portion of JAMA. It reported on the latest data that has caused concern about excess calcium consumption. The authors noted that more than half of US women who are middle age or older take calcium supplements and that there are now concerns about potential cardiovascular disease risk with the supplements. A new study published in the British Medical Journal in 2013 may have added to this concern, but it came with some caveats. (As do all studies!)

The study comprised 61,433 women who were followed up for up to 19 years. The researchers used questionnaires to get information about the women’s diet and supplement use and followed their subsequent health. They found that women who consumed more than 1400 mg of calcium daily had a higher rate of death from all causes (about 40%) then women who consume between 600 mg and 1,000 mg daily. Women who consumed more than 1400 mg of calcium daily also had a higher risk of death from cardiovascular disease (49%) and ischemic heart disease (14%), but not stroke. The women who were at highest risk were those who had both a high dietary intake of calcium (more than 1400 mg)  and additionally took calcium supplements. They had an all cause- risk mortality increase of 2.57 ( two and a half times more) or, if want you want to use percentages, an increase of 257 %.

The authors tried to explain these findings by stating that excess intakes of calcium may impact physiologic control of calcium levels in the body and higher levels may increase the growth of fibroblast factors. Excess fibroblast activity can stimulate the thickening of the lining of blood vessels causing subsequent lack of pliability and an inability to dilate. This can then decrease the flow of blood to the heart and other vital organs hence, contributing to higher rates of cardiovascular and all cause mortality.

Remember you get calcium in many forms of food, both dairy and non-dairy. A cup of low-fat or nonfat yogurt has as much as 400 mg of calcium (once fruit is added however,  you lose about 100 mg) and a glass of nonfat milk has 300 mg. An ounce of sliced cheese averages 200 mg but surprisingly 1/2 cup of nonfat cottage cheese only has 80 mg. A cup of broccoli gives you 170 mg of calcium. Collards and dried beans do better at 270 mg per cup. Three ounces of canned sardines with bones (it’s “in dem bones”) has 370 mg and the same portion of canned salmon has 200 mg. It’s thought that the average diet without special high calcium foods or milk has about 200 to 250 mg of calcium.

We do utilize and excrete calcium on a daily basis and we need approximately 1000 mg “to keep on top of what we lose” as adults and 1200 mg in our later years. Low calcium intake has definitely been associated with low bone mass or osteopenia and then comes  menopause and age which compound this loss. Women have a greater than 40 % lifetime risk of developing an osteoporotic fracture. So ultimately we have to weigh your bone health together with your heart health. The evidence so far is that we need our calcium, but ultimately it’s best to get it through diet if at all possible and supplement only what is missing.

Read the label of contents on what you eat and drink. It will state the percent of calcium in a portion of the food that has been labeled (obviously you can’t do this with fresh veggies, but you can use the above reference or consult a nutrition chart.) Remember the percent is calculated on a daily total of 1000 mg so 30% is the equivalent of 300 mg.)  If you do not reach that 1000 mg goal through your food, then go ahead and supplement. The authors of the British Medical Journal article emphasize that calcium supplementation should be taken by “people with a low intake of calcium rather than increasing the intake of those already consuming satisfactory amounts.”

Sounds right.

No, I am not writing this while sipping a glass of wine. I may even forgo a glass later this evening. But why should I suffer alone! So, I am sharing a brief JAMA article published in the Medical News segment with the ominous title ” Even Low, Regular Alcohol Use Increases the Risk of Dying of Cancer”. Obviously, this caught my attention. This article was a summary based on new findings reported in the American Journal of Public Health.  Researchers from both the United States, Canada and France analyzed data that had already been published on alcohol use and cancer risk and combined this with 2009 US mortality data and national surveys of alcohol sales and consumption in United States. They searched for information on seven types of cancers that have been linked with alcohol use including cancers of the oral cavity and pharynx, larynx, esophagus, colon, rectum, liver, and female breast.

They found that alcohol use actually accounted for about 3.5% of US cancer deaths in 2009. And here is the scary part for women; they attributed between 48 and 60% of alcohol-related breast cancer deaths to having, on average, three or more drinks per day. OK, so most of us don’t drink that much…but about 30% of the  breast cancer deaths were attributed to having fewer than 1.5 drinks daily!  The researchers went on to calculate that alcohol consumption actually causes about 15% of breast breast cancer deaths among US women.

We know that many studies have linked alcohol consumption (in moderation) with cardiovascular benefits and this may in part explain why public-health efforts haven’t targeted limiting alcohol use as part of cancer prevention. It’s that old quandary: “Should I drink for my heart or abstain for my breasts?” ( …and pharynx, larynx and esophagus).  So here is the final quote from the writers of the article: ” When viewed in the broad context, alcohol results in 10 times as many deaths as it prevents in United States even after one considers possible beneficial effects of low level use for cardiovascular disease and diabetes.” I think I will forgo wine tonight…but maybe just a sip tomorrow.

I’ve heard them all. Every fall and winter I order the season’s flu shots and offer them to my patients. Some refuse and although I try to argue with their reasons not to get vaccinated, I often fail to convince those that I classify as the perennial “reluctant ones”. So when I read the recent viewpoint section of JAMA titled “Examining Common Arguments Against Influenza Vaccine,” I was delighted to see that the article made the same points I have used. And perhaps since they were published in this prestigious journal, they will be more official than mine. So here they are:

The vaccine does not work.

Yes it’s not as effective as other common vaccines but “not as effective” does not mean not effective. The Centers for Disease Control and Prevention’s midyear assessment of this season’s vaccine shows effectiveness of 62% for the prevention of significant respiratory illness. Sixty percent or better is still a noted achievement and not a failure.

The vaccine causes flu.

The shot contains an  inactivated vaccine, i.e. only killed virus and viral antigens that absolutely cannot cause influenza infection. There have been placebo-controlled, randomized trials that show that there is no higher frequency of systemic reactions in those who receive the vaccine when compared with those receiving placebo. If someone does get some sort of viral infection after-the-fact, it has to do with exposure to that virus before immunity from the vaccine had time to develop. Remember, it takes two weeks to build up antibodies that will fight off influenza after the vaccine.

I have an allergy to eggs.

Apparently all egg allergies are not equal. And now according to the Advisory Committee on Immunization Practices, those who only experience hives after egg exposure should receive the influenza vaccine and simply be observed for 30 minutes. However, egg-allergic patients with a history of swelling, breathing problems, nausea, vomiting or another major reactions that required use of an epinephrine or emergency medical attention should not get the current vaccine. Ah, but there is good news…the next round of flu vaccines approved by the FDA will be produced using a genetically engineered insect virus that infects cells grown in culture and doesn’t involve eggs. (It’s way complicated, so I will resist a 2 paragraph attempt to explain the vaccine biology here.) But the end result is that a non egg produced vaccine will provide a new option for people with egg allergies.

 I cannot get the vaccine because I am pregnant or have an underlying medical condition or because I live with an immune compromised person.

 You or your loved one are actually at the greatest risk of complications from influenza and the vaccine will not compromise your medical condition! If you get the flu and transmit it to a person who is at risk (or during pregnancy), you can cause them to suffer grave consequences. It’s your medical “duty” to diminish their exposure and risk.

I never get the flu, I am healthy.

Even if you don’t develop classic flu-like illness ( and you could get it with very minimal
symptoms and not know it), you can still transmit the virus to others. So do the ethical thing and get that shot.

So let’s stop procrastinating and protesting and make sure we protect ourselves and our loved ones. There are really no excuses. 

I was horrified to be told, while traveling in Mozambique, that life expectancy in that country was about 45. I attributed this statistic to the lack of healthcare resources, especially in rural communities where the closest health clinic requires a 20 to 40 km walk, as well as the hideously high maternal and neonatal death rates. And upon my return to the US, I felt somewhat smug as I went to my office and offered women, what I thought, was the best of health care. Apparently this is not a national attribute. This week, JAMA came out with an article titled “The US health disadvantage relative to other high income countries.”

The article is based on a report of the findings from the National Research Council Council/Institute of Medicine (NRC/IOM… yes there are initials for everything official) which documents the health of US females and males up to the age of 75. The Council compared our population to their counterparts in 16 other wealthy, developed nations including Australia, Austria, Canada, Denmark, Finland, France, Germany, Italy, Japan, Norway, Portugal, Spain, Sweden, Switzerland, the Netherlands, and the United Kingdom. Here are some of the facts that were presented:

• US children: Our newborns are less likely to reach the life expectancy of newborns in other wealthy countries. US infants are also less likely to reach their first birthday. They’re more likely to have low birth weights and their mortality rates up to age 5 are higher.

•  Adolescence: US adolescents die at higher rates from motor vehicle crashes and homicides than their counterparts in the other countries. They are also more likely to have unwanted pregnancies and sexually-transmitted infections. They have the second highest prevalence of HIV infection among 17 countries and the highest incidence of AIDS in their age group.

• Adults: The United States has the highest obesity rates. We also have the highest prevalence of diabetes among adults aged 20 years and older and the second highest death rate from ischemic heart disease. Lung disease and drug related deaths are more prevalent in the United States, and older US adults report higher rates of arthritis and activity limitations. The life expectancy at age 50 years is lower in the United States then in 16 other high-income countries.

Oy!  But the report did point out some of our health advantages, and these included better control of hypertension and serum lipids, lower cancer and stroke mortality rates and higher life expectancy after age 75 years. US adults are also less likely to smoke and drink less alcohol than adults in other countries but they have a greater propensity for other unhealthy behaviors such as high caloric intake, abuse of drugs, more motor vehicle crashes involving alcohol and finally own (and have injuries and deaths from) more firearms than those in the other high- income countries. US adolescents are also less likely to practice safe sex then adolescents in European countries.  We have the highest rate of child poverty of all the wealthy nations (what a “shanda”). We also rank below other countries in the ability of our children to achieve social and economic levels that are higher than their parents.

The authors (from the Department of Family Medicine and Center on Human Needs at the Virginia Commonwealth University and Center on Labor, Human Services and Population, Urban Institute in Washington, DC…just to be exact) went on to report on the reasons given by the NRC/IOM for our health disadvantages. And apparently, the chief reason is, unlike those other countries, we lack universal health insurance coverage!  Primary care is less available and there are greater barriers to access and affordable care. US patients are more likely than patients elsewhere to have lapses in care quality and safety outside of hospitals; moreover they are likely to require emergency department visits or even readmissions after hospital discharge, perhaps because of premature discharge (it’s expensive to stay in the hospital) or problems with ambulatory care.

So is all this because of a financial inability to get to the best doctors or hospitals? It’s not so simple; according to the NRC/IOM even non-Hispanic white adults or those with health insurance, a college education, high incomes, or healthy behaviors appear to be in worse health in the United States then in other high income countries.

So what should be done? The NRC/IMO recommends that the public be alerted to the scope of our US health disadvantages. Most individuals and even most doctors are not aware of these poor statistics. The Council suggests that these stats be used to stimulate the national discussion about the investments and trade-off the public is prepared to consider to attain the health status that other countries now enjoy. IN short, the message here it that we need affordable universal health care that starts with prevention, primary care and proven, best practice of medical care. I’m not sure that knowing all this will get sufficient attention from the public, physicians or our politicians. But they certainly should be informed. (And I am doing my small public service in reporting all this.)

I struggled to end this newsletter, I don’t have a reassuring message or effective personal advice. All I can say is that each of us has to try to maintain our own healthy behaviors and seek access to preventive and effective healthcare not just for ourselves, but for our children and our communities. We have a national health challenge that should not be insurmountable… Our research and major institutions are foremost in the world!  We should be able to do as well, and one would hope, even better than all those other countries!

So here is another website article written at 35,000 feet. I am on my way from LA to NY for a board meeting of Save the Children. (And I am excited to show the board members the pictures of the school the LA Associates of Save the Children built in Mozambique…pictures that I shared with you in my last newsletter.) I just purchased all the journals I missed in the last two weeks in order to find an article that I thought would be of interest to report.  Finally, I came upon one in the journal Menopause. (The journal with the bright red cover). The title: “Initiating therapy with antidepressants after discontinuation of hormone therapy.”

Just in case you don’t want to read further… the answer is yes, some women need to take anti-depressants when they stop their hormone therapy (HT).

Now for the study: Once more it comes from epidemiological data gathered by researchers at the Karolinska Institute in Sweden where there is an amazing drug and population register. These contain information on patients’ age, sex, and personal identification number for all medications prescribed and dispensed to the entire Swedish population of 9 million inhabitants. Data were obtained for women who had been dispensed systemic hormones, including natural and semisynthetic estrogens as well as progestogens and estrogen combinations. The researchers also obtained data on dispensed antidepressants. (I won’t list them by name but there were many classifications). The study included women between the ages of 45 and 70 who had used HT continuously for more than 6 months. The group included 101,911 women, 39.8% of whom discontinued HT during follow up. The drug register showed that discontinuation was associated with an increased risk of antidepressant use by 24%. Women who were 65 or older who had used HT for 3 years or more had the highest risk.

The authors noted in the conclusion of the article that “it is important to take into account that about 20% of all women will start HT and that 15% of them might avoid treatment with antidepressants if they continue HT.  The results suggest that clinicians should be aware of depressive symptoms, particularly in older women who discontinue HT. Therefore, the decision to continue or discontinue HT should be individualized based on the severity of symptoms and current benefit-risk ratio consideration.”

Since I, like most physicians, currently will tell patients who wish to continue their HT for many years, that long term use may increase their risk for breast cancer and that the positive impact of HT on coronary vascular disease decreases in later age… we are once more left with a depressing conundrum: To continue to take HT or stop, and possibly need “withdrawal” antidepressants.  So as usual, I will end my report with a ”discuss this with your doctor!”

Last week, I traveled to Mozambique with two other members of the LA Associates of Save the Children. If you look at a map of Africa, you’ll find that Mozambique is situated above South Africa on the east coast of the African continent. In order to get there, we had to fly to Atlanta, from Atlanta to Johannesburg (a flight that took over 15 hours) and from there to the capital of Mozambique, Maputo. Unfortunately just before we arrived there was a major explosion in the main power plant and as a result there was no electricity for nearly 3 days! Oh and did I mention it was in the 90s with 90% humidity?

After meeting the staff of the central Mozambique Save the Children office and a tour of the city, we flew to Chimoio where Save the Children has a district office with 45 employees. Together with the government, they develop and run programs in teacher and child education, health, nutrition, child rights and prevention of child trafficking. We drove 50 km to a very isolated rural village where families barely eke out a living farming maize and raising chickens. There was no electricity or public transportation.The roads consisted of sand tracks often washed out by floods.

   

There had been no school what so ever in this community until 2004. The children and most adults were illiterate. Several years ago, the community got together and constructed a special hut made of sticks in which untrained “volunteers”  worked with about 100 children. After several years, the government sent several trained teachers and the population of children able to occasionally go to school grew.  

The drop out rate however was high and most girls were not allowed to attend school because they were responsible for obtaining clean water and often had to walk 10 or 15 km to a well to bring the water back home. There was also concern that if they did not have separate latrines from the boys, they would be accosted or trafficked.

Once Save the Children identified the tremendous need in this community, the LA Associates of Save the Children quickly raised the funds to build a school which not only had proper classrooms but also had separate latrines for girls and boys and a well so that parents would allow girls to attend.

This week I am in Mozambique to visit the school that many of you helped build through the LA Associates of Save the Children. I return the 19th of February and look forward to sharing pictures and stories about the trip in upcoming newsletters.