Charter communications supports cspan2 is a public service. Good afternoon thanks for joining us today with university of pennsylvania others. My name is richard, and the library for the university of pennsylvania my race. Im happy to have the opportunity to talk to jason about his new book the problem of alzheimers, how science, culture and politics turned a rare disease into a crisis and what we can do about it. A physician and writer who researches and writes about issues in bioethics, aging and neural sciences. Previous works include open one, tragic possession of doctor william and jason is written for the new york times, washington post,ew forbes, and step news as well as hundreds of Research Articles in the most influential journals. Professor of medical policy and neurology at the university of pennsylvania and coat director of a Memory Center where he cares for patients. Lives and thought of you. Todays talk is being recorded. Since its a webinar, you dont have to worry about muting yourself or going off camera and we expect to have time after our dialogue to take questions from todays onlinens audience so please use the q and a feature to suggest questions and i will keep an eye on them and bring them in later in the presentation. I pickedte up my copy. We describe complex medical problems and audiences and weaving broader humanistic social context. It sparks a lot of questions for me as i was reading it and i will take my product prerogative. Thank you for joining us. I regret we cant see each other live on campus but what a thrill to do this event at the university of pennsylvania. Thank you and im looking forward to the day we can get back we talked about maybe doing a panel of authors of alzheimers, that would be a tremendous opportunity. But my question today is basic and fundamental, alzheimers disease and dementia, what is the difference . Can you briefly speak of the positions . Why is it important scientifically . Perhaps the opening line of the book of Family Member asking the difference between alzheimers and dementia, a common question in understandable. Dementia describes progressive ngCognitive Impairment, concentration and causing disability and other keeping. I talked about in the book is a disability, the larger piece there in the first part of the book, the first part of the book is about the transformation the way we think about alzheimers in the bottom line when i trained and for much of the 20th century you had to have dementia to have the physician sites what is the cause . The most common disease was alzheimers so no dimension. As a chronicle in the book, although i was 2 unbound, that began to change. No longer have to have dementia to have alzheimers. Its possible with alzheimers who does not have dementia, we talk aboutos cognitive imperatis and biomarkers and when you put it together is this diagnosis before dementia. So thats a big part of the story of discovery and progress in the disease has been redefined. Be defined as a biological diagnosis following histories of other diseases like cardiovascular disease or you dont have to have a heart heart attack to be diagnosed, it said various markers, the levels will label you as being a patient even though youre not suffering get your labeled encountered and treated thats whats happening in the oldtimers space is a talk about in the book. And that labeling seems different in alzheimers because it is bundled up in the x potential crisis, if i am diagnosis by diabetic, its something i have to address with lifestyle and medication but it seems more diagnosis of diabetes and cardiovascular disease into my identity in a way thats different with alzheimers. And in your remark is the crux of the issue, theres something about integrating disease identity, the physical disease versus oldtimers and its about identity because fundamentally, one of the revelations i arrived at, not just the scientific advancement the cultural transformation the left to become a disease it is think the recognition is these disease of identity, the disease itself of determination because early on the moment it becomes symptomatic, its not about the physical problem that occurs later in the disease but early on in thess course of the diseae problems around selfdetermination, a person is a little less able in the beginning to live as he or she wants to live. A little less able to organize a trip or plan a collocated meal in the beginning, aspects part of our selfdetermination. As the disease progresses harder and harder away or more and more away the ability so a revelation on the book, its a disease of autonomy. We did have widely accepted ethic of respect for autonomy all adults should enjoy, it be hard to see alzheimers fully disease until there is the dramatic behavior problems and physical disabilities in the disease so youre i right, it ia disease thats different, diseases of the cortex because they the ability of our mind to exercise selfdetermination. And like many diseases, its another unique way that encompasses this broader context of the individual diagnosed with the disease. You say that moment in the book the caregiver says i have alzheimers. Some of the best i use a lot of stories of my clinical practice and researches work in the book and it wasnt just to add color in between but at key times my patients were my best teachers and one moment is a husband of a patient of mine in the midst of narrating his wifes problems because we make a family coming and hes sitting there telling me whats going on, explaining everything and he grabbed his chest like this and said i have alzheimers and he was right in a sense, he can have degeneration like his wife did but is also doctor bringing her time whats going on in getting the plan and taking the plan home and implement think the plan and in a sense he had her disease as well and one of the things unique about this disease and others the creation of the caregiver, this separate entity and a chronicle in the bookua how caregiving role is incredibly modern. Caregivers have been around since the bible, the book of ruth, naomi ruth is the daughterinlaw of naomi and cares for her motherinlaw but never did she call her caregiver and the word is a chronicle in the book visit appear until about 19 and its link to the level of oldtimers disease is a recognized disease as opposed to aging so have been caring for each other since we were humans but the recognition role that i am a caregiver is a modern iaphenomena, talk about the economic events explained that. Is it a western phenomena or industrial developed nations . I recounting the book culturalur, in the latin communities, the word caregiver does not exist. Nthey have translated our word there isnt that recognition across cultures absolutely if you dont have a recognition of the caregivers as control, what it is is another part of the whole loving daughter, fly, daughterinlaw. Its the recognition of the distinct role of the caregiver and support they need particularly in the modern developed world for families are spread out so theres no question in all diseases are wrapped up in culture but if you pick one disease thats all encompassing him wrapped up in culture, it is this. Are thinking about going back to my early career experience working in nursing but the elderly in theth late 80s, i have a vivid memory of one of my patients and a longterm care unit, severely dimensions, the nature of his dementia was he had the 24 7 experience he believed he was in a pub. Was the happiest man, the physical disabilities that went along with the condition, he was happy and it made me think, the impact on the family unit is often clear, the phenomenology of sickness and illness is more impact on the person who has the biological condition or disease but in alzheimers, especially because there is less awareness increasing. That is often flipped, youre right. I recount an example of that phenomena at large where he writes his wife, jane is okay, its me suffering. His wife had oldtimers and he about butok experience as well that came out about a year ago but all of us with the disability more or less adjusts to a well described phenomena and we see that in individuals with dementia. What makes it even more mysterious is a neurological, or certain lesions in the brain can cause it to recognize the presence of a limb or etc. Is this interesting mix of disability paradox and adjustment but also probably be lesions based and you are right with a Family Member oftentimes suffering is more evident and persistent especially over the course of the disease than it is for the individual. As i have pointed out in the book, one of the reasons i think alzheimers became a crisis, such as because weve not made great progress in treatment but is not made great progress providing longterm Care Solutions for Family Members as well and i think its a combination of failures at the root or one of the roots of the crisis. The book to the tote subtitle, how science, culture and politics turned it into a crisis, can you give this view of the process . The subtitle, the original part of the book was going to because called disease of the century and i remembered gathering at the beginning of last year, i said to a friend a book coming out is a book about covid, i think we will have to change the title so i changed the title to the problem of alzheimers which im glad i did, i got the heart of what the book is about and the subtitled wentll through so lets walk through it. How science, culture and politics turned into a crisis. The first part that fully explained it, over the course of the 20th century a chronicle how science and culture turned a rare disease into a common disease in those events began early 1900s and germany, scientific events and as a spoiler alert, a chronicle in the book, its because they occurred in germany that there was what some call the dark ages were nothing seems to have an the talk in detail in the book what happened, basically germany fell apart. World war one and then economic chaos, brutal nationalism and antisemitism combined together to shut down was spectacular progress in psychiatry and it was because it was so germany based germany would shut that down so it was not until later science picked up that they are looking was culture pick up nick its back to earlier remarks and the respect for autonomy and if you look at Google Search on words in our language, was the historical trend of the word . If you look at the arch of the word autonomy, its fairly used until 1900 and then autonomy starts to pick up mid 20th century autonomy becomes much more prevalent. The cultural events and the third part of the book, the birth of oldtimers on the rise and autonomy and as a result the changing structure of the American Family and the changing if you losing your autonomy with aging is natural, is just the latest to view combine advances and studies that show something going on, together with cultural value losing your autonomy is not of value he end of the 80s, the consensus that existed for Long Term Care began to fall apart and by the end of the 90s it had vanished. That is that the origins of why it became a crisis. I think that the transition from that shakespearean viewpoint of aging and where that trajectory from dependence is very sort of chartered out. But i wonder if the shift and balance between autonomy is somehow reflected in the diminished relevance of the church. You can sort of see that it has a potential connection. One of the things that struck me in reading the Research Story that i think connects with this is how little respect the research had. I felt as i was reading through some of the biomarkers and innovators that they had these operations that were, you know, bandaids and seemed very poorly resourced, like very little interest, very poorly funded and poorly respected by the institutions they worked for. What were the reasons for reasons for that . The National Institute was roughly the 50s, National Cancer act and hordes money into cancer but even before it existed from cancer was recognized, again the disease was so recent in the 1980s is an enormous cash as part of the biomedical world to recognize older had to see as a problem and congress had to find research. Er whats interesting and a chronicle in the book, association made a strategic decision early in the time to not pursue with a call disease of the month funding you dont go to congress and say i want money for copd, i wanted for diabetes. The word is Congress Wont do that, they get the money and they decide to spend it. That wasnt true. Congress had done that for National Cancer act and in the early 90s would do that with age creating budgets that allowed nih to ask for how much money and bypass the process. The community didnt got there o find chronicled in great detail, the work of clever activists in the association who managed to get a budget passed for alzheimers and boost funding. I ramble because what has happened is an enormous boost in funding since about 2011 which led to are gross in the field. So hard to get funded, used struggle and research is looking toki see how hard it is to get funding. I want to say they follow the money but we are seeing now it veis possible to get funded the last couple of years and we are seeing more folks going into the field so we got culture, failure to recognize the disease and weve got money. Each has begun to correct worldwide recognition of alzheimers is a problem, congress allowing dramatic increase in funding needed to occur and we are seeing results of that. Wicked talk, to amazing the work they did. I really did wonder, you think about the guy, it seems to be such a distant possibility doing it with so little like what were his motivations . The olympics of the dynamicso and a chronicle to work, they were determined to figure out how to use these technologies to image amyloid and i interviewed both of them and theyre doing their research and they said in the beginning they were like writing want to do that . Imaging the garbage can . The kind of had to in their own in between their grant funded war they would get grants and whatnot and move along. Their discoveries transformed the field and open up a new paradigm in the disease and its a fascinating story. The other thing they did, spoiler alert, they t took enormous reputational risk, they dont say that because i think in the light of history, it all worked out but its obvious there is a moment with her experiment were not working. Its a fascinating story. We are now in this phase were seemed like the big news is about trial and drugs are pretty new and the possibility for oldtimers in the big news recently, i wont even say it but one of the maps. The results are still mixed and controversial like what to the recent stories say about developing drug therapies . I come down as am realist about the possibilities meaning i think we should expect someday that we will have therapies that change the disease. For some patients it will be impressive and brothers it will be a modest success and for others it will be improbable or not effective. Er its not just alzheimers. Other diseases. Anyway having said that lets look at whats happened. Where we are right l now is the fda is poised to potentially approve the drug which is sort of steeped in controversy because unfortunately the companyy performed an interim analysis to save the sources to pursue the further study. It will shut down and the data came in and looks positive. Its a bit of a mess but that study even the most optimistic take on the result it has some effect on the trajectory and eli lilly issued a phase 2 study of a different drug the same idea to go after amyloids and the same thing in effect but not a halting or herself but that change in the decline. The book how and that b model of going after amyloids with antibody approach of the novel idea of going after amyloids like it was a foreign invader using antibody technologies. And win his first paper came out in nature on the cover of nature it was so groundbreaking it actually made the National News and mind you this was not a study done on humans who had alzheimers. It was a study done on genetically engineered mice who were engineered with these amyloids and they did this experiment on them but it was so groundbreaking some of the investigators at the time actually said this field is figure out and they were going to pivot on the disease. I chronicle and the book of the initial enthusiasm has certainly been dampened if ive explained and even studies that dont have controversy you see the slow effect. Again progress can canakaris therapeutics but i think we are in for world of having to live with this disease. We will have to learn how to live with Cognitive Impairment and there are enormous opportunities but also enormous challenges. Bullets its the same with the drug therapy that has that same tech curve about the initial highly inflated hopes and aspirations trailing into the of disappointment and then the adoption. What karl marx called the dialogue of existence and accommodation. Im certainly in the Biotech Program here and interested in the theatrics. I had a lot of interesting questions that i thought were interesting related to some of those topics because as you point out we are going to have to care for an increasing amount of people and very prolonged therapy at the time in response to i maybe drug therapies that e effective in slowing but not ceasing increasing Cognitive Impairment and theres a lot of really kind of great examples of therapists that are not drug therapists and one of them that i know is somewhat controversial its the dementia village concept. You sort of sketched the daily life with dimension this whole concept of deception and thinking back to when i was working in health care and i did a stint in a Psychiatric Hospital with people with dementia and we have are very much instructed that we needed to orient people to reality and that was part of the care of people was not to engage in deception and i think some of that is ethically bounded and some of what was thought to be kind of a therapy in itself and what are the parameters of the loving deception and alzheimers . Yeah a chapter in the book called the world we create is the penalty met chapter of the last chapter about death. But in the world we create it was a lot of fun writing that. That took me to the areas that i enjoyed so without spoiling the whole thing iow came up with ths idea of homelessness mainly there comes a time in the course of a person living with dementia in their life that they are not homeless. They have a place but they are loosened from that idea of home. The idea of home you recognize where you are and you know the things and the people around you and theres no question some persons with dementia there comes a time where they will stand in the kitchen of the home from 60 years and say i want to go home. And they say you are home or their look at a spouse or 30s and say we ought to get married. The question of how to respond to that elusiveness are the essence of home one approach is reality orientation. Take them back to reality. I am your spouse. This is your home. However gently you say it you say it. Another approach says go with their reality. That reality of loving this there are some patients for whom reality works and they are some patients for whom deception is the only way to get through to them. What i do try to bring out in the chapter in a world we create is we have to be open to a third way in the third way and i chronicle in that chapter this idea of being the person of dementia is capable of creativity. Another way to respond to the question when are we going home . The want to go home is you are home or we are going to go home in 20 minutes or the third way switches what you like best about home . The its the answer not with the facts. With the question. I chronicle the work of an accident who wrote it phenomenal book and anne describes the cs and approach where you respond to someones question and a request for something to get them to create from it. So who would we invite etc. And i want to broaden it in part cold hard truth or loving deception of the truth. This is a big stake stuff exists its not just a Family Member dealing with a relative who says i want to call but its also people sayingco lets go to community for people or who are homeless. The question is how can you design and longterm care and you can go to communities that are designed to look like san diego in the 1960s. Literally National Geographic eisenhowers the president on the wall and they cultivate this design and architectural deception. Im not saying its wrong and we have talked about that but might there be a third way of designing communities that cater to peoples tastes, classical, modern colonial and within that case didnt think about how we can use Creative Care to address some of these challenges and behaviors. So a third vision for that. The one thing i have a problem with this communities that are based on philadelphia 1948. Is your residential population ages 1948 is not going to seem like they are in childhood anymore. I asked on the guys about that and they said you are probably right. Well probably have to update the architecture and change the movie posters and things. I found that an amusing point. So you are continuously updating and adding in the National Geographic year by year. Exactly. Its once upon a time what you listen to and now what you listen to. I did think when i was creating those certainly there are examples geographically andg what we think about the population and taking advantage of these care models that you are presumably quite expensive. But you know they seem very designed around people and theres a risk to that. Yeah i know. If youre going to curt recreates aside the 1950s. Its a very good point which is what part of what nostalgic culture do we want to bring into this community . No, i think we going to the idea ofo its made for love. Like many things inep love thins get complex. Its very class bound to. In america we dont have a system of longterm Care Services. For example if you run an Adult Day Activity Program in america you are running that program on the margins. You are dependent on medicaid funding. That state funding for individuals in poverty. He get a little money from the d. A. It may not be a lot and then you ask people to private pay in private pay is expensive. Most longterm Care Services in north america are either at the margin of surviving fiscally or they say the heck with it well going to charge a whole lot of money and just treat rich people and thats the tragedy. The middle class that are neither rich nor poor are at this lurch in america and how to provide support for their relatives and that has got to change. One of the things that i was very touched by in some of these descriptions and you had mentioned investing because i have the kid who is adolescent is incredibly enriched by participation and drama. High School Musicals and drama you know and you describe yourself as a physician and a writer so presumably you are steeped in the humanities. And i look at the information about them memory sensor and there are a lot of programs there. Do youe see those as a complementary therapy in the physical structure or are they a primary therapy collects you know i think for disease of autonomy and selfdetermination at disease with a humanitarian problem things like the philadelphia art program these are just things to pass the time and fill space. These are essential. We are talking about a disease about selfdetermination and identity. Think about it. How do we self determine our lives . A lot of it is through art. The people who are disabled i think theres a moral petition to bring them art and make art accessible to them. This is part of the therapy not to say the one thing i try to make clear in my writing in my book is its not care versus care that we can advance good therapies and got what cancer center. They are prescribing therapy were was also making available nonbiomedicalbased therapies to help people cope with their cancer. We should have the same attitude for alzheimers. And some of that is still somewhat controversial the complementary therapist and i feel when you talk about adult daycare and some these programs they are often presented in the idea of this is how we can relieve the caregiver which is important. Fits tremendously important. Again the person with the disease seems rhetorically to why those services are being. Yeah its a very good point in spoiler alert i wont say it. If youve read the book and you read about adult Activity Program still have a whole new perspective and come away with a whole new appreciation for it. The flipside of that is these therapists earn tremendously appealing but how supportive are they and how does the 10 memory sensors support this kind of Program Within the distance model . The its not like running out of penn medicine money. I got a sad email about the pandemic from a program that they were closing down during a pandemic. How does the 10 Memory Center survive cliques and depend its dependent on colloquial. The reason we are able to offer excellent social services and support for all of our patientso with diagnostic followup and longterm care is because you like and gave us a very generous donation to support that. Thats the case for most. There are very few Memory Centers in america. I found one that i chronicled in the book which is not that Academic Medical Center. Most are affiliated with an Academic Medical Center with research and philanthropy. Some exist privately. Generally their operations where their goal is to see if hell youll be eligible for our clinical trial. To test the drug. Its an indictment of our system that for all of our dances and medical care that we dont have a coherent organized system of dementia centers in america. We could and i think covid has woken us up to the fact that we can deliver telemedicine far more effectively than we thought we could and that poses an enormous opportunity for those models to deliver diagnoses despite the fact that you could be geographically quite far away from that. Theres this need need to support innovation and treatment and whatever the modality of that treatment is an improving thend ongoing karen this spes back to the advocacycy movement and do we need another war on alzheimers like we had on other diseases . A couple of comparisons you make your other countries. He mentioned at one point they redirected some statelevel funding from Current Research to social care an example of policies in germany to. What do these options look like in the american system of delivering and advocating for health care because i certainly i am an advocate and i got a health. And you are in with 100 different disease groups every day on capitol hill. Instead of knocking on the doors the reps have one meeting after another with representatives. What happened and by the way france, france made the decision to no longer reimburse prescriptions for that most recognize have minimal effect. They said we are are going to take those drugs and will use that money to provide local care Service Support and pay for Memory Centers. So that was their decision. Germany has a social Insurance Program thats been in place since the 90s they buy the payroll tax. All peace persons pay into it and enjoys wide support in the german population. The netherlands has a system of an Activity Program for anyone who wants access to one can get access to one. They have immediate access to a care manager to organize their care plans of their models out there. Of course United States is a bigger country etc. We are a cando kind of country and we certainly havent done it and as you point out a lot of its been a failure and i have a lot of chapters in the book on the political failures. You mention capitol hill. I chronicled in the book how the alzheimers act abacus and early 90s arent capitol hill going from congressperson to congresspersons office. Its a really dramatic day. So the advocates go to the office and the congressmen protected and they make their case for families and persons with dementia. His heart goes out to them in police and their cause and its all good. And then they leave and the reporter stays in the reporter says one of their big efficacy problems is the need for longterm care social or agram. They say thats where we begin to part ways because tell us how youll pay for that. The congressmen the majority whip when the dangerous gingrich takeover bid once once i do that ill simply said no new tax and that was the campaign line read my lips no new taxes so if you have that is your position no new taxes you cant do what germany did. You cant implement a payroll tax to raise funds for social Insurance Programs they are left with what you are doing in and that conversation has been going on in america for the last 30 years. Maybe now event in washington the last few months have been rather interesting and the reaction of the American Public is also interesting. Using the same kind of this is socialism we have got to stop it. I think people recognize theres a role for government to step in to help solve massive large problems. If the problem of putting a man on the moon. I was watching the show yesterday where they played a song from 1969 which is his response to the urban man and the space program. What was in this for me and my situation is the same. So some of these innovations in some of these programs and priorities are humanistic and offer some kind of equitable wideranging population wide advantage for people. The fourth part of the book is called a humanitarian problem in the central premise is we are going to draw our way out of polio this problem like with polio. Like cancer in my cart disease how are we going to learn to live with it and when you start to think about the vast scope of the problem and how it so much about her selfdetermination you have to take it on this you. Would take on the humanitarian problem. Its not just medicine. Medicine is the law of the culture all working together so we can learn to live with it. Doesnt mean its good and not not going to make alzheimers disease and dementia somethinget fun. Of course its unpleasant but we can make it more meaningful and more livable than the wait is now. Thats how i wrap up and conclude the story in the book. Do you think intertwined we will have some way for spotting two questions that some of these advantages be they technical or pharmaceutical are they going to reduce, start reducing the stigma of with the disease . From the beginning of the book to the end it starts and ends the book actually. You know i think that the approach to addressing their our stigmas of alzheimers. The stigma of alzheimers disease will be addressed by changing the names of things and changing the way we think about the disease and talking about the disease. I talk in the book in my own career i discharged my way out of stigma. I used to say that and i dont talk that way now. I noticed that way permeated the field. When i meet with colleagues and professionals as we say. We say that the person with dementia think we need to do that and thats a change of phrase compared to etc. And its those kinds of transformations that will begin to weaken the stigma of this disease. I in the book taking a pretty critical view of some of the imagerys and most of the amyloid hypothesis that produces images that look like the phantom of the opera. While that may sell drugs because it scares people or whatever does is that the imagery of we want to create . Terms like zombie and whatnot made gin up the fear to motivate people to do the walk or give the money or Lobby Congress or whatever but they have the Collateral Damage which is what we are essentially saying. People with dementia are not persons and they are not moral beings. We have to be careful when you cultivate that rhetoric in our culture. That could lead us to things like will add rather be dead than have this disease. Again its not that the disease is pleasant but i dont think we want to create a record rhetoric that conflates death as a treatment for disease and you see that simmering when people talk about it. It and what do we know about the subject of a person with alzheimers . We dont know as much as we need to know in one of the points in the last chapter of the book i go intense into provoking people to think about the interior life of a person with advanced dementia and by and with the stories from the graphic of how caregivers experience in persons with advanced dementia and despite the severity of their disabilities and problems of communications and i present some stories in order to provoke them and in order to say you know how is it and why is it we attribute minds to other things whether its a human or an animal and we are pretty frisky when we talk about dementia about being. Caregivers will tell you theres a connection and i want people generally to start thinking about that because i think it starts to broaden the way we approach attitudes about advance care planning. Im very bothered by the directive. I can understand why people make them and i get it. If thats a cultural norm i think that runs ragged over the moral status of the mind. In the last year the last four years of the last 10 years have shown strongly that we need to be there for each other and people use substances in people with dementia. Theres also been a little backsliding in the past year or soso and there has been politicl in the last campaign of political weaponization of dementia from both sides a man and woman camera tv and on the other hand President Biden and those allegations. They were used on both sides as a weapon to underline that persons competence and fitness or position. Du jour oncologists have the same and can you diagnose someone from a distance . I think the defense of the president ialhe campaign were disturbing where the opponents cognition was turned into a political weapon as you say. I was very bothered by the billboard size on bumper stickers and would hope that our politicians would block back from that kind of rhetoric. Lets talk policy and not go after our opponent. Very volatile. Is for the individuals and society and for us who are not actively working with people with dementia every day you have built relationships with them and the very aspect of the condition. How should civil people respond individually or on social media when dementia is used as a slur or an accusation in the mind of another person . What is her role . We should take it on the same way we take on the appropriate ways to respond to an intended or unintended racist comments. Check it, call it out. Ndabsolutely, yes. This should not be a punchline. Well thank you so much. This is marvelous. Ii feel like im having a Dinner Party Conversation with you. Without the dinner. I will send you a grubhub gift. Obviously i read a lot. Ive read a fair amount of nonfiction and i highly recommend the problem of alzheimers is an interesting book whether or not its something thats in your life for affecting your life were you think will affect your life. Its a great, its not really a romp. Its a well told likely story against the complicated scientific medical concept and its really accessible and its also provocative. Highly recommended, five stars. Ive enjoyed our conversation together and again i look forward to other opportunities so thank you everybody for joining us today. Olleagues and others for joining 10. Thank you
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