It’s time for an intersectional women’s health agenda

“Sisters are more than the sum of their relative disadvantages: they are active agents who craft meaning out of their circumstances and do so in complicated and diverse ways.”

– Melissa Harris-Perry (2011), Sister Citizen

Far too often Black women’s health is defined by one of two extremes – disease and disability or extreme resilience. In reality, a comprehensive picture of Black women, health and wellness is necessarily complicated. It defies neat labels and categories, allowing for multiple narratives to describe what it means to be a Black woman in the 21st century. The time has come to explore the current landscape of Black women’s health within the realms of both health disparities and women’s health research, examine critical policies that have shaped Black women’s health and wellness over the past two decades, and highlight the many ways in which Black women articulate health and wellness for themselves.

The health of African American families depends largely on the health of Black women. Yet research focused on either ‘minority health’ or ‘women’s health’ agendas fail to fully address the needs of Black women who comprise an essential element in both groups. When Black women are left behind or become invisible intersections, our communities are left behind as well.

As such, we must review Black women’s health over the last 20 years – what do we know and what have we learned? What disease and behavioral trends – both risk and protective – contour the state of Black women’s health today? In tackling these questions, researchers take a holistic approach to understanding what has changed over time to facilitate transitions in health status. Perhaps even more importantly, what can the past teach us about how to reclaim our health moving forward?

Are Black women at risk? Part II: Black Women Face Greater Risk of Exposure to Violence

IPV2Did you know that homicide is the second leading cause of death for Black women aged 20-24? The truth is that for some Black women, they feel as though they are surviving day-to-day instead of living.

“To face the realities of our lives is not a reason for despair—despair is a tool of your enemies. Facing the realities of our lives gives us motivation for action. For you are not powerless… You know why the hard questions must be asked. It is not altruism, it is self-preservation—survival.”
– Audre Lorde (1989), Oberlin College Commencement Address

We might better understand the reason behind this sentiment considering the statistics facing Black women and the exposure to violence. Black women are especially likely to be a victim of violence in America. The fact that no woman is more likely to be raped in America today than a Black woman is sobering. Black women are more than three times as likely to be murdered as are white women and are in fact, the most likely group of women in America to become a victim of homicide. Though only approximately 8% of the population, Black women comprise 29% of women who experience intimate partner violence (IPV). Yet Black women are less likely than other groups to utilize social services, such as battered women’s programs. These statistics represent a cry for action to expand public health research and public policy to reconsider protections afforded Black women.

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Unfortunately, young Black girls face similar challenges in navigating environments marked by violence and peril. Black adolescent girls are disproportionately impacted by zero tolerance school policies, and experience an increased risk of becoming involved in the criminal justice system at some point during elementary school education. #BlackGirlsMatter!

Reports also reveal that nearly 60 percent of Black girls are abused by an intimate partner before reaching the age of 18. Yet, Black women are less likely to go to the police or file a report against their attacker. Why? While complicated, we may be able to understand this paradox in the cultural and political context of systematic racism, fear and distrust in official authorities. Reports claim that Black women have the “tendency to withstand abuse, subordinate feelings and concerns with safety, and make a conscious self-sacrifice for what she perceives as the greater good of the community, but to her own physical, psychological and spiritual detriment.” (Bent-Goodley, 2001)

IPV kidWhile shedding some light on the complicated nature of disclosure and IPV, these claims only scratch the surface. Black women who don’t report IPV are often in the position of protecting their families, partners and children while averting the reality of abuse. Regardless of the rationale, the fact that partner abuse is a life-altering experience is a truism. The long-reaching effects can be traumatic for the women and their families; in some cases, cycles of violence are reproduced over generations. Victims of IPV often experience guilt, anxiety, phobias, substance and alcohol abuse, sleep issues, alienation, aggression and sexual dysfunction. They are three times more likely to suffer from depression and six times more likely to develop post-traumatic stress disorder.

Isn’t it time that we sound the alarm that domestic violence is a national priority for Black women’s health?

Are Black women at risk?

We-Stand-Counter-Campaign

When we think of the most pressing health concern facing Black women over the past 20 years, a recurring theme arises: obesity. Granted, the relationship between Black women and weight is complicated. It is often reported that Black women don’t perceive themselves as obese or overweight because they have higher body image ideals compared to other ethnic groups of women. Black women also seem to prize additional weight on the body frame as an enhancement, rather than a negative feature, which may lead to skewed ideals about weight and health concerns.

The fact that despite a generally higher body mass, Black women are more satisfied with their bodies than White women may be part of the reason why rates of obesity have increased more among Black women than other groups. The question you might be asking is, “why?” Some research supports what conventional wisdoms only allude: that Black women are less susceptible to body dissatisfaction compared to other racial groups because of their cultural ideals that promote a heavier body type and discourage stringent weight loss strategies.

Regardless of the reason for maintaining a higher weight, health researchers are concerned that tolerance for heavier body types may contribute to high obesity prevalence in the Black community, particularly among Black women. Obesity related health issues disproportionally affect Black women, and weight gain is a strong risk factor for a variety of other chronic conditions found in the African American community – hypertension, diabetes and heart disease.

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While several explanations can help us to understand causes for obesity, one thing is sure: to make a difference, we may need to fully understand to what extent body size presents a real issue for Black women, and whether obesity is the sole driver of health-related complications. In fact, recent studies question the notion that simply being overweight is unhealthy. The health education program Health At Every Size (HAES), for example, challenges popular misconceptions about the health effects of being overweight.

One study comparing obese women on a typical diet with another group who were following a HAES program found that while the diet group was successful in limiting calorie intake, the HAES program supported women in accepting their bodies and listening to internal cues of hunger and fullness. After two years, the HAES group had improved blood pressure, total cholesterol, LDL, and depression, among other health benefits. Innovative approaches to healthy lifestyles may combine the high body ideals of Black women with newer, improved ways of living healthier lives.

What is your take? Is the “obesity epidemic” real or fabricated?

Health Disparities and ACA: Where are we now? Where could we be?

The logical sequel to “where are we now?” is “where could we be?” in relation to the Patient Protection and Affordable Care Act (ACA). We must remember that there are (at least!) two sides to every policy issue. Ignoring the political debate about whether ACA has been successful for a moment, let’s consider how ACA is impacting marginalized groups, and how it could be useful in closing gaps in care for those same groups. Essentially, let’s address two simple questions – What are health and health care disparities? And how does the ACA impact disparities?

What are health and health care disparities?
For the sake of simplicity, we will define health disparities as a disproportionately higher burden of illness, injury, disability and/or mortality experienced by one population group relative to another group. Of course, disparities are not mere differences, but are instead a particular type of health difference closely linked with social and economic factors, systematic oppression and/or environmental disadvantage. Health care disparities are differences between groups in health insurance coverage, access to care, and quality of care. Ok, so what does this have to do with ACA?

Courtesy of Kaiser Family Foundation
Courtesy of Kaiser Family Foundation
The ACA was passed with the primary goal of filling in gaps in the availability of affordable health coverage in the United States. Major provisions included documenting disparities through data collection and research, expanding preventive health benefits (especially for groups that previously had little access to preventive services) and the expansion of public health insurance (Medicaid/Medicare) benefits. Recall briefly that prior to the passing of ACA, certain groups meeting certain guidelines were “covered” and able to access Medicaid benefits. However, due to strict eligibility requirements, not everyone was able to qualify and access benefits (red portion of umbrella). However, post-ACA, modifications to Medicaid requirements expanded benefits to more people (blue portion of umbrella) and many of those that were previously excluded are now “covered” and able to access a reasonable array of heath benefits and services. Yes – Success!

Not so fast. While ACA is a national policy, Medicaid, the primary government-funded insurance program to provide health care to low-income individuals and vulnerable groups is state-run or managed by cooperative agreements between the federal and state government. Recall also that in 2012 the Supreme Court decided that while the Medicaid coverage expansion would be maintained, the Secretary would be limited in authority to enforce the expansion (in National Federation of Independent Business v. Sebelius), effectively making the expansion optional for states.

How does the ACA impact disparities?

Holey umbrellaIn a nutshell, states are not required to expand Medicaid benefits, leaving those who would be “covered” well, holding an umbrella with a giant hole in it. In fact, as of August 2014, 28 states including the District of Columbia were expanding Medicaid to provide additional benefits and services; however, 21 states were not and 2 were undecided. It also just so happens that a sizable number of states not moving forward with Medicaid expansions at this time are also states located in the South, among the poorest states and home to large percentages (~50%+) of communities of color. States in the South and largely rural states also serve more older adults, have more Medicaid/Medicare patients and maintain the highest rates of chronic health burden.

Image Courtesy of Kaiser Family Foundation
Image Courtesy of Kaiser Family Foundation
Is it all making sense now? Rather than expanding coverage, in many states where health disparities are the most striking there is a widening coverage gap. For states opting not to implement the Medicaid expansion, millions of adults (nearly 4 million) will remain outside the reach of the ACA and continue to have limited, if any, option for health coverage. This creates issues not only for Medicaid reform, but for a growing group of individuals and families (holding the holey umbrella) who are essentially the working poor, the uninsured, the undocumented and those who can’t afford to buy private insurance on the Exchange.

Not the warm-fuzzy you were expecting? Well, I did say that there was hope, no? “Where could we be?” is the pressing question that will continue to shape our health care system as we think of new ways to deliver care. The beautiful thing about state-run Medicaid programs is that states have some autonomy, at least in those opting to expand Medicaid, to actually address change at the SYSTEM level. In New York State for example, a primary goal is to “break the mold” of the current Medicaid program to offer innovative new ways of delivering a mix of services to improve population health. Streamlining emergency Medicaid processes, developing new ways to provide supportive housing and providing competency training to the NYS healthcare workforce are just a few ways New York is taking on service integration and system reform. One can only hope that such innovation, especially as it relates to training the health care workforce, follows a structural competency model to highlight the underlying root of health inequalities and how we, as health professionals, can change them.

It is an exciting time to be engaged in Medicaid redesign as policy makers and public health researchers are actually thinking through and talking to one another about how to offer more community services for those caught in the gap and how to meet people in need where they are. System change is indeed a beautiful thing. It will be an interesting experiment to observe how it all plays out and what the changes associated with ACA will bring in the years to come.

Women’s Health and ACA: Where are we now?

ACA White House

As we enter into the third quarter of 2014, it seems like a good time to review the changes enacted by the Affordable Care Act (ACA) and what good/bad impacts these changes have had for women’s health and underserved groups. It’s a larger discussion than to be had here for sure, but engaging in the conversation is important in ensuring that we continue to push for not only accessibility, but equity in health care as well.

infographic-how-aca-affects-women-e1368557320211The passing of the ACA signals a significant advancement in women’s health and public policy in general, ensuring that millions of women now have access to affordable health coverage. Women no longer pay more than men just for being women (e.g., gender rating). Unbelievably, for the first time in history – this overt gender discrimination is now prohibited in federally funded health care. Women will also not be denied coverage for pre-existing conditions, such as a Caesarean section or having received medical treatment for domestic violence. Lifetime dollar-value caps are no more, maternity coverage is now considered an essential health benefit and preventive services have been expanded to include contraceptives, mammograms and cervical cancer screenings with no deductibles or co-pays. Although the contraceptive mandate has stirred controversy in public discourse, the fact that birth control is available on both public insurance and private plans without out-of-pockets costs represents progress. Employers (non-religious) are not only required to provide birth control as part of insurance plans offered to employees, companies must also – and this is a big one for anyone who has ever breastfed – offer hourly employees a clean, safe space in which to pump (e.g., not an office closet or restroom).

And what about older women? One of our fastest growing demographics? They benefit too through a host of programs to support caregivers (typically women). Dual-eligibles will also maintain a more integrated balance between Medicare/Medicaid and will be able cover more prescription drug costs.

With these benefits, its hard to imagine that the ACA is anything but a resounding success. Still, coverage gaps remain. Of the currently uninsured, approximately 20% are women. Furthermore, the failure of some states to expand Medicaid eligibility benefits will undoubtedly affect women’s health in profound ways. All in all, the report card is not yet conclusive as to whether individual mandates and state expansions fully address the needs of women in this country. There is a sizable proportion of women who will be excluded from receiving any benefits due to immigration status or costs associated with buying insurance on the individual marketplace.

minority woman21 Many women fall between a space where they fail to meet eligibility criteria for Medicaid and can’t afford to purchase private insurance on the exchange, even with tax credits and subsidies. And while primary care at federally qualified health centers is available, access and quality depend on geographic location. Its possible for women with limited options to continue to receive clinic and inpatient care at the remaining public hospitals and some non-profit hospitals that provide charity care, yet this is far from ideal and free clinics are few and far between. In addition to that, abortion is still not federally supported and accessibility and affordability varies on the health exchange. Drug coverage continues to be a priced at a premium and even though certain medications are subsidized by pharmaceutical companies, ultimately, mandating insurance coverage for the poor and underserved – many of whom are struggling to meet ends – is a difficult imperative. Ironically enough, the two ways in which the ACA was close to gaps – provide access and expanded benefits (at reduced cost) – are precisely the areas in which the most marginalized still find themselves lacking, with Medicaid expansions in many states (26) at a standstill.

Of course, its not simple to overhaul a national system that historically, was never intended to provide universal access to care. And the ACA shouldn’t be blamed for the complicated and dysfunctional system it took centuries to create. Some parts of the ACA are working; but others still need tweaking. For those of us working in the community and serving underserved populations, its important to not only understand these shortcomings, but also to advocate on behalf of women, children and the un(under)insured who may be navigating a complicated system or shut out altogether.

Disrupting Hair Habitus

bourdieu, 1977Could “hair habitus” be a thing? Or as one reviewer suggested, “acceptable presentation habitus”? In any case, I’m curious how hair intersects with the concept of habitus and health intervention research. Habitus originates from Bourdieu (1977), in which he argues that certain mundane acts are an elaborate performance. What do we perform, you ask? Well, there’s no short answer because there are a myriad of ways we perform gender, social class and identity every day. In essence, habitus refers to implicit practices and routines that structure the logic of everyday life.

In this way, I think about how Black women’s relationships to hair are formed differently across class lines. Perhaps the primary question is, are they? Are attachments to hair and specifically hairstyle, more salient for certain class groups? Of course, these theoretical musings are not simply rhetorical questions. They matter in the sense of understanding and breaking cycles involving health, class and the racialized gendered body. From my standpoint, hairstyling and daily grooming is a significant daily performance. For Black women in particular, our hair conveys messages to the world about who we are and how we want to be seen. Yet I struggle in articulating a theory that expresses the way in which hair is in conversation with our bodies and our health. How do we meaningfully incorporate ideals of beauty, femininity, hair and health?

let's talk about hair_oprahA second tenet is that habitus is shaped by social and economic conditions. Perhaps one primary strategy for transforming the dissonance between *some* Black women who struggle with maintaining hair and a daily exercise practice, for example, includes disrupting habitus. According to Bourdieu, mundane acts of everyday life can be restructured to accommodate new interests and practices. So for example, if we encourage women to exercise at work, then we must design interventions that focus on the challenges associated with integrating workplace-exercise with daily grooming practices. We must purposefully restructure our routine in a way that successfully incorporates physical activity. Exercise interventions cannot be disconnected from the sociocultural contexts in which we live. By providing models that integrate structure and “real world” application, we are able to design culturally appropriate ways to meet the needs of women’s health.

theory into practiceAs public health professionals, it is imperative to acknowledge, not discount, the reality that hair management for some women is a barrier to exercise. In moving forward, our aims should include disrupting the notion that one cannot both preserve hairstyles while exercising. To do so requires identifying strategies that incorporate flexible planning and social support into intervention research.

Policing bodies: The larger discussion behind Black women’s hair in the military

Black hair is multidimensional, layered and complex.

We get a sense of this complexity with the recent media attention given to the military’s hairstyling guidelines that unfairly target Black women. The truth is, the military is not different from larger society’s expectations and constructions of idealized or “acceptable” presentations of hair. There’s a long history here, and it’s been covered before so I won’t rehash it.

There are multiple issues with the military’s styling guidelines; I will focus on two. First, the framing of the guidelines suggest that all women should be able to achieve the same hairstyling, regardless of ethnic/racial background or even more practical considerations, such as hair length and texture.

Army Black HairAccording to Troy Rolan, an Army spokesman, “The updates in appearance standards were crafted, in part, with the help of African-American female soldiers and are intended to clarify the professional look of soldiers.” Question: Is it logical for a few African American women to “clarify” how all African American women should wear their hair? I’m sure this goes without saying, but Black women are not all the same and neither is their hair. African American hair textures are quite diverse. And while I appreciate the military’s emphasis on neatness, their standards are contradictory. (Dread)Locs, for example, are neat and can be worn down. Yet they are banned according to military guidelines. What gives? As Imani Perry puts it, “While it is reasonable for the military to expect some degree of conformity and neatness in hairstyles, those expectations ought to take into account the variety of natural hair textures people have.”

Precisely.

Perhaps the larger issue in this debate feeds into the messaging we communicate to society and more importantly, to our young Black girls about hair and work-identity performance. Are we telling our young girls that in order to serve your country, you must manipulate or even chemically alter the state of your hair? Moreover, that the way you wear your hair may jeopardize your job or job security? Yet Black women are unfairly subject to this policing of their bodies, both in and outside the military confines. How are Black women in the workplace compelled to either conform to or perform Eurocentric standards of beauty in ways that suppress their identities and natural sense of self? When an employer mandates that hair be worn in a specific, “acceptable” manner, what does that mean? Does that mean that one cannot be their authentic selves?

Essentially, military officials may do well to first understand the complexities of how African American hair grows naturally, and then design guidelines that accommodate that diversity. Hairstyles should not be demeaned or subject to criticism simply because they are perceived to be different. Instead the approach to grooming standards – whether in corporate America or the military – might focus less on gendered-racial policing disguised as regulation and more on job performance.

Just a thought –

Ageism in a modern society

greedy simpsonAre you a greedy geezer? You know, one of those resource-draining, money-sucking seniors at the center of the debate on some of the nation’s most important health policy issues (e.g., Medicare, Social Security)? If not, rest assured that you will be at some point. Or at least so goes the myth. Old people have morphed into the new ‘welfare queens’ of the future in that there is a pervasive public perception that old people are greedy and consume resources to the detriment of the younger members of society. These sentiments not only feed into public discourse about policy decisions, but contribute to an even larger issue of intergenerational division and age segregation.

You may be wondering why (or even if) age segregation is a significant public health issue. Indulge for a moment in a brief thought experiment and substitute the word “age” in the previous sentence for “racial” or “residential” segregation. Decades of research have concluded that segregation is bad for the health of individuals, communities and society at large. While researchers have scrutinized residential segregation and health disparities in great detail, segregation by age has received far less attention. grandpa simpson happy Yet age segregation represents one of the most important policy-relevant issues facing a future aging society. Why? On a fundamental level, age segregation blocks essential opportunities for interaction and discussion across generational lines, which may foster cultural dissonance and ageism (e.g., greedy geezer myth). We (non-old adults) rarely forge relationships with older adults, and are left to form our own assumptions, biases and stereotypes based on very little factual information. Second, for older adults, age segregation is a threat to continued productive activities, mobility and exercise, and it thwarts embeddedness, social interaction, and increases the risk for isolation and loneliness in later life. The benefits of social embeddedness have been well documented. Furthermore, because elders are at increased risk of decline in functional independence as they age, having a network of close friends and family that can provide support may be particularly useful for maintaining well-being and an independent aging-in-place lifestyle in later years.

Simpson togetherThus, shifting perceptions and stereotypes about old people is ultimately paramount to aging policy and interventions geared toward accommodating and integrating older adults into the fabric of American society. So what do we do as public health researchers? How do we design interventions to promote an age-integrated society? How can intergenerational social bonds be strengthened? And finally, how do we address the issue of age and the structural lag for current and future generations of aging adults?

One means of achieving such a shift entails promoting generativity, or more specifically, a generative society. A generative society can evolve by motivating and incentivizing prosocial and cooperative behaviors, and perhaps most importantly, designing generativity-based programs that are sustainable. Early foundational research in this area has found that creating intergenerational programs that provide educational benefits for the young and allow the old to serve in productive roles is a viable means to reduce generational tension and create successfully aging societies. My work to date examines generativity as a feature of personal development and a correlate of successful aging. I believe expanding this work will help bridge the gap between translating individual motivations for prosocial and cooperative behaviors to a community-level effort, and provide the framework for building strategies that will increase the visibility and integration of older adults into communities.

Silence at the intersection

cece-mcdonaldI recently posted a link for Free CeCe (a documentary-in-progress by Laverne Cox and CeCe McDonald) to a listserv of friends and colleagues. CeCe McDonald is a Black transgender woman and activist. She was sentenced to 41 months in a male prison for stabbing a man who attacked CeCe and her friends in Minneapolis, Minnesota. CeCe’s case generated a significant amount of media attention and public discussion surrounding the victimization and harassment suffered by trans-women and particularly trans-women of color (WOC). Cece was released from prison in January 2014 after serving 19 months, and in her subsequent media appearances CeCe used her platform to discuss her life experiences as a trans-woman, her prison sentence and regaining her life.

In my e-mail post, I solicited opinions about CeCe. I was curious what a group of college-educated, middle class, African American thirty-something professionals thought about CeCe’s (and other trans-WOC) experiences that often entail violence and abuse? How do we think about the voices of Black LGBT*Q folks at the intersection? Where do we place sexuality in the politics of antiracism efforts? And how do we teach our peers and children about acceptance and the importance of being allies?

Good questions, right? I thought so too. Until a day, then 2 days passed. No response. A week. Still no response. The silence was deafening. A group of very knowledgeable people who definitely had opinions on a wide range of issues and not one. single. comment. about my post? Surprised and outraged, I followed up. “What gives? Why the silence?”

Then, someone offered this:

“For most people, until they know someone, until it affects them directly, or until it is right in their own back yard do people rarely care (or pay attention to) specific issues. Until then, it’s just an abstract thought that you may be aware of but not really motivated to do anything about.

It’s even more a problem in the Black community since we tend to suppress/ignore issues even when they do affect us (dietary behaviors, depression, sexual assault, sexuality, etc.). AND because we (compared to other groups) strongly stick to a religious dogma that teaches us to blindly accept/ignore things and to pray away our “problems” instead of talking about them.

The key is having an open dialogue on all of these things which, in a way, makes the world smaller and makes relating to people/issues easier even if not directly affected. I think younger generations growing up with social media exposes them to topics that older generations (all of us included) didn’t have access to.”

Finally.

Vigil Held For Transgender Woman Beaten And Killed In HarlemHowever, as on-point as the comment was, I still had questions. Are we now part of an “older generation” that is too set in traditional ways of thinking to grapple with these issues? Is not knowing an excuse for not caring? How can we begin to engage in difficult dialogues, and more importantly solutions, if we remain SILENT? I wondered what the other 99% of the listserv thought? Did they agree and if so, why didn’t they speak up? Again, why are we so SILENT?

As I consider my own research dealing with the complicated nature of intersectionality, I can’t help but notice that everyone has not come to join my party at the crossroads. In fact, many people don’t consider their identities (much less the identities of others) as intersectional. It was a sobering moment. A moment that makes me realize that beyond the academic labor, there is real work to be done on the ground in raising the consciousness of people living ‘at the intersection’ and outside of it. For instance, there is real work to help our brothers understand how to work together in helping to empower, not objectify and destroy, Black women. There is real work in getting the word out that (black) feminism is not a dirty word and yes, men, you too can join the movement. And, there is real work in paying attention to – and understanding the experiences of – the CeCe’s of the world.

The list continues to grow.

If Crenshaw really did conceptualize the term intersectionality from a schema of intersecting roadways, then it stands to reason that in all of its complexity, some people will be left in the median wondering where they fit (if at all). Isn’t it time we did something to translate and disseminate the message of what it means to be a true ally – and to “do intersectionality” – far and wide? While we debate the future of intersectionality, with the conceptual and measurement issues on one front, we also need to coordinate ways to do the work required to reach everywoman/man.

Carbado et al. (2013) explain:

“When Kimberlé Crenshaw drew upon Black feminist multiplicitous conceptions of power and identity as the analytic lens for intersectionality, she used it to demonstrate the limitations of the single-axis frameworks that dominated antidiscrimination regimes and antiracist and feminist discourses. Yet…the goal was not simply to understand social relations of power, but to bring the often hidden dynamics forward in order to transform them. Understood in this way, intersectionality, like Critical Race Theory more generally, is a concept animated by the imperative of social change.”

As we see, the very essence of intersectionality is historically steeped in centering perspectives as a tool of analytical, theoretical and social development. Our potential to be transformative depends on facilitating efforts to change structural invisibility and inequality. So what are we waiting for? Let’s get on with it.