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Feb 2, 2014

Bonnie Bassler: How bacteria "talk"



Transcript of TED talk

I know you guys think of yourself as humans, and this is sort of how I think of you. This man is supposed to represent a generic human being, and all of the circles in that man are all of the cells that make up your body. There is about a trillion human cells that make each one of us who we are and able to do all the things that we do, but you have 10 trillion bacterial cells in you or on you at any moment in your life. So, 10 times more bacterial cells than human cells on a human being. And of course it's the DNA that counts, so here's all the A, T, Gs and Cs that make up your genetic code, and give you all your charming characteristics. You have about 30,000 genes. Well it turns out you have 100 times more bacterial genes playing a role in you or on you all of your life. At the best, you're 10 percent human, but more likely about one percent human, depending on which of these metrics you like. I know you think of yourself as human beings, but I think of you as 90 or 99 percent bacterial.
The reason that Vibrio fischeri is doing that comes from the biology. Again, another plug for the animals in the ocean, Vibrio fischeri lives in this squid. What you are looking at is the Hawaiian Bobtail Squid, and it's been turned on its back, and what I hope you can see are these two glowing lobes and these house the Vibrio fischeri cells, they live in there, at high cell number that molecule is there, and they're making light. The reason the squid is willing to put up with these shenanigans is because it wants that light. The way that this symbiosis works is that this little squid lives just off the coast of Hawaii, just in sort of shallow knee-deep water. The squid is nocturnal, so during the day it buries itself in the sand and sleeps,but then at night it has to come out to hunt. On bright nights when there is lots of starlight or moonlight that light can penetrate the depth of the water the squid lives in, since it's just in those couple feet of water. What the squid has developed is a shutter that can open and close over this specialized light organ housing the bacteria. Then it has detectors on its back so it can sense how much starlight or moonlight is hitting its back. And it opens and closes the shutter so the amount of light coming out of the bottom -- which is made by the bacterium -- exactly matches how much light hits the squid's back, so the squid doesn't make a shadow. It actually uses the light from the bacteria to counter-illuminate itself in an anti-predation device so predators can't see its shadow, calculate its trajectory, and eat it.This is like the stealth bomber of the ocean.
First we figured out how this bacterium does this, but then we brought the tools of molecular biology to this to figure out really what's the mechanism. And what we found -- so this is now supposed to be, again, my bacterial cell -- is that Vibrio fischeri has a protein -- that's the red box -- it's an enzyme that makes that little hormone molecule, the red triangle. And then as the cells grow, they're all releasing that molecule into the environment, so there's lots of molecule there. And the bacteria also have a receptor on their cell surface that fits like a lock and key with that molecule. These are just like the receptors on the surfaces of your cells. When the molecule increases to a certain amount -- which says something about the number of cells -- it locks down into that receptor and information comes into the cells that tells the cells to turn on this collective behavior of making light.
We also then went to look at what are these molecules -- these were the red triangles on my slides before. This is the Vibrio fischeri molecule. This is the word that it talks with. So then we started to look at other bacteria, and these are just a smattering of the molecules that we've discovered. What I hope you can see is that the molecules are related. The left-hand part of the molecule is identical in every single species of bacteria. But the right-hand part of the molecule is a little bit different in every single species. What that does is to confer exquisite species specificities to these languages. Each molecule fits into its partner receptor and no other. So these are private, secret conversations. These conversations are for intraspecies communication. Each bacteria uses a particular molecule that's its language that allows it to count its own siblings.
Once we got that far we thought we were starting to understand that bacteria have these social behaviors. But what we were really thinking about is that most of the time bacteria don't live by themselves, they live in incredible mixtures, with hundreds or thousands of other species of bacteria. And that's depicted on this slide. This is your skin. So this is just a picture -- a micrograph of your skin. Anywhere on your body, it looks pretty much like this, and what I hope you can see is that there's all kinds of bacteria there. And so we started to think if this really is about communication in bacteria, and it's about counting your neighbors, it's not enough to be able to only talk within your species. There has to be a way to take a census of the rest of the bacteria in the population.
So we went back to molecular biology and started studying different bacteria, and what we've found now is that in fact, bacteria are multilingual. They all have a species-specific system -- they have a molecule that says "me." But then, running in parallel to that is a second system that we've discovered, that's generic. So, they have a second enzyme that makes a second signal and it has its own receptor, and this molecule is the trade language of bacteria. It's used by all different bacteria and it's the language of interspecies communication. What happens is that bacteria are able to count how many of me and how many of you. They take that information inside, and they decide what tasks to carry outdepending on who's in the minority and who's in the majority of any given population.
To finish I'll just show you the strategy. In this one I'm just using the interspecies molecule,but the logic is exactly the same. What you know is that when that bacterium gets into the animal, in this case, a mouse, it doesn't initiate virulence right away. It gets in, it starts growing, it starts secreting its quorum sensing molecules. It recognizes when it has enough bacteria that now they're going to launch their attack, and the animal dies. What we've been able to do is to give these virulent infections, but we give them in conjunction with our anti-quorum sensing molecules -- so these are molecules that look kind of like the real thing, but they're a little bit different which I've depicted on this slide. What we now know is that if we treat the animal with a pathogenic bacterium -- a multi-drug-resistant pathogenic bacterium -- in the same time we give our anti-quorum sensing molecule, in fact, the animal lives.
What I would hope that I could further argue to you is that this is the invention of multicellularity. Bacteria have been on the Earth for billions of years; humans, couple hundred thousand. We think bacteria made the rules for how multicellular organization works. We think, by studying bacteria, we're going to be able to have insight about multicellularity in the human body. We know that the principles and the rules, if we can figure them out in these sort of primitive organisms, the hope is that they will be applied to other human diseases and human behaviors as well. I hope that what you've learned is that bacteria can distinguish self from other. By using these two molecules they can say "me" and they can say "you." Again of course that's what we do, both in a molecular way, and also in an outward way, but I think about the molecular stuff.
Finally, I wanted to show you this is my gang at Princeton, New Jersey. Everything I told you about was discovered by someone in that picture. I hope when you learn things, like about how the natural world works -- I just want to say that whenever you read something in the newspaper or you get to hear some talk about something ridiculous in the natural worldit was done by a child. Science is done by that demographic. All of those people are between 20 and 30 years old, and they are the engine that drives scientific discovery in this country. It's a really lucky demographic to work with. I keep getting older and older and they're always the same age, and it's just a crazy delightful job. I want to thank you for inviting me here. It's a big treat for me to get to come to this conference.

Jan 30, 2014

Why immunization and its challenges?

Immunization is the process whereby a person is made immune or resistant to an infectious disease, typically by administration of a vaccine. Vaccines stimulate the body's own immune system to protect the person against subsequent infection or disease (1). Immunization saves 2 to 3 million people every year against contagious and life-threatening vaccine-preventable diseases (1, 2). We have to say that the knowledge of immunization is a gift to humankind for that we have safe, effective and affordable preventive measure. However, there are various issues that still remain as challenges to health system at every level. 


As a health professional having years of first hand knowledge or experiences of conducting mass vaccination and surveillance of vaccine preventable diseases (VPDs), let me throw light so as to understand the public health landscape that may be similar in most of the low income countries (LIC). First, there is an increasing divide between rich and poor in terms of socio - politico - economic opportunities. This divide exists in both high income to low income countries across all continent although this may be more pronounced in Asia, Africa and South America. Now, there are also other differences that are visible between urban and rural population. The most remarkable would be the growing number of slums, which have resulted from poverty due to unequal distribution of wealth, population explosion, unemployment and destruction of habitat. In this population, thousand and thousands children as well as adults / old people get sick and die as result of preventable illness or diseases related with poor water supply / sanitation, food scarcity leading to malnutrition and crowding exposing people to various respiratory illness. This means many children miss the opportunity to get vaccinated or even if they get vaccinated, they may not complete the doses, so why does this happen? This brings us to another level of daily challenges that a family has to go through. I will not come to this discussion right now. Another problem, we see most of the time in low income countries are issues related with access and utilization of immunization services. The challenges that we face the most is cold chain maintenance of the vaccines, which can either freeze or heat sensitive. So maintaining cold chain and providing vaccine in safe and potent vaccine is one challenge that requires high priority and importance. Another common problem that we see is inadequate human resource in hard to reach communities. Many of times, parents miss their children get vaccinated just because there are no vaccinator in their village. Is this fair?

Reference:
1. http://www.who.int/topics/immunization/en/
2. http://www.cdc.gov/globalhealth/immunization/

Jan 24, 2014

Nanopatch: Future Vaccine Delivery Method



Looking a bit like a fuzzy computer chip, the Nanopatch uses tiny powder-coated spikes to deliver a small dose of vaccine just under the skin, immunizing a person in about a minute. Made for less than $1, it uses only a fraction of a vaccine dose delivered by traditional syringe method (which was invented in 1853), at the same time eliminating the risk of needle injuries. What’s more, a Nanopatch infused with vaccine is designed to be heat-stable, so it can be transported without refrigeration. And the process doesn't draw blood, reducing the risk of infections.
Mark Kendall, an Australian biomedical engineer, was part of a team at the University of Queensland that advanced the Nanopatch by vaccinating animals. Now his company, Vaxxas, is on a mission to commercialize the device for human use. He plans to run an international trial using the Nanopatch, starting with the human papilloma virus (HPV) vaccine to protect against cervical cancer.
Source: http://www.ted.com/

Jan 10, 2014

My Bio Sketch _ Anuj Bhattachan

I come from a rural background in hilly district of western part of Nepal. I received primary & secondary level education in my village, where I have seen both happiness and suffering. I have seen my uncle die young on the way to hospital 3 days away from our village. I have also seen neighbors die untimely just because he could not receive timely quality care. It was common to see people suffering from ailments due to worm infestations, protein energy malnutrition, diarrhea & vomiting, which were thought to be bad omen as a result of angry spirits / local deity. So, it was a common practice to rely on faith healers rather than health professionals. This scenario was of 1980s & 90s that I remember vividly just like yesterday. During those period, I was not aware of what all these mean in a rationale mind. I was only a child with playful innocence as any child, only to be perplexed at a time by suffering or death of near and dear ones. One moment I still remember, our grandmother crying when we had to lose our uncle at a tender age. This had a deep impact on me with some kind of uneasy feeling. Now, I realize what all this means to lose your near and dear ones including good neighbors and villagers to preventable & treatable ailments and what possibly went wrong so we had to lose them. Passing by all this moments in rural environment, I grew up with various impressions on my subconscious mind. After I completed my high school, I entered university to pursue intermediate science (I.Sc.) in Kathmandu. I studied science as a major that included biology, chemistry and physics.

After the completion of I.Sc. I got an opportunity to pursue Bachelor in Medicine and Surgery (M.B.B.S.) in BPK Institute of Health Sciences (BPKIHS, a centre for excellence, located in eastern part of Nepal. After completion of MBBS, I worked for around 2 years in Accident / Emergency and General Outpatient Department (A/E & GOPD) in the same institute. During this period, I had a privilege to partly understand diseases that are rampant in low income countries. Here, I utilized skills to assess and manage variety of medical including paediatrics problems common in developing countries. Managed infectious diseases like Malaria, Visceral leishmaniasis, Acute gastroenteritis including Cholera, Enteric fever, Japanese encephalitis, Dengue fever / Dengue Hemorrhagic fever, Worm infestation, Protein Energy Malnutrition, Acute / Chronic viral hepatitis, Measles / Rubella, Vitamin deficiency, Micro- nutrient deficiencies as well as growing Non –Communicable Diseases (NCD) that require ongoing care like diabetes, hypertension, chronic lung and renal diseases. This was also a turning point for me. I began to realize the importance of preventive care at primordial, primary and secondary level. I felt, we were treating only the negative outcome of poor sanitation and hygiene rather than the cause of all these ailments. So, I headed to take up a job as a surveillance medical officer (SMO) working with World Health Organization (WHO) – Nepal. Our primary task was surveillance of vaccine preventable diseases like paralytic poliomyelitis, neonatal tetanus, measles / rubella and Japanese encephalitis. All of these diseases are / were major cause of child hood morbidity & mortality, while viral encephalitis, which is a major cause of death and neuro – motor handicap, was creating havoc in Terai belt of Nepal. I found this period a real time experience, which enabled me to comprehend wider public health landscape in Nepal. 

During my job as SMO, I worked extensively in public health mode and learnt a lot. However, I equally felt deep down a necessity to upgrade myself with public health core competencies. Fortunately, I got another opportunity to pursue Masters of Public Health (MPH) at Mahidol University, Thailand in 2009. Here, I was able to clarify many unanswered questions which I was unable to understand. I also wrote my dissertation paper on epidemiological profile of paralytic poliomyelitis reported through country wide surveillance network in Nepal. This dissertation was submitted to Child Health Division, Ministry of Health & Population and WHO - Program for Immunization Preventable Diseases (IPD), Nepal. The primary recommendation was of my dissertation paper was to focus surveillance in high risk areas / population. Now, Nepal has achieved WHO - Acute flaccid paralysis (AFP) surveillance performance indicator leading to polio free state, which is a great achievement in the field of health sector along with measles / neonatal tetanus elimination / introduction of rubella and Japanese encephalitis vaccine. This dissertation was presented in 15th International Congress on Infectious Disease (ICID), 13 – 16 June, 2012, Bangkok, Thailand.

In 2011, I joined International Vaccine Institute (IVI), Seoul, where my job is to coordinate clinical development process of safe / affordable / effective vaccines against enteric diseases that are still a burden in low income countries. As of now, I have been involved with Killed Whole Cell Oral Cholera Vaccine development, especially the pilot introduction of this vaccine in real public health setting of Orissa, India.  Just recently, I presented a paper on “Cholera in Nepal” in Joint International Tropical Medicine Meeting (JITMM), 11 – 13 Dec, 2013, Bangkok, Thailand to make a case for a research & introduction of cholera vaccination in high risk areas. Let us see how far we can go.

Dec 21, 2013

Joint International Tropical Medicine Meeting (JITMM), 11 - 13 Dec, 2013 Bangkok, Thailand















Recently attended Joint International Tropical Medicine Meeting (JITMM) held on 11 - 13 Dec, 2013 in Bangkok, Thailand. This 3 days meeting was attended by infectious disease researchers all around the world especially from Asian countries. There was also presentation on parasitology, which was an attraction for many delegates with special sessions on malaria & its related issues like Aretemesin Result FP malaria. I presented a poster titled "Cholera in Nepal". Cholera is a public health issue that still hounds rural areas in the country that can be associated with eith man made or natural disaster. My message was primarily that health authorities must emphasize on disease surveillance and timely preventive measures. Please find here the link for abstract book:

http://www.jitmm.com/uploadDoc/AbstractBook.pdf

Nov 26, 2013

WHO and the Philippine Government launch mass vaccination campaign

MANILA, Philippines – WHO and the Philippine Department of Health have launched a vaccination campaign to prevent outbreaks of measles and polio among survivors of Typhoon Haiyan (Yolanda)…The campaign targets children in areas hardest hit by the disaster – starting with the evacuation centres in the city of Tacloban and at receiving centres in Cebu, where evacuated families are finding temporary shelter. Children under 5 years old are being vaccinated against polio and measles and given Vitamin A drops to boost their immune systems. ..WHO worked with the Department of Health to finalize plans and procure all necessary vaccines and supplies to carry out the campaign and set up immunization stations…WHO is working with partners to arrange for the delivery of vaccines using gas-powered and generator-powered fridges, freezers, vaccine-cases, cold boxes and ice packs for affected areas that have lost power. This “cold chain” is necessary to keep the vaccines from being spoiled. USAID has sent 6 solar-powered refrigerators to Tacloban.
WHO – Humanitarian Health Action 
http://www.who.int/hac/en/index.html
WHO responding to health needs caused by typhoon Haiyan (Yolanda) 2013 – Health Cluster Bulletin – 20 November 2013

Nov 20, 2013

Definition: Emerging and Re - Emerging Infectious diseases

"Emerging infectious diseases are diseases that (1) have not occurred in humans before (this type of emergence is difficult to establish and is probably rare); (2) have occurred previously but affected only small numbers of people in isolated places (AIDS and Ebola hemorrhagic fever are examples); or (3) have occurred throughout human history but have only recently been recognized as distinct diseases due to an infectious agent (Lyme disease and gastric ulcers are examples). "
"Re-emerging infectious diseases are diseases that once were major health problems globally or in a particular country, and then declined dramatically, but are again becoming health problems for a significant proportion of the population (malaria and tuberculosis are examples). Many specialists in infectious diseases include re-emerging diseases as a subcategory of emerging diseases."

Nov 16, 2013

Vaccination

 
Vaccination is protects you from something that might happen in the future.

Nov 12, 2013

What most schools do not teach you !!!

 


Very Relevant Article re: Natural Disasters, Armed Conflict with its implication on Global Health

Review Article - Global Health

Natural Disasters, Armed Conflict, and Public Health
Jennifer Leaning, M.D., and Debarati Guha-Sapir, Ph.D.
N Engl J Med 2013; 369:1836-1842November 7, 2013DOI: 10.1056/NEJMra1109877
http://www.nejm.org/doi/full/10.1056/NEJMra1109877
Excerpt
Natural disasters and armed conflict have marked human existence throughout history and have always caused peaks in mortality and morbidity. But in recent times, the scale and scope of these events have increased markedly. Since 1990, natural disasters have affected about 217 million people every year,1 and about 300 million people now live amidst violent insecurity around the world.The immediate and longer-term effects of these disruptions on large populations constitute humanitarian crises. In recent decades, public health interventions in the humanitarian response have made gains in the equity and quality of emergency assistance…
Conclusions
The effects of armed conflict and natural disasters on global public health are widespread. Much progress has been made in the technical quality, normative coherence, and efficiency of the health care response. But action after the fact remains insufficient. In the years ahead, the international community must address the root causes of these crises. Natural disasters, particularly floods and storms, will become more frequent and severe because of climate change. Organized deadly onslaughts against civilian populations will continue, fueled by the availability of small arms, persistent social and political inequities, and, increasingly, by a struggle for natural resources. These events affect the mortality, morbidity, and well-being of large populations. Humanitarian relief will always be required, and there is a demonstrable need, as in other areas of global health, to place greater emphasis on prevention and mitigation.
 

Nov 5, 2013

WHO: Oral Cholera Vaccine Stockpile

A global stockpile of oral cholera vaccine (OCV) has been created, as an additional tool to help control cholera epidemics. Over the period July 2013 /June 2014 the stockpile will have available 2 million doses of vaccine.
The OCV stockpile, is managed as a rotating fund, by the International Coordinating Group (ICG) which already manages similar stockpiles of meningococcal meningitis and Yellow Fever vaccines for outbreak response.
The ICG is comprised of four decision making partners: the International Federation of Red Cross and Red Crescent Societies (IFRC), Médecins Sans Frontières (MSF), United Nations Children’s Fund (UNICEF) and WHO, which also serves as the Secretariat.
The ICG members will continue to communicate with partners and stakeholders to increase awareness of the OCV stockpile, placing vaccine in the context of an integrated cholera response which is based around early detection, case management, provision of safe water, sanitation, and raising awareness among the affected communities.
November 2013
Resource:
More information, applications and guidance is available here:
http://www.who.int/cholera/vaccines/ocv_stockpile_2013/en/index.html

Oct 17, 2013

Vaccine Preventable Diseases (VPDs)

            We are living in 21st century, the age of supercomputers. With the story of super computers, we should not forget that millions of people are still living with abject poverty and millions of children having to lose their life before fifth birthday. If we go through pages of human history, we will read of global pandemics that created havocs across Europe to Asia. Millions of people had to lose their invaluable life to cholera, flu pandemics, smallpox, tuberculosis, and thousands of children got handicapped and live crippled life due to paralytic poliomyelitis. So this is a story that we should not forget in the backdrop of increasing population, climate change, poverty and rise in multi drug resistant micro – organisms due to inadvertent use of antibiotics.

As a fruit of science has ripened, so do we have various tools to deal with many infectious diseases of impoverished like cholera. Among those tools available, one is vaccines, which are safe, effective and affordable compared to other measures. Vaccine should be understood as a biological product that when given in the form of injection, droplet, skin patch or aerosol protect against targeted diseases producing protective response. I have a faith in vaccine and its long term health impact thereby its contribution in reducing childhood illness and death. So, I do say again and again that vaccine is boon to human kind. As an example, the greatest achievement in the human history is the eradication of small pox so far. The last case of this disease was detected in Ethiopia in 1980s. Another success story can be the endgame of paralytic poliomyelitis, which will soon be eradicated from this globe.

A decade long experience as a disease detective (surveillance medical officer - SMO) in hard to reach area (HRA) of Nepal searching for vaccine preventable diseases (VPDs) is a testimony to my faith in vaccine. During my tenure as a medical officer, we had to manage infectious diseases like Malaria, Visceral leishmaniasis, Cholera, Enteric fever, Japanese encephalitis, Dengue fever / Dengue Hemorrhagic fever, Worm infestation, Acute gastroenteritis, Protein Energy Malnutrition, Acute / Chronic viral hepatitis, Measles / rubella, Vitamin deficiency, micro- nutrient deficiencies. These diseases are rampant and many people even lose their life bringing socio –economic rift in family as well as community as a consequence. Now, the government of Nepal (GoN) has successfully controlled various infectious diseases through introduction of vaccines against diseases like measles & rubella, poliomyelitis, neonatal tetanus, Japanese encephalitis. Some of these diseases are virtually eliminated and some in the process of elimination. Therefore, the introduction of vaccines along with other public health measures has contributed significantly in reducing under 5 mortality. I also have to say and should not forget that the role of health professionals from centre to periphery is commendable. In this efficient public health delivery mechanism, thousands of female community health volunteers (FCHVs) are the backbone in its delivery to the community. They are like a bridge between health system and community. Though, there was a time, Nepal was going through political instability all over the country, it was FCHVs who made routine immunization (RI) run in its usual course and mass vaccination like polio / measles campaign happen throughout country a successful story. However, there are still some diseases like cholera, enteric fever, viral hepatitis, which need attention from government and international organization.  

In Nepal, a large proportion of people rely on unimproved sources for drinking water.  Around half of the population (49 %) opts for open defecation, more so in the rural areas. Only 17 % of populations have adequate access to proper sewage conditions in urban areas, whereas it is almost non - existent in rural areas. Also, there are major limitations in disease reporting through government health system due to incomplete data, and irregular and inconsistent data reporting, so that the burden of disease is seriously under - reported. In 2009, there was a huge cholera outbreak in hilly districts of mid western region, where thousands of people succumbed to this deadly infectious disease. This disease created havoc in the region that led to panicky situation causing socio – political disruption. Since the hilly regions of Nepal is geographically challenging in terms of access to health care and its delivery, many people have to lose their life and bear unnecessary suffering. Therefore, the Government of Nepal (GoN) needs to strengthen surveillance and consider cholera vaccination as a supplement to other preventive measures (i.e. provision of clean water, sanitation and personal hygiene) and the provision of treatment, particularly in high risk areas.
Anuj Bhattachan
15th Oct, 2013

Oct 13, 2013

International Vaccine Institute

We are living in 21st century, the age of supercomputers. For some of us, diseases related with poor water / food supply and sanitation may sound as a story of medieval period. However, it is a fact that millions of people are still living with abject poverty and millions of children have to lose their life before fifth birthday. Even if we go through pages of our history, we read global pandemics that created havocs across Europe to Asia. Millions of people lost their invaluable life to cholera, flu pandemics, smallpox, tuberculosis, and thousands of children got handicapped & live crippled life due to paralytic poliomyelitis.  On positive note, however, we have successfully controlled, eliminated or even eradicated many of these infectious diseases with the use of vaccine and public health measures since science took its foothold in the society from early 1900s. As an example, the greatest achievement in the human history is the eradication of small pox. The last case of this disease was detected in Ethiopia in 1980s. Now, we are almost nearing poliomyelitis eradication from the globe. In the backdrop of this success story, however, people in developing countries are still fighting death and illnesses caused by waterborne, airborne & vector borne diseases in whatever capacity they can through local and modern remedies available.  But on sad note, this is further compounded by increasing population density, deforestation, climate changes, increasing numbers of multi – drug resistance bacteria, urbanization and poverty.  It is reported that millions of children still miss regular vaccination either zero dose or incomplete dose.  The reasons are related with gap in access and utilization of vaccination that are available through government health care delivery services. This means that all these missed children are at increased risk of vaccine preventable diseases and thus, outbreaks in the community. These unfortunate missed children are usually from poor family, especially tribal community, who are under – privileged and illiteracy rampant. So, International vaccine Institute (IVI) has a mission to reach these High Risk populations and provide them access to safe, effective and affordable vaccine against diseases of impoverished using science as its means. IVI's ultimate goal is therefore to transcend vaccine science research from laboratory to the reach of community in high risk areas of developing countries.
 

Anuj in Himalayas

Hi i am connecting disqus with my blog for healthy interaction and open dialogue