In Cap-Haïtien, Haiti, everyone rises with the roosters, and by 8 a.m. the unpaved streets outside Hospital Justinien are jammed. Taxicabs and pickup trucks, some painted with religious slogans and turned into makeshift buses called taptaps, jostle for space on the narrow thoroughfares, dodging potholes and negotiating chaotic corners unregulated by traffic lights.
Amid the exhaust and swirls of dust, pedestrians hustle alongside the roar of traffic. Men push wheelbarrows filled with electronics and blocks of ice. Women balance trays of eggs and bananas atop their heads. Little girls hurry on their way to school, dressed in neat white blouses, kilts and lacy socks, a half-dozen bows in their hair.
On Tuesday, trash day, towers of raw garbage stand on the sidewalk, ready for collection. Goats and the occasional pig scale the piles and nibble at scraps of food and cardboard. Shopkeepers sweep carefully around the waste before raising their storefront grilles.
Here on Haiti's northern coast, 150 miles from Port-au-Prince, life goes on in the country's second-largest city, much as it did before last January's earthquake, and another working day has begun.
Inside Justinien's pediatrics ward, high barred windows keep out the harsh morning light, and thick concrete walls seal off the noise. Hot, humid air settles over rows of cribs where babies, some attached to IV drips, lie near watchful mothers.
A small room off to the side is bare except for an examination table, a makeshift desk piled with folders and bottles of medicine, and two narrow wooden benches pushed up against the walls. A tall Haitian nurse wearing a white dress and a cap and stockings, straight out of the 1950s, confers with a smaller, wiry American woman over a pair of height-and-weight charts.
The Haitian is Marie Fleurese Gourges, head nurse of Justinien's infant malnutrition clinic. The American is Dr. Patricia Wolff, a St. Louis pediatrician. Wolff is 62 years old. She has large blue eyes, short blond hair, a pointed chin — and a commanding presence. As her friend Mary McElwain puts it: "Pat is a person who feels people should listen to her."
Wolff has a black belt in Kenpo karate and usually carries a stun gun and a can of pepper spray in her purse. She is a woman to be reckoned with. Two months ago, when someone snatched her iPhone from her front pocket, Wolff hopped aboard a motorcycle taxi and chased the thief through the streets of Cap-Haïtien until he disappeared into a market.
One of the charts Gourges and Wolff are studying shows that a healthy ten-month-old baby should weigh five and a half kilograms, a little more than 12 pounds. "That's not right," Wolff says. "I know how much a ten-month-old is supposed to weigh."
The child in question is Robenson Yean, who sits on a narrow bench beside his mother. He wears a dirty brown T-shirt and a pair of shorts. He is unusually small for his age. His face and belly are swollen, and there are tiny dark spots on his feet, all telltale signs of malnutrition.
Gourges, with the aid of the height-and-weight chart provided by the World Health Organization, has determined that Robenson is indeed malnourished and eligible for Justinien's treatment program sponsored by Wolff's organization, Meds & Food for Kids, also known as MFK.
Over the next month and a half, Robenson will make weekly visits to the clinic. Gourges or another nurse will wrap him in a sling and hang him from the scale suspended from the ceiling inside the clinic door. They'll stretch him out beside a ruler on the examination table to calculate his height — a delicate operation, because, as Wolff points out, even a centimeter can alter his ideal weight.
The nurses will mark the boy's progress on a chart they keep in a file folder on the table; Justinien, like most institutions in Haiti, has no computers. Then they'll hand his mother a green plastic packet containing half a kilogram (1.1 pounds) of medika mamba — "peanut butter medicine" — which she'll feed to Robenson throughout the week. By his next visit, he'll likely have gained a few ounces, and within a month or two, he'll reach a healthy weight.
It is medika mamba that brought Wolff to Cap-Haïtien. For the past seven years, she's been working to build a factory where Haitian workers will use the peanuts grown by Haitian farmers and transform them into peanut butter (enhanced by vitamins and minerals), which will be distributed and fed to malnourished children in clinics throughout Haiti.
A few minutes before Robenson and his mother arrived, Wolff and Gourges were studying the medical chart of another child, a one-and-a-half-year-old boy named Blaise. He weighed 13.25 pounds when he entered the program, and his goal weight was set at 16.5 pounds. At his last visit, though, he weighed in at a little more than 14 pounds; the week before that, he'd been at 13.
The numbers make Wolff suspicious. When used properly, medika mamba has a 75 percent success rate.
"Maybe he had diarrhea," Wolff speculates. "Or maybe his family was giving [the medika mamba] away. He missed two visits. They gave him a warning. He was supposed to be kicked out if he missed a visit, but the kid probably looks so sick and scrawny they decided to keep him in."
A nurse hired by MFK used to monitor the patients at the Cap-Haïtien-area clinics and make sure they ate their medika mamba. But the nurse resigned, overextended from her other, full-time job. Now Wolff must find a replacement. "Without an enforcer from MFK to make sure they're using medika mamba correctly, the outcomes aren't as good," she explains.
But when the peanut butter is used the right way, "it's a marvel," exclaims Dave Polage, an American who runs a clinic in Terre Blanche, Haiti.
"After we got the product and began using it, we were just amazed by the results," Licia Betor, who runs the Real Hope for Haiti Rescue Center in Cazale, writes in an e-mail. "After living here for 15 years, you hear lots and lots of stories of products that are good for malnourished children. Many of them are great, but the kids do not like the taste. But the kids loved the medika mamba, and it works so well for those who were so sick."
Still, without more good outcomes, Wolff won't be able to prove to potential donors back in the United States that medika mamba is the best way to fight childhood malnutrition in Haiti. Without donations, MFK won't be able to build a new factory. Without the new factory, it won't be able to produce sufficient quantities of medika mamba to sell to big aid organizations such as UNICEF and USAID.
And without turning a profit, the factory will never be self-sustaining and will, like so many other projects in Haiti, find itself completely dependent on foreign aid.
That is precisely what Wolff does not want.
"Shoot, you need to stay and develop the country," she says. "They don't need to be rescued."
Nothing had prepared Pat Wolff for her first trip to Haiti in 1988. "It felt as though I was at the scene of an accident," she remembers.
She'd traveled to Port-au-Prince with the Haiti Project, a mission group led by Bob Corbett, a retired Webster University professor who had become an expert on Haiti, and his wife, Jane. Wolff and her husband Michael, now a Missouri state Supreme Court justice, and their two sons, then 11 and 14, planned to volunteer at Mother Teresa's homes for dying children and dying adults.
As a girl growing up in Minnesota, attending Catholic school, Wolff had been taught that she had an obligation to help the less fortunate. "The underlying message was that you are your brother's keeper, and you should be grateful for what you have," she remembers. "When you have more, you can start making the world a better place. They told us, 'Start doing something; it'll help.' The nuns made it clear: We were not necessarily deserving; we were just lucky."
Wolff had chosen a career in medicine, with the plan of doing missionary work one day. But the demands of a family and a medical practice had gotten in the way. Now she had her chance.
"It was a profoundly awful experience," she recalls. "Most of the people there were dying of something that could have been treated with proper equipment: tuberculosis, malnutrition, infections. All we could do was comfort them as they needlessly died. It was way too little and way too late."
Bob Corbett arranged for Wolff, another doctor and a nurse to travel into the mountains to volunteer at a start-up clinic. They rode horses and donkeys and brought all the medicine they could carry.
"The first day, 300 people showed up," recounts Wolff. "Some of them had walked miles and miles. They had never seen a doctor before. They had heart disease, kidney failure. It couldn't be solved with a Band-Aid. It was eye-opening and upsetting. I went home bedraggled and grief-stricken."
Over the next 15 years, Wolff returned often to Haiti, mostly to a clinic near Cap-Haïtien. But, she says, "It was like spitting into the ocean. We needed to solve the underlying problem." One in five Haitian children, Wolff learned, is malnourished. One in ten dies before his fifth birthday.
"Malnutrition leads to immune deficiencies," Wolff explains. "They got diseases because they were malnourished."
As it happened, one of Wolff's colleagues at Washington University's medical school, Dr. Mark Manary, had been experimenting in the east African nation of Malawi with a radical new treatment for malnutrition. A combination of ground peanuts, powdered milk, sugar, oil and vitamins, it was cheap, easy to produce and high in protein. It was also easy to store, even in a tropical climate. Best of all, patients could be treated at home.
"The only treatment for malnutrition [in developing countries] was in the hospital," Wolff explains. "People would wait in the hospital for months. There was only a 20 or 25 percent recovery rate. And none of the hospitals were free. Mothers would have to stay there with their children, so no one was taking care of the kids left at home."
Manary doesn't know why it took so long to come up with the peanut-butter solution. "In the Middle East," he says, "they've been using halvah, the same notion, for 2,000 years, but we didn't come to it so fast."
But he and his research partner, André Briend, saw immediate results. From the earliest trials, the peanut butter, known in the scientific community as ready-to-use therapeutic food (RUTF), showed an 85 percent success rate. Amazingly — again, no one is sure why — peanut allergies are extremely rare in the developing world. By 2007, the World Health Organization declared RUTF the gold standard in treating childhood malnutrition.
Manary and Briend decided that if RUTF were to be of any use, it would have to move beyond research studies and into mass production. Briend established a partnership with a French company called Nutriset, which would manufacture the peanut butter, called Plumpy'nut, in its Rouen factory and export it around the world. Nutriset now controls 90 percent of the world RUTF market.
Manary, however, saw RUTF's potential for economic development, and by the time Wolff visited his clinic in Malawi in 2001 and again in 2002, he'd already started his own NGO, Project Peanut Butter. The organization would buy peanuts from Malawian farmers and produce RUTF in a local factory. There was no way Project Peanut Butter would be able to compete with Plumpy'nut on a global scale, but it would provide jobs and pump money back into Malawi's economy.
Wolff liked what she saw, and with Manary's help, she started her own program. She got a grant from Rotary International, and she purchased a peanut grinder. She learned how to operate it, take it apart and put it back together. "It was a little tricky," she says. "But now I was set. I could go to Haiti."
She set up the grinder in a church classroom in Cap-Haïtien and began making peanut butter.
Wolff alternates three weeks in Haiti with three weeks in St. Louis, where she tends to her pediatric practice. "My new patients know they'll only see me half the time," she explains. "The people who mind most are the ones who need me the least. If I died tomorrow, they'd say, 'It's a pity she's dead, but I need my medical records transferred immediately!'"
In Haiti, Wolff wakes up at dawn. She fills a French press with hot water and coffee grounds and, still in her nightgown, sits down with her laptop at the dining room table to answer the day's e-mails.
At 7 a.m. she leaves for the factory, a house in the Cap-Haïtien suburb of Mombin Lataille, and arrives in time for the daily morning meeting with the factory supervisor. "We talk about who's going to use the one car because the other car's been broken for a week," she says. "I talk to the quality control manager. I talk to the product supervisor, and we figure out how much medika mamba we need. We check to make sure we have the right kinds of bags and cups in storage.
"We talk about what's broken. There's always something broken — the car, electricity, water, the roaster — there's always something. Or someone didn't get their order of medika mamba. Or the head of nutrition for the entire country wants me in Port-au-Prince in two minutes. Or the missionary flights are coming in, and we talk about how customs is going to rip us off." She laughs. "That's how you spend all day, every day. You really have to like problem solving. And you can't get flustered."
A problem that in the United States might be solved in a single afternoon can drag out into a monthlong saga in Haiti. MFK's broken Land Cruiser, for instance, needs a rubber seal for its engine. None of the Cap-Haïtien mechanics can afford to keep parts on hand; the seal had to be specially ordered from a dealer in Port-au-Prince. When the part arrived and didn't fit, a replacement had to be ordered from the Dominican Republic. When that part didn't work, the mechanic offered to use a lathe to make it fit.
That's the Haitian way, though: improvise solutions with what little you have. It's very different from America, where, Wolff notes, "our ability to solve problems comes at our mother's knee. We have resources. In a land with nobody to ask and no stuff to buy, you can't solve the problem."
Most Haitians cook their meals in iron pots over a charcoal fire. Electricity is spotty. There are no newspapers. Most of the roads were built during the American occupation in the 1920s and '30s and haven't been repaired since. And, adds Jamie Rhoads, MFK's agricultural development specialist, "the wonderful, corrupt government makes things even more tricky."
Natural disasters and political unrest regularly plague the country. "Haitians are professionals at dealing with tragedy," observes Frank Popper, a St. Louis filmmaker who, along with his partner Lori Dowd, is working on a documentary about MFK.
MFK has experienced its own share of disasters. For several years now, Wolff has been working to bring the factory up to international food safety standards. It's a necessary measure so that MFK will have credibility with UNICEF and USAID, who are accustomed to Plumpy'nut's first-world facilities in France.
"We needed stainless steel," Wolff recalls. "There's no stainless steel in Haiti. It all had to be imported from the Dominican Republic. The Easter before our audit, there was a fire. The plumber had hooked up the propane fridge wrong, and there was a leak. On Sunday afternoon — kaboom! The whole place went up in flames. There was nothing left. Everything had disintegrated. That was two years ago. We had to replace everything in the lab and restore the house to its previous status. It cost $30,000, a huge amount of money for us."
Members of the neighborhood bucket brigade who had put out the fire had also made off with MFK's car keys. There was nothing to do but fly back to St. Louis and organize a fund-raising drive so they could start all over again.
After seven years, Wolff and the Haitians are still trying to figure each other out.
"Working with Dr. Pat has been very interesting," says Maryse Sterlin Sine, the factory's general administrator. "She's very demanding" — she laughs — "like a typical American. Americans expect things to be" — she snaps her fingers — "one-two-three."
Sine, an authoritative woman in her forties, was born in Haiti but lived 18 years in New York and New Jersey. ("I hated it.") It usually falls to her to explain Haitian culture to Wolff and the other Americans — things like when Haitians say "eight days," they actually mean "one week."
"The culture of work is different," Wolff reflects. "It's difficult to get across the idea that the American idea of work is much more strict. We've had to impose our idea of work — and the Haitians consider it imposing. Showing up to work for a boss is a foreign concept. A lot of Haitians work for themselves. The employment situation has an underlying theme: We will never be slaves again."
Dealing with the Haitian bureaucracy can be just as difficult. One morning last month, Wolff and several staff and board members went to a Haitian notary's office to buy a one-and-a-half-acre parcel of land for the new factory. They brought with them a pile of paperwork and a check for $157,500. An hour later, they left again, without a deed for the property. The paperwork was insufficient, the notary told them. They needed to fill out more forms and produce more signatures. The owners needed to be present.
It took two more weeks for the deal to go through. Although Haitian law states that the notary fee should be one percent, the notary tried to charge MFK 5 percent, or an additional $7,875, for his services. Wolff negotiated him down to 4 percent on the grounds that MFK is a nonprofit.
"If it had been Haitian-to-Haitian," she says, "it would have been 3 percent. But that's the way things are done. It's a Robin Hood idea."
Last August, the peanut-butter factory finally passed its international food safety inspection. Still, it received the rating "adequate, but suboptimal" in so many categories that the phrase has become a joke among the MFK staff.
That it exists at all, says filmmaker Lori Dowd, "is a fucking miracle."
By the end of next year, Wolff hopes to build a new factory capable of producing enough of the peanut-butter supplement to be able to supply UNICEF and USAID, the two biggest aid organizations in Haiti. It's a project Wolff estimates will cost $2 million. MFK has raised half that sum already from grants and donations, and now that they have the land, they'll be able to break ground later this summer.
The current factory produces 22,000 pounds of medika mamba every month. Administrative offices and a large storeroom occupy the first floor of the two-story pink concrete house; the upstairs houses the peanut-butter-making equipment, a peanut-testing lab and packaging facilities. Nobody, not even Wolff, is allowed upstairs without first donning a hair net, a pair of paper booties and a lab coat.
The four-chamber, propane-powered peanut dryer dominates the courtyard. (It's so large, a full-grown adult can climb inside.) The peanut-shelling machine sits on a covered platform. Two workers sift through the shelled nuts by hand, looking for mold. There's also a machine shed and a small lean-to where a woman named Therese cooks lunch for all the workers.
The whole operation is hidden from the outside world by a concrete wall ten feet high and topped with barbed wire. On the other side, there's an open field where small children roam among oxen and cows, and squatters have built an open cooking fire on a pile of old tires.
The first step in making medika mamba is to dry and shell the peanuts. Then you roast them and grind them into a paste. In a large Hobart industrial mixer, you combine the powdered milk, sugar, oil and vitamins. Then you run it all through the grinder again to refine the sugar granules. The result is a sweet, creamy, gloppy substance that tastes remarkably similar to the product you can buy in an American supermarket.
No American peanut-butter manufacturer, however, produces batches as small as MFK's. All the equipment has been rigged to serve the organization's purposes: The Hobart, for instance, was originally intended to mix pizza dough. "It's from the head of Zeus," Wolff jokes, shuffling between the two tabletop grinders in her paper booties. "Nobody uses it but us."
In the final stage, three workers, dressed in dark blue hospital scrubs donated by Wolff's colleagues at Washington University, spoon the peanut butter in 1.1-pound quantities into plastic bags, seal them and place them, 40 at a time, into cardboard boxes, which will eventually be transported by truck to the distribution center in Port-au-Prince.
As always, there are problems. Recently, a batch of medika mamba had a very high aerobic count, meaning there were some foreign microorganisms within the peanut butter that made it vulnerable to spoilage. The whole batch had to be thrown out.
Wolff, who was in St. Louis at the time, takes the news calmly. Still, she bombards Ken Thercy, the systems engineer, with questions. Were some of the plastic bins in the factory contaminated? Did the staff close all the windows and doors? Did everyone change their clothes before they went to work?
Thercy isn't sure what happened, but he assures Wolff that subsequent batches have been fine. She extracts a promise that he'll check the pH content of the water every week to make sure it's not too acidic.
The good news is that the peanuts weren't contaminated with aflatoxin, a mold that thrives in hot, moist climates like Haiti's and can be deadly if ingested. Several years ago, hurricanes made dry storage almost impossible, and there were very few aflatoxin-free peanuts to be found in the entire country. In Popper and Dowd's documentary, there's a scene of Rhoads staring in despair at a pallet that holds $800 worth of bad peanuts.
"The board members said the project was over," Wolff remembers. "I said, 'It's not over. People need to eat.' I started calling aflatoxin experts in the U.S., and we set up a program for abating aflatoxin."
In the Haitian coutryside, farmers don't like to try new methods of peanut growing or experiment with fungicides.
"If you educate 400 farmers," Wolff posits, "ten will do it the way you taught them, and the other 390 will do it the way their father and grandfather taught them." But she understands: "If you're living on a shoestring, would you take risks? No."
Jamie Rhoads is MFK's ambassador to the farmers. He speaks fluent Creole, learned during a period in his late teens when he lived in a village in southern Haiti so remote it was only accessible by a two-hour hike through the forest. He has a longstanding love/hate relationship with the country. When, after he got his master's in agronomy from Cornell, Wolff asked him to come and work for MFK, it took him a month to say yes.
These days he travels to several towns within a one-hour radius of Cap-Haïtien and persuades local farmers to form peanut-growing cooperatives. "One person organizes all the farmers in the community and distributes the money," Rhoads explains. "It's easier than MFK going house-to-house."
Coeurcius Jonas leads the cooperative in Bas-Limbé, a 30-minute drive west of Cap-Haïtien. It's less a town than a collection of tiny houses nestled between the main dirt road and the fields. People draw their water from a pump in the front yard and hang their clothes to dry on trees.
Jonas grows corn and peas and, this year, peanuts, all mingled together so his fields look like gardens. His neighbors grow okra and cassava and sugarcane; only one has bothered to plow. "There's a mixed crop because they're hedging their bets," Rhoads says. The peanut plants, tiny and low to the ground, are good for filling up extra space in the fields.
"Peanuts are suited for Haitian growing conditions," Rhoads explains. "The soil is high in calcium, which is good for peanuts. But there's no winter, so there's lots of disease pressure, which is exacerbated by high temperatures and drought. They don't have post-harvest technology to dry and store the peanuts properly, so a tiny bit of mold will spread like wildfire."
Rhoads routinely consults with agronomists in the United States, and plans to try out new fungicides and maybe experiment with a new variety of peanut from India that has a shorter growing period.
This year Rhoads persuaded Jonas to allow him to spray fungicide over one of his fields. They planted the peanuts three months ago and, although the crop won't be ready for harvest for another four to six weeks, the two men walk out into the field for an inspection.
Rhoads finds a few rusty spots on some of the peanut leaves. "That's a sign of aflatoxin," he says, "but late-leaf spot won't do much damage." He pulls the plant from the ground. Damp white embryonic peanuts dangle from the roots.
Though the peanut plants in this field appear healthier than the ones that haven't been sprayed with fungicide, Rhoads is still unsure of the outcome. "Will one spray keep it down?" he asks rhetorically. "I don't know."
Wolff's ultimate plan is to set up a "farmer school" where MFK will till the soil and plant peanuts. Different plots will have different growing conditions, and the Haitian farmers will be able to see which strategy works best. Wolff wants to be strict: "We'll tell them, 'We will buy your peanuts, if you will do it right.'"
Shada is the worst slum in Cap-Haïtien. It sits on what used to be a mangrove swamp. Now there's a riverbank made of garbage. The air smells like the inside of a Dumpster, with top notes of human waste. Naked babies sit by themselves in the dirt alleys, playing in shit. No one in Shada has a job. No one goes to school. A little girl wearing nothing but a T-shirt dances for money. Her hair has turned red from protein deficiency.
Madame Bwa, the neighborhood midwife, has organized classes on hygiene and sex education, but she can't treat worms or tuberculosis or malaria. None of her patients can afford the 50-cent taptap fare to the Justinien clinic.
A doctor who comes to Shada holds office hours for two hours a week. It's not nearly enough. Usually there are more than 100 patients waiting to see him.
"It's hard to see kids die of malnutrition after getting called in the middle of the night to bring them into the world," Bwa says (in Creole, with Rhoads translating).
The Shada clinic rarely receives medika mamba. A 1.1-pound bag currently costs $2.50. Few residents can afford to pay for it, and MFK can't afford — at least, not yet — to donate it. In addition to the $2 million for the new factory, the organization requires $66,000 a month just to stay afloat.
"We need to keep growing," says Steve Taviner, MFK's director of development, who works in the St. Louis office. "This is what makes the new factory imperative. We've hit the wall for how much we can make. With the new factory, we can make four or five times as much more cheaply and efficiently. In five years, we want to be the primary supplier of RUTF in Haiti."
Though MFK's sales have been steadily increasing, Taviner says they only account for one-third of the organization's overall revenue. Most of the funding still comes from donations, from places like Google, Nestlé, Christian World Relief, the Macaulay Foundation, Novus International, Scottrade and Emerson Electric. Inmates and employees at three federal prisons in Illinois read about MFK and raised $2,200.
"In many ways, ironically, the earthquake was a remarkable opportunity," says Taviner. "It raised lots of interest and funds. The phone was going nonstop. We've raised $1 million since January 12."
Wolff is still looking for donors.
"I almost got on Oprah," she wisecracks, "but they went for star power and went with Wyclef Jean instead. God knows why." She continues more seriously: "The development business is very complicated. It's not filled with altruistic people. But there are people within it who are altruistic. We need to find those people and have them pull the levers."
Six weeks ago, though, Wolff decided she needed to take a more radical step. The day after the land purchase was delayed, she got on a plane to Rouen, France, to meet with executives from Nutriset, the parent company of Plumpy'nut, MFK's chief competitor in Haiti.
Nutriset once owned a 50 percent interest in Vitaset, a Plumpy'nut franchise in the Dominican Republic. "I made everybody feel bad about importing from the Dominican Republic," Wolff says. She's not entirely joking. But now Wolff wants to talk about becoming a Nutriset franchisee.
Working with Nutriset would give Wolff access to UNICEF and USAID. "Plumpy'nut taught UNICEF everything about RUTF," she says. "UNICEF takes its orders from Nutriset. We're trying to get the best deal we can."
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In order to do that, Wolff is willing to compromise. MFK will start using Nutriset's peanut-butter recipe, which contains slightly different ingredients, including special stabilizers. "It's a trade secret," Wolff says. "We'll never find out what they are." The size of the peanut butter packets will also shrink. Instead of 1.1 pounds, they'll be .2 pounds, the same size as Plumpy'nut's.
"Nurses prefer the bigger packets," Wolff says. "That way your neighbors won't ask you for [an extra packet]. You're not supposed to share. But UNICEF is the biggest buyer in the world."
More significantly, MFK will have to alter its plans for the new factory to meet Nutriset's production demands, which means more equipment and more training for the workers.
"It's the way to a sustainable future," Wolff says. "We're having growing pains, but we need to make it happen. It's a bigger and more complex vision than we had before. It's kind of exhausting, but it's never boring. Boring could be worse."