Cherokee Nation citizen Stacie Guthrie receives a flu shot from licensed practical nurse Sharon Morton at the Gadugi Health Clinic in Tahlequah, Okla. JAMI CUSTER/CHEROKE PHOENIX

Influenza hits CN but vaccines still available

Nationwide, during the week that ended on Jan. 12, 4.6 percent of patient visits reported to the U.S. Outpatient Influenza-like Illness Surveillance Network were due to influenza-like illness. This percentage is above the national baseline of 2.2 percent. CENTERS FOR DISEASE CONTROL By Jan. 12, the Centers for Disease Control reported that the flu had reached 48 states and influenza activity remained elevated in the United States. CENTERS FOR DISEASE CONTROL To help fight against influenza and inform people about the virus, Dr. Jorge Mera, of Cherokee Nation Health Services, provides a presentation on Jan. 18 in Tahlequah, Okla. TESINA JACKSON/CHEROKEE PHOENIX
Nationwide, during the week that ended on Jan. 12, 4.6 percent of patient visits reported to the U.S. Outpatient Influenza-like Illness Surveillance Network were due to influenza-like illness. This percentage is above the national baseline of 2.2 percent. CENTERS FOR DISEASE CONTROL
02/01/2013 08:01 AM
TAHLEQUAH, Okla. – With more than 230 people testing positive for influenza within the Cherokee Nation, officials say tribal health clinics have vaccines available and urge people to get one.

Flu is a contagious respiratory illness caused by viruses. It causes mild to severe illness, and at times, leads to death. Some people, such as older people, young children and people with certain health conditions, are higher risks for flu complications.

“The flu is a virus and viruses are very, very smart you might say,” Dr. Roger Montgomery, CN medical director, said. “They change themselves every year and try to morph themselves so they can have a better success of causing illness. And there are also different strains out there, and so the CDC tries to come up with an idea of what strains of virus will cause illness each year and the vaccine has three different kinds of strains of virus in it.”

According to the Centers for Disease Control, this flu season has produced a high outbreak with more than 3,600 people hospitalized since October, most of them older than 65, and at least 20 children’s deaths.

By Jan. 12, the CDC reported the flu had reached 48 states and activity remained elevated. On average, 5 percent to 20 percent of the population gets influenza. This season, it’s hit more than 30 percent.

According to the Oklahoma State Department of Health, flu season began on Sept. 30. Since then there have been more than 500 related hospitalizations and eight related deaths in the state.

There are three types of flu viruses: A, B and C. Types A and B cause the epidemics that have up to 20 percent of the population sniffling, aching, coughing and running fevers. Type C also causes flu, but its symptoms are less severe.

The Type A virus constantly changes and is spread by infected people. Type B flu may cause a less severe reaction, but occasionally it can still be harmful. Type C viruses are milder than type A and B. People generally do not become extremely ill from them and they do not cause epidemics.

The flu usually starts suddenly and may include fever or feeling feverish/chills, cough, sore throat, runny or stuffy nose, muscle or body aches, headaches, fatigue and tiredness. Some people have vomiting and diarrhea, though it’s more common in children.

Some complications caused by flu are pneumonia, dehydration and worsening of chronic medical conditions such as heart or lung disease, asthma or diabetes. Children may get sinus problems or ear infections.

“The deaths that you see reported are not really from the virus itself. They’re from the super-imposed illness that occurs after they’ve had influenza that causes them to develop respiratory failure and pneumonia,” Montgomery said.

The flu spreads by droplets released by coughing and sneezing. Occasionally touching something with a virus on it and then touching the mouth or nose may cause infection. People with the flu can spread it to others up to about six feet away.

“That’s why we emphasize if you’re out there going to work, going to public places, touching objects that other people touch don’t take your hand and rub your nose without first washing your hands thoroughly and wash them frequently,” Montgomery said.

People with flu are contagious and can infect others beginning one day before getting symptoms. Adults remain contagious up to seven days after getting sick, and children can remain contagious even longer.

“If you came in contact with the person who had the flu, you’ve contracted the virus,” Dr. Sohail Khan, of CN Health Services, said. “Within two days you will start to develop symptoms, and the important thing to remember is that you can be infectious for the next five to seven days.”

The best way to prevent the flu is vaccination. The vaccination rate for the American Indian/Alaskan Native population is 29 percent, according to Indian Health Services.

“I think as a group, because the prevalent of diabetes is so great, that it’s just recommended broadly that all Native Americans be vaccinated,” Montgomery said.

According to WebMD, the vaccine is highly effective for preventing the flu, though not 100 percent. People can get the flu despite getting vaccinated, although it’s usually less severe and resolves quicker. According to the CDC, vaccines given this year appear to be about 62 percent effective overall. Of people who got the flu, 32 percent were vaccinated.

“It can either completely eliminate you from having any symptoms at all or it can, the word we use is, attenuate,” Montgomery said. “It can lessen the severity of the duration of symptoms that you have.”

There are two types of vaccines: the shot and nasal spray. The shot is contains a dead virus that’s given with a needle. The shot given in the muscle is for people older than 6 months, including healthy people and people with chronic medical conditions. The shot given below the skin is for 18- to 64-year-olds.

The nasal spray vaccine contains live, weakened viruses. It’s for healthy people ages 2 to 49 who are not pregnant. Neither vaccine causes the flu.

It takes about two weeks for antibodies to develop that protect against infection for the entire year. Flu vaccines will not protect against illnesses caused by other viruses such as the common cold.

If positive for flu, there are antiviral drugs that can be used to treat the illness.

“The main one that most people have heard about is called Tamiflu,” Montgomery said. “It’s most effective if you start it within 48 hours of the onset of your symptoms.”

Annual vaccination is recommended for everyone regardless of past vaccination status or flu infection. Vaccination should begin in September or as soon as the vaccine is available and continue throughout the flu season, which can last as late as May.

To view a CN Health Services flu presentation, visit
and click on influenza presentation.

918-453-5000, ext. 6139


Tahlequah Daily Press
06/29/2016 08:30 AM
HULBERT, Okla. – A date to the prom with someone special is a dream shared by many girls and boys, and one that recently came true for Cherokee Nation citizen Paige Walls. The Hulbert High School senior expected her dad to be her escort to prom, but when he couldn’t get off work, another stand-in was given a written invitation with “yes” and “no” boxes to check in reply. Dr. James Lewis, a W.W. Hastings Hospital pediatrician, said he didn’t hesitate to say “Yes” to the young girl who calls him “Dr. Grandpa” while on a follow-up visit. Lewis has been the 18-year-old’s pediatrician since birth, when she was diagnosed with CDKL5, a rare neurological seizure disorder. Children with CDKL5 all have developmental delay and Paige can’t communicate. “I was blown away, very honored,” said Lewis. “I said ‘I’d love to.’ She’s part of the family. I even did a house call when she was so sick.” Paige’s mom, Mona Walls, said Lewis was the “next best thing” because he’s been in her life so long. “He loves her just like a granddaughter,” said Mona, who crafted the written invitation. “It’s probably a little old fashioned, but I wanted Paige to be able to ask him. She handed him the invitation.” Lewis read it out loud to Paige. “Mona deserves all the praise. She has taken her everywhere for help, from Houston to Memphis, and taken training in epilepsy. When Mona says ‘Jump,’ I say ‘How high?’ She’s very knowledgeable,” Lewis said. He said the invitation reminded him of his high school prom at Tulsa Edison in 1964. “She even offered to pick me up,” Lewis said, “but I live just up the street so I hopped into the little bug and met her there.” For this special occasion, a purple corsage in the school colors was given to his date and Lewis received a boutonniere when they met that evening. “It was a fun evening. I escorted her inside. We had our picture taken by an old car and lots of kids came up and said ‘Hi,’ and gave her hugs,” Lewis said. “We had a delicious meal of steak and chicken. An amateur magician was the entertainment.” Mona was also in attendance, but scooted a little away from her daughter and date at dinner so they could have “their time.” “I think she was excited. She was aware she was on a date with him,” Mona said. “While they were watching the magic show, she was holding his hand. When he let go she got a little irritated so he held her hand again. She was happy.” Gratitude is what the Walls family felt. “I was glad she was able to experience that. He made her feel very special,” Mona said. “We were honored he took her. He’s so selfless.” “Dr. Grandpa” also was greeted by many of his patients with “Hi, Dr. Lewis.” “In that 17- and 18-year-old crowd there were some Joe Cool types,” Lewis said, “and girls wearing prom dresses and gowns, and guys in cowboy hats, boots and string ties.” He saw friends and a former neighbor, Marilyn DeWoody, superintendent of Hulbert Public Schools. “I hadn’t seen her in ages,” he said. “She thanked me for taking Paige.” The two also shared a wish for special needs people because once the students reach 18 years old and graduate, there’s nothing for them, such as services during the day. “I wish the tribe would consider a respite center for the handicapped to go to during the day with recreational, physical and occupational therapy, a teacher, a great classroom, activities and other people too,” Lewis said. “There’s a bunch of vacant buildings in town for rent.” Mona agreed, saying she doesn’t know what she’ll do with her daughter now that she’s graduated. “She loves music and quality time with people and art. If someone would do it two hours a day a couple of days of week that would be great,” she said. At prom, when the magician finished, it was after 8 p.m. and they took more pictures. “A lot of people came up to her and took pictures with her,” Mona said. The dance started next, which signaled it was time to call it a night. It was Lewis’ first time to be a prom escort, although he’s attended many high school graduations. “It was sort of cool. I had a great time,” he said. <strong>– Reprinted with permission from the Tahlequah Daily Press</strong>
Special Correspondent
06/28/2016 12:00 PM
TAHLEQUAH, Okla. – The Cherokee Nation is blazing a path in hepatitis C treatment with a project that is curing Cherokees infected with the disease. At the project’s center is Dr. Jorge Mera, infectious diseases director, who in October founded a hepatitis C elimination project. The CN has the first health organization in the country to start such a program, he said. “But before the elimination program we started addressing the problem in 2012 through September of 2015 with increased screenings other patient care,” Mera said. The project has screened 12,000 Cherokee patients for hepatitis C, and among those testing positive, more than 300 have been treated and are considered cured of the infection that causes liver disease, officials said. That project earned Mera the distinction of being honored in May at the White House ceremony on National Hepatitis Testing Day. “The award is a wonderful recognition from the White House to all the Cherokee Nation providers, health professionals and administration for making this program a success in changing lives and combating hepatitis C,” Mera said after the ceremony. “We have a lot of work ahead, but I think we have made the invisible epidemic, now visible.” An estimated 3.5 million people have hepatitis C, according to the U.S. Health and Human Services. According to a CN press release, the number of hepatitis C-related deaths reached an all-time high of 19,659. However, Mera said, patients are now being treated with Food and Drug Administration-approved hepatitis C virus antivirals. “The cost of a treatment varies, but a treatment may cost from $52,000 to over $100,000 depending on the combination of drugs used,” Mera said. “Of the patients who have completed treatment we have a cure rate that is around 90 percent.” The program’s protocol follows the American Association for the Study of Liver Disease and Extended Community Health Outcomes recommendations. “No patients have died while receiving antiviral drugs but several patients have died of end stage liver disease either before they received treatment or after they completed treatment,” Mera said. No hepatitis C vaccine exists, but there is ongoing research to develop one, he said. “It is the No. 1 cause of mortality of the reportable infectious diseases in the United States,” Mera said. “It causes more deaths than the other 59 diseases combined.” Mera said in the United States more that 70 percent of the infected are in the Baby Boomer Generation, people born between 1945-65. “In Cherokee Nation the patients we are detecting now have an average age of 44,” Mera said. “Around 50 percent of our patients are in the Baby Boomer age group but the other half is younger.” Within the elimination program, there are research studies regarding transmission risk factors in the CN population, Mera said. The highest risk of contracting hepatitis C is probably in people who inject drugs by sharing contaminated needles, syringes or paraphernalia used during the injection process and having unprotected sex with an infected partner, he said. Treatment of patients with substance abuse disorders is also important because this will decrease their chances of using drugs. So having behavioral health, rehab services and opioid substitution programs are also important parts of prevention. “Also, tattooing is a possible risk factor so only getting tattoos done by professionals who are licensed,” Mera said. Treatment of infected patients also is a form of prevention because once a patient is cured he or she cannot transmit the infection, he said. “Most patients are asymptomatic,” Mera said. “When symptoms appear it usually is a manifestation of advanced liver disease or liver cancer.” Screening is the key to early detection of the disease, he said. Eighty-five percent of patients will develop a chronic infection and between 20 percent and 30 percent will develop cirrhosis of the liver, he said. <strong>Facts About Hepatitis C</strong> • Hepatitis C can begin as acute infections, but in some people, the virus remains in the body, resulting in chronic disease and long-term liver problems. • Hepatitis C ranges in severity from a mild illness lasting a few weeks to a serious, lifelong illness that attacks the liver. It is spread primarily through contact with the blood of an infected person. About 75 percent to 80 percent of people infected with the virus develop chronic infection, a long-term illness when the virus remains in a person’s body. It can lead to serious liver problems, including cirrhosis or scarring of the liver or liver cancer.
06/27/2016 04:00 PM
OKLAHOMA CITY (AP) – The Cherokee Nation has been awarded a $1 million grant as part of an effort to get more children enrolled in federal welfare programs for which they are eligible, federal officials announced on June 13. The Center for Medicare and Medicaid Services announced the Tahlequah-based tribe is one of 38 recipients from 27 states to receive part of the $32 million in awards that are called Connecting Kids to Coverage grants. The money is aimed at enrolling eligible children in Medicaid and the Children’s Health Insurance Program, or CHIP, which is another program that provides health coverage to children. “Unfortunately, the Cherokee Nation has 22 percent of their (eligible) kids who have not signed up,” Principal Chief Bill John Baker said. “This million-dollar grant gives us the opportunity to do more outreach, to get in the communities, to PTA meetings, school functions, maybe even some billboard advertising, things like that to educate and make more of our citizens aware that this health care is available to the kids. Baker said because CN citizens who live within the tribe’s boundaries already receive free health care at tribal clinics, they may not be aware that they also qualify for federal programs like Medicaid. The CN was the only Oklahoma recipient in the latest round of awards, which specifically target vulnerable populations, including teenagers, children in rural communities and Hispanic and American Indian children, said Victoria Wachino, director of CMS’ Center for Medicaid and CHIP Services. “Today’s announcement means more children will have access to coverage early in their lives which will help them grow into healthy adults, succeed in school and reduce financial burdens on their families,” Wachino said. Figures released on June 13 by CMS show more than 710,000 Oklahoma children enrolled in Medicaid and CHIP programs in 2015, an increase of nearly 2 percent from 2014, but still below the national average of 2.5 percent. “Since the passage of the Affordable Care Act, the rate of uninsurance for children has declined to its lowest levels on record,” U.S. Secretary of Health and Human Services said. “Fewer than 1 in 20 children are now uninsured.”
06/10/2016 12:00 PM
WASHINGTON – A Cherokee Nation physician was honored at the White House on May 19 for the tribe’s commitment to testing and treating patients for hepatitis C, which has led to more patients being cured of hepatitis C and living longer lives. Acting Assistant Secretary of Health Karen B. DeSalvo presented Dr. Jorge Mera, CN infectious diseases director, his award during a White House ceremony in observance of National Hepatitis Testing Day. “The award is a wonderful recognition from the White House to all the Cherokee Nation providers, health professionals and administration for making this program a success in changing lives and combating hepatitis C,” Mera said. “In the last couple of years we have tested thousands of patients and cured hundreds who suffer from the hepatitis C virus. We have a lot of work ahead, but I think we have made the invisible epidemic, now visible.” The CN, thanks in large part to Mera, began a hepatitis C elimination project in 2015. The tribe executed plans developed by the U.S. Centers for Disease Control and Prevention. To date, the CN has screened more than 12,000 Native American patients for hepatitis C. Among those testing positive, more than 300 have been treated and are considered cured of the infection that causes liver disease. “At Cherokee Nation we are diligently addressing hepatitis C infection within our tribal population. We are able to do that because of the ongoing partnership with the CDC, and I thank Dr. Mera and his team for their work. It is a pioneering effort and I am proud we are making great strides,” Principal Chief Bill John Baker said. “Indian people face a huge disparity in the rate of contracting hepatitis C in America, but through our efforts we are educating our citizens and systematically fighting, and even curing, hepatitis C. Hopefully, these best practices will soon be replicated across Indian Country.” An estimated 850,000 Americans have hepatitis B and 3.5 million have hepatitis C, and fewer than half are aware of their infections, according to the U.S. Department of Health and Human Services. Since 2012, deaths associated with hepatitis C outpaced deaths due to all 60 other infectious diseases, and in 2014, the number of hepatitis C-related deaths reached an all-time high of 19,659. National Viral Hepatitis Testing Day is an annual CDC-sponsored observance. This year, the HHS collaborated with the White House Office of National AIDS Policy and Office of National Drug Control Policy for the Hepatitis Testing Day event to highlight the impact of viral hepatitis in the United States. It is the first year the HHS presented awards to organizations testing for hepatitis. Other health organizations recognized were from Hawaii, Rhode Island, New York, New Jersey, Washington, D.C., San Diego, Dallas and Wyoming. “Increasing testing for hepatitis B and C is a critical part of ensuring good health for all Americans,” DeSalvo said. “With coordinated efforts by diverse partners like those being recognized…we can reduce deaths and disparities in hB and C and improve the lives of people living with chronic viral hepatitis.”
Reporter – @cp_sguthrie
06/03/2016 08:15 AM
KENWOOD, Okla. – The Cherokee Nation’s Trust Land Kenwood Units have plants such as Trillium, which contain medicinal properties, and Buckbrush, which can be used for making baskets. Pat Gwin, administrative liaison, said the approximately 160-acre Delaware County tract, which is not accessible to the general public, is home to culturally significant and medicinal plants. “We might have hit five acres of it and we saw this list of what is twentyish really important plants, so that’s a neat tract,” he said. While on the tract, Gwin spotted Trillium, a short-lived medicinal plant. “A lot of Cherokee medicinal, cultural food plants only grow in like a two-to-four-week window here in the spring, and Trillium is one of those. It’s a medicinal plant and there are years when it is very prevalent and there are years when you can’t find it very often,” he said. Gwin declined to comment on the plant’s medicinal purposes for safety reasons. He suggested people wanting to use medicinal plants seek a Cherokee medicine person. He did the same for May Apple, which he also found. “May Apple was another one of those medicinal plants, cultural-use plants. The strange thing about the May Apple is that it was used for a lot of cures that western medicine hasn’t really done a lot of research on or is just now starting to do some research on. If you go to other parts of the world it’s been used for a lot of the same medicinal uses that the tribe has for centuries,” he said. He said another plant he saw was Sassafras, which was used as a blood thinner. “Sassafras, its medicinal qualities have been made known for a longtime. It’s used as a blood thinner,” he said. “Today, it’s got some controversy surrounding it because one of the main ingredients, the Safrole Oil, is a carcinogen, so there’s a lot of warning out there for people that do partake of it do so in moderation. It has three distinct leaves. It has the sock that’s the round leaf and then it has the mitten and then it has the glove. No other tree has that so I think that’s pretty cool.” Other notable plants found were Wild Ginger, which Gwin said is used as a food additive and for medical purposes; Solomon Seal, which he said “highly skilled Cherokee healers” would have used; and Green Dragon, which Gwin said is kin to Jack-in-the-Pulpit and used for medicinal purposes. Gwin also found Sochan, a plant offered through the tribe’s Seed Bank Program. “(It’s) one of the traditional Cherokee greens that’s eaten in the spring,” he said. “You might say it’s somewhat a kin to Watercress, but most people don’t know that Watercress probably isn’t even from North America.” He said another plant in the area that is culturally important is Buckbrush. “Buckbrush would have been the one they (Cherokee baskets weavers) used,” he said. “A lot more difficult than Honeysuckle because it just doesn’t grow as long.” Gwin said most of these plants would be found in “low-lying wetland areas.” “One of the things that when you look for areas that are going have a lot of Cherokee plants you have to think at a couple of things. Cherokees always needed water,” he said. “A significant number of those plants would be found in those low-lying wetland areas, which environmentally, those are sensitive areas.” Gwin said it’s important for Cherokees to know about plants that are important to their people. “There were a couple of things that our ancestors told us that we had to retain in order to be Cherokee. Obviously one of them was language. Obviously one of them was the ability to grow our own food. The ability to utilize and respect plants was another one of those things,” he said. “The Cherokee homeland is a very diverse plant environment as is northeastern Oklahoma. I always found it interesting. The relocation could have been far worse than what it was, but they stopped here in northeastern Oklahoma where we may not have all the same plants as we did back there but, for example Jack-in-the-Pulpit, very cultural Cherokee plant, very prevalent back East, not so much here but we have the Green Dragon, which…it’s so close in relation.” He said he plants are some of the things that helped Cherokees thrive in the modern CN. “Even now we might not have the exact same plants. We have very, very close cousins, kins to them. That’s one of the things that I always thought allowed us to, once we got here, build up the tribe as quickly as we did,” he said. “I’m not sure any other population on the planet would have been able to survive that but that was one of the things that we were able to do, and I truly think the plants was one of the reasons for that.” For information about Cherokee-important plants or to tour the tribe’s Garden and Native Plant Site, email <a href="mailto:"></a>.
Special Correspondent
05/27/2016 09:00 AM
TAHLEQUAH, Okla. – With international health officials sounding the alarm, Cherokee Nation Public Health officials are preparing for the Zika virus. Earlier this year, the CN was one of three tribes to participate in the Centers for Disease Control’s Zika summit in Atlanta. Lisa Pivec, Public Health senior director, said while the CN’s jurisdiction is considered to be a low risk for an outbreak, plans and partnerships with the Oklahoma Department of Health and the CDC are in place as a proactive measure. “The most important thing for us right now is getting a process in place,” she said. “The CDC has been great about helping us with that. We’ve seen what they’ve done with other infectious diseases, and they’re great about helping us get that done at the local level.” For now that process involves keeping current information available to the public through and maintaining regular contact among epidemiologists, communications professionals and environmental health specialists with all three entities. As part of that partnership, any testing for the virus conducted at the tribe’s facilities is at no cost to the CN. Samples taken for testing are sent to the state health department’s offices in Oklahoma City and to the CDC in Atlanta where the actual test will be conducted. So far, no tests have been submitted from a CN health facility, but Dr. David Gahn, Public Health medical director, said the tribe would be immediately notified if that changes. According to the Oklahoma Department of Health, as of May 5, four cases of Zika had been reported statewide. All four were caused by travel to one of the more than 40 countries with a reported case of the virus. The most common symptoms are fever, rash, joint pain, muscle pain, headaches and conjunctivitis. However, with the incubation period estimated at up to seven days, only 20 percent to 25 percent of those infected with the virus show any symptoms. No vaccine is available. The people highest at risk of contracting the virus are men and women who have traveled to one of the countries or U.S. territories on the CDC’s advisory list. Pregnant women are considered particularly vulnerable due to the virus’ link to birth defects, including microcephaly, stunted fetal growth, vision problems and hearing problems. “Most people who get Zika don’t really get ill,” Gahn said. “Among those who do, it’s very rare for even children to need hospitalization.” The virus is also linked to an increased risk for Guillian-Barre syndrome, a disorder in which the body’s immune system attacks part of the peripheral nervous system. However, the CDC and other epidemiologists have not determined what causes the connection or which populations are more likely to be at risk of developing Guillian-Barre as a side effect of the Zika virus. “We don’t know what’s the risk yet, as in how many people who are infected with Zika will get and which ones,” Gahn said. “We just don’t know the risk factors yet. Does it go after older people? Men? Women? Teenagers?” Although the virus can also be spread through unprotected sexual contact with an infected man, many of the preventative measures being touted to the public are aimed at its other means of transmission: mosquitoes. As a mosquito-borne virus, many measures used to curb the spread of the West Nile virus are equally effective against Zika. Along with the use of an EPA-registered insect repellant, wear long-sleeved shirts and long pants whenever possible and citizens are encouraged to not leave doors and windows propped open unless covered with a properly maintained screen. Additionally, mosquitoes can be kept at bay by not leaving standing water around the home. Birdbaths, rainwater collectors, kiddie pools, trash cans and other containers that could potentially hold water should be emptied out at least weekly, as mosquitoes lay eggs in standing water. Cracks or gaps in septic tanks should be patched and any exposed vents or plumbing pipes should be covered. More preventative measures are available at <a href="" target="_blank"></a>. The two main species of mosquito that carry Zika, Aedes aegypti and Aedes albopictus, are generally not found in Oklahoma. However, that has not deterred officials with tribe’s health department from encouraging CN citizens from taking a proactive approach to prevent Oklahoma’s first mosquito-borne case from arising in the jurisdiction. “For us, it’s about putting together the best plans we can based on risk levels and being as responsive as possible without creating worry or concerns that are not warranted,” Pivec said. “We know that we’re prepared if the situation changes.”