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Emigration: Access is more than just medical access, it’s also about business

As Ireland continues to enforce prohibition, we meet Aoife McConnell who has moved her yoga business to Spain

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Access: A red Irish passport on top of a blue covid mask with a stop watch on top to highlight emigration

In a new series, Cannabis Health News talks to people who have experienced emigration in search of safe, legal cannabis access.

Read last week’s story here

Previous stories have focused on the difficulty of packing your entire life into boxes and emigrating with your family to a new country for access. But there is more to Irish prohibition than patients and access, it’s the loss of local businesses moving abroad.

In our fourth instalment, we speak to yoga expert, Aoife McConnell about moving her life and yoga business, Puff Puff Pose to Spain.

Aoife left Ireland during the summer of 2021 so has only recently arrived in Granada. She packed her entire life into boxes to get better access to cannabis and also, set up a yoga studio with a difference. She runs the popular, Puff Puff Pose, cannabis yoga studio which encourages practitioners to combine relaxing yoga with cannabis. The studio went online during the pandemic but she hopes to be able to establish a physical space now that she has left Ireland.

Safe, legal access abroad

Like most people in Ireland, her use started as recreational when she shared cannabis with friends. While she acknowledges the recreational side, she says she gets all the benefits of cannabis.

Prohibition in Ireland, and all over the world means that most people when they consume cannabis, often they have no idea what they are actually being given. Unlike legal states in America where someone can select what they need and know the THC or CBD content of a strain. Once Aoife became involved in the community, she realised how prohibition also stifles education about the plant.

Her use is mainly recreational however, while in Ireland she was forced to run her cannabis yoga business online or outdoors as it was illegal.

“In the last two or three years, I’ve become a lot more involved in the community of cannabis. Before then, I had no idea that were even strains of cannabis like Indica or Sativa. You were given what you were given. There is no source of understanding because there is no education around the whole thing. It could have been anything in a bag as we wouldn’t know the difference.”

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She added: “When you realise they actually have completely different profiles or effects then that matters for someone who needs the plant for medicinal purposes. It matters how it’s grown, taken care of or what the product actually is. I think it was just teenage ignorance but I didn’t even think of the fact there was so much to it. You just take what you are given and like it.”

Access: A woman with dark hair laughs against a dark background

Finding a space

Prohibition meant her classes were unable to find a space despite their emphasis on wellness and relaxation. Aoife began to consider the longevity of her business especially as COVID rules relaxing meant people were starting to look for offline classes again. She realised it was time to leave Ireland.

“I’ve been doing my classes mostly online or outdoors because it’s unregulated or illegal. It’s hard to get into a space to facilitate those classes. I wondered where I could go in Europe that could facilitate those classes. The Netherlands are starting to pull back their laws a bit and get more strict, especially after COVID so you never know how they are going to react. Spain is moving in the opposite direction.”

The global cannabis industry is expected to reach $90.4 by 2026 thanks to the growing acceptance of cannabis consumption along with the medical side. This is everything from edibles to dispensaries to products. Ireland currently allows CBD and medical cannabis but the recreational side is still illegal. The current systems in place for medical cannabis are not functional with the MCAP program yet to even start despite being introduced in 2019.

It has been highlighted that the tax and profits raised by a legal recreational system could contribute to some of the financial problems experienced by the country. Legal systems in countries such as Atlanta Georgia, California and Massachusetts have proven to be successful. Sales in Massachusetts recently topped $2 billion which is almost double what the state reported in November 2020. Cannabis was legalised for adult use in late 2018.

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Access to the Spanish model

While Spain has legalised the growth of up to two plants in your own home, there are still issues with the system. There have been reports of cannabis clubs, where it is legal to consume cannabis, being potentially closed. But for the meantime, a patient must sign to say they are addicted to cannabis and a resident before being allowed entry to one of the clubs.

“There are a lot of regulations around the clubs. You have to sign an affidavit to say you are addicted to cannabis and seeking out the club to facilitate your addiction. You have to say the club is not enticing you or advertising in any way. Most of them look like a door and you wouldn’t even know apart from the smell.”

Once you are inside, there is a loophole that allows this club to operate as cannabis is a ‘hobby.’ The illegal part is the buying and selling of the cannabis. I’m not sure where the government thinks they are getting this cannabis from. So I started to think that Spain was where I wanted to be.”

Access - a cbd topical on a wooden surface with other herbs around in glass jars

Deciding where to go in Spain was easy. Aoife had a friend based in Granada in the south so she chose to go there. She visited during the summer and fell in love with the architecture, history and feel of the city. She felt it was the perfect place to move the business. Aoife also teaches English online so her day job was perfectly suited to moving abroad.

“I quit my job and went on a tour of Europe. I’m still settling in here and learning the siesta way of life. But so far so good. There are a lot of experts here and everyone understands where I am coming from so they are very helpful.

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Aoife highlights how the leap into the unknown is often the hardest part of emigration. She feels she has never been this self-sufficient. Her day starts with tutoring online to pay bills but she will be opening the yoga business soon. In an unusual move, Aoife’s previous experience was as an airline hostess.

“It’s exciting to be stepping out and owning my own business. I’m still terrified about it but also really excited. I used to work for an international airline, Emirates when I lived in Dubai. I travelled everywhere. I was always looking for a studio or thinking about building my own.”

“I struggled to make friends in yoga class especially when moving to a new city. In my classes, at the beginning, we always consume together then chat. I’ll always bring orange juice, kombucha and biscuits. We sit around for as long as people want. It’s a real community-building atmosphere.”

Time to leave

Aoife is proud to be Irish but explains the problems with the country mean she is not thinking about staying.

“I love the fact I’m Irish and that part of my personality. I would love for my kids to have that much Irish in them. I couldn’t afford to live there as we are being priced out of the country. I couldn’t afford the type of lifestyle I would like to have. It’s ridiculous. The fact that we didn’t have a green passport for so long. We’re the only country in the EU who weren’t ready when that was rolled out speaks volumes.”

Read our previous stories on emigration here: “I would tell people if they are thinking about it, to go as you’ll get better access.”

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How do I access a medical cannabis prescription?

Two experts discuss the process of accessing a medical cannabis prescription

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Medical cannabis prescriptions: A pair of hands being held out. One hand has pink and blue pills in the palm and the other has cannabis flower. The person wears a white lab coat

Curious about accessing a medical cannabis prescription? It can be difficult to know where to start or what to expect.

Cannabis Health News editor, Caroline Barry, who has a medical cannabis prescription for ADHD, and Dr Jean Gerard Sinovich, medical director of the Cannabis Access Clinics discuss how the process works.

When I decided to get a medical cannabis prescription, I had exhausted all the other options. I had tried prescription drugs for ADHD like Ritalin with little success over my teenage years before moving to various therapies as an adult.

I tried holistic approaches such as acupuncture or CBD which improved my sleep and anxiety but did little to my hyperactivity. Eventually, I reached out to the NHS for medication before having no luck.

Prepare your paperwork

I found a clinic in the UK that offered cannabis prescriptions for ADHD and reached out to them for assessment. The first thing I needed to do was collect my paperwork. As I already had my diagnosis from a psychiatrist, I needed to get proof of this along with which medications I had had over the years.

Dr Sinovich said: “To be assessed for medical cannabis, you need to apply to a clinic either directly or through your GP. We normally advise people to get a full medical history from the GP as to what medications they tried in the past. The person is assessed on an individual basis to find out what the patient is presented with and who specialises in that.”

He continued: “The aim of medical cannabis is to improve your pain, sleep and mood. Patients would have had to have tried other conventional medications for their conditions. If they have exhausted most possibilities and avenues then they could be assessed for medical cannabis. It doesn’t mean that every patient who comes to the clinic is prescribed cannabis.”

Prepare for your assessment

When it was time for my assessment, I was actually really nervous. When you are speaking to doctors, it can be extremely nerve-wracking to accurately get across the level of pain or discomfort you are in. I find that because my ADHD is not visible, I worry about being believed or qualifying for medication. Having had no luck with conventional medications, I was worried that this was my last resort and I wouldn’t get a prescription.

My assessment was with a psychiatrist online. A lot of medical cannabis clinics are based in London which I am not. It’s one of the few positive things to come out of Covid-19, that we have held on to telemedicine.

My appointment was very thorough, but none of the questions were difficult. The feeling of relief when the doctor said he thought I qualified was immense.

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Dr Sinovich added: “The consultation process normally lasts anything from half an hour to 45 minutes where we go through the medical history, what their aims are, their views and why they decided to access cannabis at this stage in their life. We also have to make sure there are no possible interactions with any of the other medications.”

Medical Cannabis Prescriptions: A doctor in a white lab coat signed a prescription. In front of him, there is a yellow bottle with oil in it next to CBD capsules and a cannabis bud

Costing out medical cannabis prescriptions

Dr Sinovich highlighted one of the key issues with accessing medical cannabis which patients need to be aware of – the cost.

“The most important thing is that it’s not [widely available on the NHS] so it’s all privately funded. People must be aware of the costs that it entails,” he said.

“It takes time for cannabis to work, it’s not overnight. It can take a good six to eight weeks and you need to follow up continuously to make sure there are no side effects.”

Affording medical cannabis can be difficult as there are few options available for support. Despite cannabis being legalised on NHS three years ago, there remains only a handful of prescriptions which have been written.

Project Twenty21 can help with capped prescription costs as long as patients can qualify for the conditions listed and have a history of two or more prescriptions that have proved ineffective. They have recently launched a student scheme aimed at helping patients affording medical cannabis while on a college-friendly budget.

The cost of medical cannabis tends to be dose-dependent. Cannabis Access Clinic estimate that the average cost of cannabis prescriptions in the UK is around “£150 to £250 per month for a THC and CBD inclusive prescription.”

A CBD only prescription is listed as being on average £100 to £150 a month although they note that some epileptic disorders will require much higher doses.

Patients also have to take into account the consultation fees which can vary from £100 to £200 depending on the clinic. Integro Medical Clinic lists their initial consultation at £95 to £195 with repeat consultations at the same price. Patients are also monitored through online questionnaires about their moods.

Medical cannabis prescriptions: A hand in a black rubber glove holds a small glass jar of cannabis flower

Speaking to your GP

When it comes to speaking to your doctor about a decision to try medical cannabis, they may not be supportive. If a patient prefers not to speak to their GP about it, they can ask for a copy of their medical records and self-refer.

I spoke to my GPs in both Ireland and the UK. While I had a positive reaction from my English GP who was interested in what effect this would have, my Irish GP was not as supportive. He was dismissive of my seeking medication as an adult in general so the medical cannabis element was a step too far for him. I got my paperwork and have not been in touch with either about my ADHD since then.

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Dr Sinovich said: “Most of the time, you can request paperwork from the GP because it’s your details at the end of the day. Most GPs are quite open to medical cannabis in terms of an augmentative treatment to help with different conditions. You get very few GPs that say no. If patients are having trouble with GPs then they can always arrange a call to explain the benefits. We do a lot of educational work with GPs as it’s new and with anything new to a market, people want to see results and can be sceptical about it.”

Don’t be nervous

Before I went for my assessment, I was very nervous. I have had bad experiences with doctors not listening or taking my ADHD symptoms seriously because they may not always believe in the condition. My Irish GP once said to me when I phoned to say I was seeking medication, that ADHD adults ‘grow out of it’, which is a common misconception about ADHD and some forms of neurodiversity. No wonder I was nervous but I need not have been, as the doctors were incredibly supportive. Knowing your symptoms is key though.

Where does my medical cannabis come from?

Once my assessments were over and the team had discussed my case and decided I qualified, I had to decide what the best course of medication was for me. I opted for a vape because it’s easy for me to fit that into my lifestyle in comparison to oils. ADHD people are often forgetful, and I know this applies to me, so I worried I would forget to take an oil dose. My prescription was sent to Rockshaw pharmacy and arrived at my door discreetly. No one would have had a clue as to what the parcel actually was.

“Once you’ve had your consult – and every clinic is different – the script is approved by a multi-disciplinary team then goes to an independent pharmacy,” explained Dr Sinovich.

“The pharmacy will then get the product to them in the next day or within 24 hours. If you are outside of the UK then you may have to wait a little bit longer. For example, we have Guernsey patients who have to apply for a licence so it does take a little bit longer for that process. The patient deals directly with the pharmacy in terms of costs.”

Medical cannabis prescription abroad

It’s worth noting that if you travel, you may not be able to take your prescription with you. As an Irish woman living in the UK with a prescription, I can’t travel with my medication back to Ireland. If you do travel then be prepared for the potentially negative outcome.

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Dr Sinovich agreed: “It’s a very difficult one, unfortunately. If you look at the United States and Canada then you can’t travel between borders as there are strict rules in place. We normally advise patients to consult with the consultant and the terms of the country that they want to visit. There are no blanket rules for everyone but most countries in Europe are happy for individuals to transport their medical cannabis across borders. It varies from country to country.  Normally we issue a script that they have to carry in hand luggage.”

Read more about travelling with medical cannabis here

Police involvement

“We normally advise individuals that it’s not for public use. It’s why a lot of people converted to oil or a capsule. People must realise that if they do get stopped then they need to show proof that they are taking medical cannabis legally and according to doctor’s guidelines,” said Dr Sinovich.

“In the UK, it’s still relatively new so people are starting to get more access to products. It’s going to take some time but the law will change.”

Patients can also apply for ID cards such as MedcannID and Cancard which has been designed with the help of the police to identify medical cannabis patients.

Medical Cannabis Prescriptions: A doctor in a white lab coat signed a prescription. In front of him while examining a cannabis leaf

Still thinking about accessing a medical cannabis prescription?

My prescription has been the best thing I’ve ever done. It’s helped me to enjoy my evenings instead of being hyper-focused and tense and I also sleep better now.

Dr Sinovich said: “The nice thing about medical cannabis is it is tailored to an individual. I don’t think I have a single patient with exactly the same dose. It’s a tailor-made plan for an individual and you assess them to see if it’s working. You can adjust the CBD to THC ratios and there are lots of different products to choose from.”

He added: “It’s another armour you can use in treatment. There are multiple CBD receptors in the central nervous system. It’s about adjusting the mindset, obviously, it takes time and individuals need to invest in it. It’s investing in your future itself and what you could achieve or how you could improve your life.

“I have a lot of patients that I’ve seen for whom it is life-changing.”

Read more: New study: can cannabis alter speech production?

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Patient Voices: “I feel like I can plan for the future instead of having to take one day at a time”

Lex Wolfe shares how medical cannabis has allowed them to thrive while living with multiple health conditions

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Lex Wolfe was diagnosed with Ehlers Danlos syndromes in 2018

Introduced to cannabis while struggling with symptoms of Ehlers Danlos syndromes as a teenager, getting a prescription has allowed Lex Wolfe to plan for the future and thrive while living with multiple chronic health conditions. 

Lex Wolfe has just graduated from an undergraduate degree in forensic science. 

Now considering a Masters in biochemistry, this was unimaginable to their teenage self, who just a few years ago was struggling to make it through GCSE exams.

“I thought I wasn’t going to make it past high school in terms of education, I barely survived my GCSEs. Although I got good grades, it was exhausting,” says the 21-year-old.

“I didn’t think about whether I would go to sixth form or actually what I was going to do after school, I just needed to find a way of living that was comfortable.” 

After being diagnosed with autism spectrum disorder and depression and anxiety as a child, the classroom environment combined with symptoms of social anxiety meant that Lex struggled in school. But as a teenager they began experiencing physical symptoms too. 

“I started to notice that I was in quite a lot of pain – I shouldn’t have been in that much pain, it wasn’t normal,” they say.

“At the time I had hundreds and hundreds of trips to see doctors and other healthcare professionals but nobody could figure out what was wrong because I seemed to have a weird collection of symptoms.”

Lex says they tried everything for pain relief and was prescribed “hundreds” of pharmaceutical painkillers. 

“I was told it was growing pains, I was told that I was just being pathetic, that it was just normal aches and pains and I would grow out of it,” they add.

“They thought my pain might have been psychological.”

At the age of 15, Lex’s mum revealed she also lived with chronic pain. And she had been consuming cannabis for years to help with the symptoms. 

“It was my mum who first introduced me to cannabis,” says Lex.

“She turned around to me and said, ‘by the way, you’re not the only one with chronic pain – I struggle with it too’.”

“It was kind of a revelation, I felt relieved that I wasn’t the only one.”

Lex began accessing cannabis and says they “haven’t looked back” since. 

medical cannabis patient Lex Wolfe

“The first thing I noticed was that my anxiety levels were massively reduced. I was actually able to talk to people – if I wasn’t medicating this conversation wouldn’t be happening right now,” they say.

“I didn’t notice pain relief to begin with, it wasn’t until a couple of months later, when I decided not to take my prescription painkillers and see what happened. 

“It doesn’t remove my pain completely but it’s now at a level that is easy enough for me to manage. I can continue with life like a normal human being, whilst also not rattling because I’m full of pharmaceutical drugs.”

Lex’s family were always supportive, but they kept it a secret from school friends.

“I’d heard about how it was a bad drug, the typical stuff they tell you in school, but that kind of thing was never mentioned in my family, it was always just seen as a medicine,” they say.

“Even still, it was something I was always told to keep secret, because you don’t know how other people will react to it.”

When their friends discovered cannabis for themselves and began using it recreationally, Lex revealed that they had been consuming it medicinally for years.

“Although they found it a fun drug for the weekend, it was something I needed to live a decent life,” says Lex.

“My friends understood, to a certain degree, a lot of them had generalised anxiety and did experience some relief themselves, but the rest of the population just labelled me as a ‘stoner’.”

Lex was eventually diagnosed with Ehlers Danlos syndromes in 2018, nine years after the initial symptoms had begun. 

They asked their GP about the possibility of accessing cannabis on prescription, but were told as it was not available on the NHS there was no way of getting it.

“I knew I would clearly qualify for it and I asked if there was any way it would be available to me and was told no,” they explain.

“It wasn’t until I got so annoyed at the fact that I was buying off the black market and being put in an awkward position, that I started exploring whether I could find someone whom I could pay to prescribe it.”

Lex was eventually taken on as a patient at a private clinic in the UK and shortly afterwards was introduced to the patient-led organisation PLEA (Patient-Led Engagement for Access), of which they are now a member of the management committee.

“Interacting with the medical cannabis community has given me that support group, people to talk to who actually get what I’m going through,” says Lex. 

“You hear all the time that [cannabis] is an illegal drug, that it’s ‘bad’, but actually talking to people who also get relief from it for a wide range of conditions and knowing you’re not the only person, gives you the validation that it’s not just all in your head.”

Lex wolfe

Lex continues: “Having a regular prescription has made a massive difference, knowing that I’m going to have my medication when I need it and not have to worry about whether my dealer has it in stock, or whether it’s going to make me anxious because it’s got terpenes in that I’m sensitive to. Having consistency has done wonders.”

But although Lex says they are currently paying less than they would on the street, the high costs of private prescriptions are still unsustainable.

“Even with the subsidisation [through Project Twenty21] it’s not really feasible,” they say.

“I can afford it, but if I pay for my prescription I can’t do other things like going out and seeing friends.”

And even as a legal patient, Lex has experienced stigma from people assuming they are using cannabis to “get high” due to their age, as well as from doctors with a lack of knowledge around how to treat trans and gender non-conforming patients.

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“I often get comments around the assumption that I am using cannabis to get high instead of as a medication,” Lex admits.

“In terms of gender identity, many of the doctors in the industry have no idea how to treat trans and gender non-conforming people in terms of effect on hormone and qualification for gender conformation surgery.”

Whilst studying for their degree, Lex convinced their tutors to let them research cannabinoids for an undergraduate thesis and authored a paper on how cannabinoids could be used in modern medicine to treat a variety of physical and psychological conditions.

They hope to work in the industry one day and would like to help further the conversation around the role of cannabis in mental health treatment. Data from Drug Science’s Project Twenty21 shows that after pain, anxiety is the second most common condition for which medical cannabis is prescribed.

“A lot of the conversation around cannabis is centred around conditions such as pain, MS and epilepsy, we do need to talk more about how it can help with your mental health problems too,” adds Lex.

“I now feel like I’m able to plan for the future rather than just having to take everything a day at a time.”

Read more from our Patient Voices series here

Want to share your story with Cannabis Health? We’d love to hear from you. Contact sarah@handwmedia.co.uk

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UK Fibromyalgia to host two-part webinar on medical cannabis and CBD

A two-part series will educate on the experiences of those living with fibromyalgia and arthritis

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UK Fibromyalgia, a magazine dedicated to the chronic condition, will host a two-part webinar discussing the role that medical cannabis and CBD can play in treatment.

UK Fibromyalgia has joined forces with Integro Clinics, Primary Care Cannabis Network, Cannabis Patient Advocacy and Support Services (CPASS) and PLEA (Patient-led Engagement for Access) to present a two-part webinar discussing fibromyalgia, arthritis and cannabis medicines.

An approximate 1.5-2 million people suffer from fibromyalgia and 10 million have arthritis in the UK. The management of the symptoms of these conditions can take a long time to diagnose correctly and can take even longer before they are effectively brought under control.

This two-part series aims to educate attendees on the experiences and lives of those living with fibromyalgia and arthritis, as well as show the benefits that cannabis medicines and CBD can have in alleviating symptoms of these conditions.

Ann-Marie Bard is one of three patients, who will be speaking at the second episode of the webinar. She suffers from fibromyalgia and takes medical cannabis to manage her symptoms. She shares her story from diagnosis to gaining her CBMP prescription and describes how it has improved her quality of life.

Ann-Marie’s story

Ann-Marie was a respected and accomplished full-time dental surgeon, having practised for over 25 years before she developed fibromyalgia.

In October 2018, she started to experience unexplained pain all over her body, but as is very common, she did not get a final diagnosis until March 2021. She eventually saw a rheumatologist, who was able to classify what she was experiencing as fibromyalgia. This only happened as a result of an emergency dash to the hospital as she was in such crippling pain.

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Anne-Marie said: “I had a major flare-up at work and had to go to the hospital, it was just terrible. I was in severe pain and couldn’t walk, this was by far the worst attack I had ever had. That’s when things became clear and having seen a rheumatologist, I found out it was fibromyalgia, causing my pain.”

“I was put on various medications such as steroids and pain killers; tramadol, amitriptyline and duloxetine. At first, these helped the pain slightly, but the side effects made me feel like a zombie, I had ‘brain fog’, exhaustion and I wasn’t able to drive while I was on them.”

Her fibromyalgia led to her losing the full use of her hands and she was left unable to grip, which meant that she could no longer perform surgery. This had a devastating effect on her mental and psychical health.

It reached the point, that the side effects of these conventional medicines were becoming unbearable. She had first read about Dr Anthony Ordman, a well-known pain consultant and medical lead at Integro Clinics in a UK Fibromyalgia Magazine.

Ann-Marie decided that medicinal cannabis might be worth trying as a solution to her pain. After first seeing Dr Ordman, she immediately felt that she had come to the right place to help her deal with her condition.

Anne-Marie said: “Dr Ordman made me so calm and at ease. I found the whole process so easy because I was speaking to someone who truly listened, understood everything there is to know about fibromyalgia and cared. He really went the extra mile, keeping my GP in the loop and letting them know exactly what he was going to prescribe. Speaking to him made me feel secure and that I was going to get the help that I needed.”

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Ann-Marie was prescribed a mix of THC and CBD cannabis oil, which she found had a hugely positive and beneficial effect.

UK Fibromyalgia: A blue and white logo for the charity UK Fibromyalgia

Fibromyalgia and cannabis

She added: “The cannabis oil has helped me so much, taking it means I can actually get on with things like yoga, gardening and driving as there is no ‘brain fog’ effect. I can be present mentally, rather than being spaced out and spend more quality time with my family. For me, there are no side effects from the oil, it doesn’t feel like it did when I was on all of the traditional medications. The oil has given me my life back. Cannabis medicines really should be more accessible for everyone, they have changed my life and I believe they can help people in a similar situation to me.”

Ann-Marie believes that more needs to be done to raise awareness when it comes to medical cannabis. She thinks that the NHS should understand that it really is a substantial alternative to conventional medicines.

She explained: “I’m taking part in the webinar because I believe, ultimately, that this medicine should be more accessible. Fibromyalgia sufferers should have access to information about medical cannabis and I hope to raise more awareness of it, letting people know that there are other options than just traditional opioids.”

To register for this free event please follow the links to get your tickets:
Part 1: https://www.eventbrite.co.uk/e/168090997699
Part 2: https://www.eventbrite.co.uk/e/168112536121

If you would like further information or to speak to Dr Anthony Ordman please contact Integro Clinics:

Website: www.integroclinics.com
Email: Contact@integroclinics.com
Twitter: @clinicsintegro

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Dr Anthony Ordman senior clinical adviser and hon. clinical director Integro concluded: Integro Medical Clinics Ltd always recommends remaining under the care and treatment of your GP and specialist for your condition, while using cannabis-based medicines, and the Integro clinical team would always prefer to work in collaboration with them.

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