Photo of New York Attorney General Letitia James courtesy Wikimedia commons
A now-defunct New York City for-profit stem cell clinic — Park Avenue Stem Cell — was order by court to pay $5.1 million in potential consumer restitution, penalties, and costs for fraudulently and illegally advertising their stem cell procedures. The judgment resolves a 2019 lawsuit by New York State Attorney General Letitia James which claimed the defendants’ scammed patients out of thousands of dollars each for unproven and potentially harmful medical treatments involving stem cells.
According to the lawsuit, the clinic falsely advertised on their website, social media, television, and foreign language newspapers that they could treat a variety of serious medical conditions — including erectile dysfunction and Parkinson’s disease — using patients’ own stem cells. Consumers paid the clinic nearly $4,000 per procedure, with some consumers paying more than $20,000 for multiple procedures. Most of the procedures involved adipose stem cells, which are derived from a patient’s own fat tissues.
The court says the defendants misrepresented that their procedures were approved by the U.S. Food and Drug Administration (FDA), that their patients were participating in an established research study, and that their procedures had been endorsed by several scientific and medical organizations.
As a state agency, CIRM’s duty is to educate the public about the concerns over “stem cell tourism” and the growing number of predatory clinics that advertise unproven stem cell therapies at great cost to the patient.
In addition to hosting public forums on stem cell tourism concerns and resources for patients seeking stem cell treatments, CIRM partnered with California State Senator Ed Hernandez (D-West Covina) to create a new law that attempts to address the issue. The bill, SB 512, was passed in 2017 and now requires medical clinics whose stem cell treatments are not FDA approved to post notices and provide handouts to patients warning them about the potential risk.
Read more about this lawsuit at the New York Attorney general’s website.
You can’t fix a global problem at the local level. That’s the gist of a new perspective piece in the journal Stem Cell Reports that calls for a global approach to rogue stem cell clinics that offer bogus therapies.
The authors of the article are calling on the World Health Organization (WHO) to set up an advisory committee to draw up rules and regulations to help guide countries trying to shut these clinics down.
In a news release, senior author Mohamed Abou-el-Enein, the executive director of the joint University of Southern California/Children’s Hospital of Los Angeles Cell Therapy Program, says these clinics are trying to cash in on the promise of regenerative medicine.
“Starting in the early 2000s… unregulated stem cell clinics offering untested and poorly characterized treatments with insufficient information on their safety and efficacy began emerging all over the world, taking advantage of the media hype around stem cells and patients’ hope and desperation.”
The authors include Lawrence Goldstein, PhD, a CIRM Board member and a Science Policy Fellows for the International Society for Stem Cell Research (ISSCR).
Zubin Master, an associate professor of biomedical ethics at the Mayo Clinic, says the clinics prey on vulnerable people who have serious medical conditions and who have often tried conventional medical approaches without success.
“We should aim to develop pathways to provide patients with evidenced-based experimental regenerative intervention as possible options where there is oversight, especially in circumstances where there is no suitable alternative left.”
The report says: “The unproven SCI (stem cell intervention) industry threatens the advancement of regenerative medicine. Reports of adverse events from unproven SCIs has the potential to affect funding and clinical trial recruitment, as well as increasing burdens among regulatory agencies to oversee the industry.
Permitting unregulated SCIs to flourish demonstrates a lack of concern over patient welfare and undermines the need for scientific evidence for medicinal product R&D. While some regulatory agencies have limited oversight or enforcement powers, or choose not to use them, unproven SCI clinics still serve to undermine authority given to regulatory agencies and may reduce public trust impacting the development of safe and effective therapies. Addressing the continued proliferation of clinics offering unproven SCIs is a problem worth addressing now.”
The authors say the WHO is uniquely positioned to help create a framework for the field that can help address these issues. They recommend setting up an advisory committee to develop global standards for regulations governing these clinics that could be applied in all countries. They also say we need more educational materials to let physicians as well as patients understand the health risks posed by bogus clinics.
This article comes out in the same week that reports by the Pew Charitable Trust and the FDA also called for greater regulation of these predatory clinics (we blogged about that here). Clearly there is growing recognition both in the US and worldwide that these clinics pose a threat not just to the health and safety of patients, but also to the reputation of the field of regenerative medicine as a whole.
“I believe that the global spread of unproven stem cell therapies reflects critical gaps in the international system for responding to health crises, which could put the life of thousands of patients in danger,” Abou-el-Enein says. “Urgent measures are needed to enhance the global regulatory capacity to detect and respond to this eminent crisis rapidly.”
Two voices, one message, watch out for predatory stem cell clinics
Last week two new papers came out echoing each other about the dangers of bogus “therapies” being offered by predatory stem cell clinics and the risks they pose to patients.
The first was from the Pew Charitable Trusts entitled: ‘Harms Linked to Unapproved Stem Cell Interventions Highlight Need for Greater FDA Enforcement’ with a subtitle: ‘Unproven regenerative medical products have led to infections, disabilities, and deaths.’
That pretty much says everything you need to know about the report, and in pretty stark terms; need for greater FDA enforcement and infections, disabilities and deaths.
Just two days later, as if in response to the call for greater enforcement, the Food and Drug Administration (FDA) came out with its own paper titled: ‘Important Patient and Consumer Information About Regenerative Medicine Therapies.’ Like the Pew report the FDA’s paper highlighted the dangers of unproven and unapproved “therapies” saying it “has received reports of blindness, tumor formation, infections, and more… due to the use of these unapproved products.”
The FDA runs down a list of diseases and conditions that predatory clinics claim they can cure without any evidence that what they offer is even safe, let alone effective. It says Regenerative Medicine therapies have not been approved for the treatment of:
Arthritis, osteoarthritis, rheumatism, hip pain, knee pain or shoulder pain.
Blindness or vision loss, autism, chronic pain or fatigue.
Neurological conditions like Alzheimer’s and Parkinson’s.
Heart disease, lung disease or stroke.
The FDA says it has warned clinics offering these “therapies” to stop or face the risk of legal action, and it warns consumers: “Please know that if you are being charged for these products or offered these products outside of a clinical trial, you are likely being deceived and offered a product illegally.”
It tells consumers if you are offered one of these therapies – often at great personal cost running into the thousands, even tens of thousands of dollars – you should contact the FDA at firstname.lastname@example.org.
The Pew report highlights just how dangerous these “therapies” are for patients. They did a deep dive into health records and found that between 2004 and September 2020 there were more than 360 reported cases of patients experiencing serious side effects from a clinic that offered unproven and unapproved stem cell procedures.
Those side effects include 20 deaths as well as serious and even lifelong disabilities such as:
Partial or complete blindness (9).
Pulmonary embolism (6).
Heart attack (5).
Tumors, lesions, or other growths (16).
Organ damage or failure in several cases that resulted in death.
More than one hundred of the patients identified had to be hospitalized.
The most common type of procedures these patients were given were stem cells taken from their own body and then injected into their eye, spine, hip, shoulder, or knee. The second most common was stem cells from a donor that were then injected.
The Pew report cites the case of one California-based stem cell company that sold products manufactured without proper safety measures, “including a failure to properly screen for communicable diseases such as HIV and hepatitis B and C.” Those products led to at least 13 people being hospitalized due to serious bacterial infection in Texas, Arizona, Kansas, and Florida.
Shocking as these statistics are, the report says this is probably a gross under count of actual harm caused by the bogus clinics. It says the clinics themselves rarely report adverse events and many patients don’t report them either, unless they are so serious that they require medical intervention.
The Pew report concludes by saying the FDA needs more resources so it can more effectively act against these clinics and shut them down when necessary. It says the agency needs to encourage doctors and patients to report any unexpected side effects, saying: “devising effective strategies to collect more real-world evidence of harm can help the agency in its efforts to curb the growth of this unregulated market and ensure that the regenerative medicine field develops into one that clinicians and patients can trust and safely access.”
We completely support both reports and will continue to work with the FDA and anyone else opposed to these predatory clinics. You can read more here about what we have been doing to oppose these clinics, and here is information that will help inform your decision if you are thinking about taking part in a stem cell clinical trial but are not sure if it’s a legitimate one.
The product is authorized by the Food and Drug Administration (FDA) and is overseen by an IRB or ethics board,
The treatment is delivered by qualified doctors, nurses, and technicians,
Treatment occurs at a clinical treatment center with expertise in regenerative medicine, and
There is ongoing monitoring and follow-up of patients.
On April 21 of 2021, Dr. Peter Marks, Director of the Center for Biologics Evaluation and Research, indicated the FDA’s intent to ensure new regenerative medicine products are FDA-authorized. Specifically, the FDA will require product developers to obtain an Investigational New Drug or IND authorization. In his news release Dr. Marks says the agency is willing to exercise more enforcement of these rules should clinics or therapy producers fail to follow these guidelines.
“These regenerative medicine products are not without risk and are often marketed by clinics as being safe and effective for the treatment of a wide range of diseases or conditions, even though they haven’t been adequately studied in clinical trials. We’ve said previously and want to reiterate here – there is no room for manufacturers, clinics, or health care practitioners to place patients at risk through products that violate the law, including by not having an IND in effect or an approved biologics license. We will continue to take action regarding unlawfully marketed products.”
IND authorization is particularly important as the agency pays close attention to how the product is produced and whether there is a scientific rationale and potential clinical evidence that it may be effective against the specific disease condition. All CIRM-funded clinical trials and all trials conducted in the CIRM Alpha Stem Cell Clinics Network must have IND authorization.
Regenerative medicine products are generally created from human cells or tissues. These products are frequently referred to as “living medicines.” The “living” nature of these products is what contributes to their remarkable potential to relieve, stop or reverse disease in a durable or sustainable manner.
The risk with unregulated products is that there is no assurance that they have been produced in a quality controlled process or manner where all components of the injected material have been well characterized and studied for safety and efficacy for a given disease as well as a specific site in the body. In addition, there is no way to ensure that unregulated products meet standards or quality specifications such as ensuring that they have the active and beneficial component while making sure that they do not include harmful contaminants.. There have been documented examples of patients being severely injured by unregulated and inadequately characterized products. For example, in 2017 three Florida women were blinded by an unauthorized product. Dr. George Daley, a stem cell expert and the Dean of Harvard Medical School, described the clinic operators as “charlatans peddling the modern equivalent of snake oil.”
To receive FDA authorization, detailed scientific data and well controlled clinical data are required to ensure safety and a demonstration that the product is safe has the potential to improve or resolve the patient’s disease condition.
While it seems both important and self-evident that stem cell products be safe and effective and supported by evidence they can impact the patient’s disease condition, that doesn’t always happen. Unfortunately, too many patients have experienced unnecessary medical risks and financial harm from unauthorized treatments. CIRM applauds the FDA for taking additional steps to advance regenerative medicine products where the clinical benefits of such therapies outweigh any potential harms.
As the coronavirus pandemic continues to spread, one of the few bright spots is how many researchers are stepping up and trying to find new ways to tackle it, to treat it and hopefully even cure it. Unfortunately, there are also those who are simply trying to cash in on it.
In the last few years the number of predatory clinics offering so-called “stem cell therapies” for everything from Alzheimer’s and multiple sclerosis to autism and arthritis has exploded in the US. The products they offer have not undergone a clinical trial to show that they work; they haven’t been approved by the US Food and Drug Administration (FDA); they don’t have any evidence they are even safe. But that doesn’t stop them marketing these claims and it isn’t stopping some of them from now trying to cash in on the fears created by the coronavirus.
One company is hawking what it calls a rapid COVID-19 test, one that can determine if you have the virus in under ten minutes (many current tests take days to produce a result). All it takes is a few drops of blood and, from the comfort of your own home, you get to find out if you are positive for COVID-19. And best of all, it claims it is 99 percent accurate.
What could be the problem with that? A lot as it turns out.
If you go to the bottom of the page on the website marketing the test it basically says “this does not work and we’re not making any claims or are in any way responsible for any results it produces.” So much for 99 percent accurate.
It’s not the only example of this kind of shameless attempt to cash in on COVID-19. So it’s appropriate that this week the Alliance for Regenerative Medicine (ARM), issued a statement strongly condemning these attempts and the clinics behind them.
ARM warns about the growing number of “stem cell clinics” (that) are taking advantage of the “hype” around stem cells – and, in certain cases, the current concern about COVID-19 – and avoiding regulation by falsely marketing illegal and potentially harmful products to patients seeking cures.”
These so called “therapies” or tests do more than just take money – in some cases tens of thousands of dollars – from individuals: “Public health is at risk when unscrupulous providers offer stem cell products that are unapproved, unproven and fail to adhere to established rules for good manufacturing practices. Many of these providers put patients at risk by falsely marketing the benefits of treatments, and often promoting the stem cells for conditions that are outside of their area of medical expertise.”
It’s sad that even in times when so many people are working hard to find treatments for the virus, and many are risking their lives caring for those who have the virus, that there are unscrupulous people trying to make money out of it. All we can do is be mindful, be careful and be suspicious of anything that sounds too good to be true.
There are no miracle cures. No miracle treatments. No rapid blood tests you can order in the mail. Be aware. And most importantly of all, be safe.
The CIRM Board recently held a meeting to approve $5 million in emergency funding for rapid research into potential treatments for COVID-19.
We are at a turning point in regenerative medicine as the first wave of treatments have obtained FDA approval. But at the same time as we see the advance of scientifically rigorous research and regulated products we are also witnessing the continued proliferation of “unproven treatments.” This dueling environment can be overwhelming and distracting to individuals and families trying to manage life-threatening diseases.
How does a patient navigate this environment and get trusted and reliable information to help sort through their options?
CIRM teamed up with the CURA Foundation to organize a roundtable discussion intended to answer this question. The conversation included thought leaders involved in patient advocacy, therapy research and development, public policy and research funding. The roundtable was divided into three segments designed to discuss:
Examples of state-of-the-art patient navigation systems,
Policy, research and infrastructure needs required to expand navigation systems, and
Communication needs for engaging patients and the broader community.
Examples of Navigation Systems:
This session was framed around the observation that patients often do not get the best medicines or treatments available for their condition. For example, in the area of cancer care there is evidence that the top 25% of cancers are not being treated optimally. Historic barriers to optimal treatment include cost pressures that may block access to treatments, lack of knowledge about the available treatments or the absence of experts in the location where the patient is being treated. Much of the session focused on how these barriers are being overcome by partnerships between health care provides, employers and patients.
For example, new technologies such as DNA sequencing and other cell-based markers enable better diagnosis of a patient’s underlying disease. This information can be collected by a community hospital and shared with experts who work with the treating doctor to consider the best options for the patient. If patients need to access a specialty center for treatment, there are new models for the delivery of such care. Emphasis is placed on building a relationship with the patient and their family by surrounding them with a team that can address any questions that arise. The model of patient-centered care is being embraced by employers who are purchasing suites of services for their employees.
Patient advocacy groups have also supported efforts to get the best information about the patients’ underlying disease. Advocacy organizations have been building tools to connect patients with researchers with the aim of allowing secure and responsible sharing of medical information to drive the patient-centered development of new treatments. In a related initiative, the American Society of Hematology is creating a data hub for clinical trials for sickle cell disease. Collectively, these efforts are designed to accelerate new treatments by allowing critical data to be shared among researchers.
Essential Policy Infrastructure for Regenerative Medicine:
Session two dovetailed nicely with first discussion. There was continued emphasis on the need for additional evidence (data) to demonstrate that regenerative medicine treatments are having a significant effect on the patient’s disease. Various speakers echoed the need for patients in clinical trials to work with researchers to determine the benefits of treatments. Success stories with gene therapies in blood diseases were cited as proof of concept where treatments being evaluated in clinical trials are demonstrating a significant and sustained impact on diseases. Evidence of benefit is needed by both regulatory bodies that approve the treatments, such as the FDA, and by public and private payers / insurers that pay for treatments and patients that need to know the best option for their particular disease.
In addition, various speakers cited the continued proliferation of “unproven treatments” being marketed by for-profit centers. There was broad concern that the promotion of treatment where there is no evidence of effectiveness will mislead some patients and potentially harm the scientifically rigorous development of new treatments. Particularly for “stem cell” treatments, there was a desire to develop evaluation criteria that are clear and transparent to allow legitimate treatments to be distinguished from those with no evidence of effectiveness. One participant suggested there be a scorecard approach where specific treatments could be rated against specific indicators of safety, medical benefit and value in relation to alternative treatments. The idea would be to make this information widely available to patients, medical providers and the public to inform everything from medical decision making to advertising.
Communicating the Vision
The final session considered communication needs for the field of regenerative medicine. Patients and patient advocacy organizations described how they are using social media and other networking tools to share information and experiences in navigating their treatment options. Patient advocacy groups also described the challenges from providers of unproven treatments. In one case, a for profit “pop up” clinic had used the group’s videos in an attempt to legitimize their unproven treatment.
There was general consensus among the panelists that the field of regenerative medicine needs “trusted intermediaries” who can evaluate claims and help patients distinguish between high quality research and “snake oil”. These intermediaries should have the capacity to compile the most reliable evidence and utilize it to determine what options are available to patients. In addition, there needs to be shared decision making model where patients have the opportunity to explore options in an unbiased environment so they may make the best decision based on their specific needs and values.
Creating this kind of Navigation System will not be easy but the alternative is unacceptable. Too many vulnerable patients are being taken advantage of by the growing number of “predatory clinics” hawking expensive therapies that are both unproven and unapproved. We owe it to these patients to create a simple way for them to identify what are the most promising therapies, ones that have the highest chance of being both safe and effective. The roundtable discussion marked a starting point, bringing together many of the key players in the field, highlighting the key issues and beginning to identify possible solutions.
What do you do when the supposed solution to a problem actually turns out to be a part of the problem? That’s the situation facing people who want to direct patients to scientifically sound clinical trials. Turns out the site many were going to may be directing patients to therapies that are not only not scientifically sound, they may not even be safe.
The site in question
is the www.clinicaltrials.gov
website. That’s a list of all the clinical trials registered with the National
Institutes of Health. In theory that should be a rock-solid list of trials that
have been given the go-ahead by the Food and Drug Administration (FDA) to be tested
in people. Unfortunately, the reality is very different. Many of the trials
listed there have gone through the rigorous testing and approval process to
earn the right to be tested in people. But some haven’t. And figuring out which
is which is not easy.
The issue was highlighted by a terrific article on STAT News this week. The article’s title succinctly sums up the piece: “Stem cell clinics co-opt clinical-trials registry to market unproven therapies, critics say.”
The story highlights how clinics that are offering unproven and
unapproved stem cell therapies can register their “clinical trial” on the site,
even if they haven’t received FDA approval to carry out a clinical trial.
Leigh Turner, a bioethicist at the University of Minnesota and a long-time foe of these clinics, said:
“You can concoct this bogus appearance
of science, call it a clinical study, recruit people to pay to participate in
your study, and not only that: You can actually register on clinicaltrials.gov
and have the federal government help you promote what you’re doing. That struck
me as both dangerous and brilliant.”
At CIRM this is a problem we face almost every day. People call or email us asking for help finding a stem cell therapy for everything from cancer and autism to diabetes. If we are funding something or if there is one underway at one of our Alpha Stem Cell Clinics we can direct them to that particular trial. If not, the easiest thing would be to direct them to the clinicaltrials.gov site. But when you are not sure that all the programs listed are legitimate clinical trials, that’s not something we always feel comfortable doing.
As the STAT piece points out, some of the “trials” listed on the site
are even being run by companies that the FDA is trying to shut down because of
serious concerns about the “therapies” they are offering. One was for a Florida
clinic that had blinded four people. Despite that, the clinic’s projects remain
on the site where other patients can find them.
Being listed on clinicaltrials.gov gives clinics offering unproven therapies
an air or legitimacy. So how can you spot a good trial from a bad one? It’s not
One red flag is if the trial is asking you to pay for the treatment.
That’s considered unethical because it’s asking you to pay to be part of an
experiment. Only a very few legitimate clinical trials ask patients to pay, and
even then, only with permission from the FDA.
Another warning sign is anything that has a laundry list of things it
can treat, everything from arthritis to Alzheimer’s. Well-designed clinical
trials tend to be targeted at one condition not multiple ones.
We have put together some useful tools for patients considering taking
part in a clinical trial. Here is a link
to a video and infographic that tell people the questions they need to ask,
and things they need to consider, before signing up for any clinical trial.
So why does the NIH continue to allow these clinics to “advertise”
their programs on its website? One reason is that the NIH simply doesn’t have
the bandwidth to check every listing to make sure they are legit. They have
tried to make things better by including a warning, stating:
“Listing a study
does not mean it has been evaluated by the U.S. Federal Government. Read our disclaimer for
details. Before participating in a study, talk to your health care provider and
learn about the risks
and potential benefits.”
The bottom line is
that if you are in the market for a stem cell therapy you should approach it
the way you would any potentially life-changing decision: caveat emptor, buyer
When you have a great story to tell the best and most effective way to get it out to the widest audience is still the media, both traditional mainstream and new social media. Recently we have seen three great examples of how that can be done and, hopefully, the benefits that can come from it.
First, let’s go old
school. Earlier this month Caroline Chen wrote a wonderful
in-depth article about clinics that are cashing in on a gray area in stem
cell research. The piece, a collaboration between the New Yorker magazine and
ProPublica, focused on the use of amniotic stem cell treatments and the gap
between what the clinics who offer it are claiming it can do, and the reality.
Here’s one paragraph
profiling a Dr. David Greene, who runs a company providing amniotic fluid to
clinics. It’s a fine piece of writing showing how the people behind these
therapies blur the lines between fact and reality, not just about the cells but
also about themselves:
“Greene said that amniotic stem cells derive their healing power from an ability to develop into any kind of tissue, but he failed to mention that mainstream science does not support his claims. He also did not disclose that he lost his license to practice medicine in 2009, after surgeries he botched resulted in several deaths. Instead, he offered glowing statistics: amniotic stem cells could help the heart beat better, “on average by twenty per cent,” he said. “Over eighty-five per cent of patients benefit exceptionally from the treatment.”
backpedals on that claim, saying:
“I don’t claim that this is a treatment. I don’t claim that it cures anything. I don’t claim that it’s a permanent fix. All I discuss is maybe, potentially, people can get some improvements from stem-cell care.”
This week CBS2
TV in Chicago did their own investigative story about how the number of local
clinics offering unproven and unapproved therapies is on the rise. Reporter Pam
Zekman showed how misleading newspaper ads brought in people desperate for
something, anything, to ease their arthritis pain.
She interviewed two
patients who went to one of those clinics, and ended up out of pocket, and out
“They said they would regenerate the cartilage,” Patricia Korona recalled. She paid $4500 for injections in her knee, but the pain continued. Later X-rays were ordered by her orthopedic surgeon.
“He found bone on bone,” Korona said. “No cartilage grew, which tells me it failed; didn’t work.”
John Zapfel paid $14,000 for stem cell injections on each side of his neck and his shoulder. But an MRI taken by his current doctor showed no improvement.
“They ripped me off, and I was mad.” Zapfel said.
TV and print reports
like this are a great way to highlight the bogus claims made by many of these
clinics, and to shine a light on how they use hype to sell hope to people who
are in pain and looking for help.
At a time when
journalism seems to be increasingly under attack with accusations of “fake news”
it’s encouraging to see reporters like these taking the time and news outlets
devoting the resources to uncover shady practices and protect vulnerable
But the news isn’t
all bad, and the use of social media can help highlight the good news.
That’s what happened
yesterday in our latest CIRM
Facebook Live “Ask the Stem Cell Team” event. The event focused on the
future of stem cell research but also included a really thoughtful look at the
progress that’s been made over the last 10-15 years.
We had two great
guests, UC Davis stem cell researcher and one of the leading bloggers on the
field, Paul Knoepfler PhD; and David
Higgins, PhD, a scientist, member of the CIRM Board and a Patient Advocate
for Huntington’s Disease. They were able to highlight the challenges of the
early years of stem cell research, both globally and here at CIRM, and show how
the field has evolved at a remarkable rate in recent years.
subject of the “bogus clinics” came up – Paul has become a national expert on
these clinics and is quoted in the New Yorker article – as did the subject of
the frustration some people feel at what they consider to be the too-slow pace
of progress. As David Higgins noted, we all think it’s too slow, but we are not
going to race recklessly ahead in search of something that might heal if we
might also end up doing something that might kill.
A portion of the
discussion focused on funding and, in particular, what happens if CIRM is no
longer around to fund the most promising research in California. We are due to
run out of funding for new projects by the end of this year, and without a
re-infusion of funds we will be pretty much closing our doors by the end of
2020. Both Paul and David felt that could be disastrous for the field here in
California, depriving the most promising projects of support at a time when
they needed it most.
It’s probably not
too surprising that three people so closely connected to CIRM (Paul has
received funding from us in the past) would conclude that CIRM is needed for
stem cell research to not just survive but thrive in California.
A word of caution
before you watch: fashion conscious people may be appalled at how my pocket handkerchief
took on a life of its own.