Medicinal Cannabis, NDIS, Funded Therapy Assessments, Human Rights, Election 2022
As a centre-left individual, and a senior clinician, I am passionate about access and equity in social, health and educational areas. These are core human rights issues. With Australia facing a federal election next month, the moment makes me realise how much both medicalised and legalised cannabis access are in fact human rights issues.
The (Federal) Politics of Cannabis
As surprised as we are, this federal election our vote is highly influenced by each political party’s cannabis policy or lack thereof. We are not alone. Our generation of 50+ is showing increased acceptance of legalisation.
Half of Australians want to legalise cannabis, a figure that doubled since 2013 studies. The 2019 National Drug Strategy Household Survey reported that a whopping 32% of Australians have used cannabis in the last twelve months. This compares to 2.5% to 3% globally. In Canada where personal use is legal, 15% use cannabis in the last twelve months. Australia has the highest use rates globally but also has the most archaic politically motivated legal framework.
Based on 2019 population figures, 8.2 million + Australians use cannabis in recent years. This is a percentage and a population cohort that is going up given the trends over the past decade. We ask, how can the mainstream parties justify literally criminalising well over 8.2 million Australians?
Indeed, some say the war on cannabis is insanely premeditated based on very outdated prejudicial values that once served political ends. The war on drugs targets vulnerable populations for obvious reasons. Historically, sociologists study cannabis prohibition as a means to an end for Indigenous suppression, systemic racial violence, and socio-economic policies meant to keep the poor in chronic states of fear, anxiety, and so that they are more readily hit by policing and military agencies at the advantage of the ruling class.
To acknowledge these current realities and cannabis histories within the war on drugs are no longer left-wing perspectives. Today it is highly conservative to agree that science and sociology have a lot to say about the war on drugs. It is Centre Right at the moment to point to the acute need to support a health-based, person-centred, strength-based approaches to addictions treatment and therapy. It is also Centre Right and enlightened to see the social and economic benefits of regulating, taxing, and allowing adult access to cannabis. But the political flavour does not really change the facts. Nor does one’s political spectrum change the reality for people who are using substances and in need of healthy lifestyle-based medical and allied health support.
Global Legal Developments with Cannabis
Countries that have legalised medical cannabis include Argentina, Australia, Barbados, Brazil, Canada, Chile, Colombia, Costa Rica, Croatia, Cyprus, Czech, Republic, Denmark, Ecuador, Finland, Germany, Greece, Ireland, Israel, Italy, Jamaica, Lebanon, Lithuania, Luxembourg, Malawi, Malta, the Netherlands, New Zealand, North Macedonia, Norway, Panama, Peru, Poland, Portugal, Rwanda, Saint Vincent and the Grenadines, San Marino, Sri Lanka, Switzerland, Thailand, the United Kingdom, Uruguay, Vanuatu, Zambia, and Zimbabwe.
At the moment, legalisation has moved forward in Canada, Georgia, Malta, Mexico, South Africa, and Uruguay. In the USA, recent data from the National Conference of State Legislatures suggests that 37 states and Washington D.C. have legalised medical cannabis, and 18 states and Washington D.C. have legalised recreational use.
In a move to fix federal laws that contradict regional jurisdictions a couple weeks ago federal legalisation was passed in the House of Representatives in Washington, dubbed ‘The Marijuana Opportunity Reinvestment and Expungement Act‘ (PDF). Media reports that the bill seeks to decriminalise marijuana federally and that the bill would ‘establish procedures for expunging previous convictions from people’s records and impose a tax on the sale of cannabis products.‘
The Australian federal government ought to look at these developments. Particularly with the ACT having passed legalisation for recreational use, and with major work being done in Victoria, and in NSW, that will eventually lead to state level legal developments. On the 17 Feb 2021, NSW tabled legislation. The bill was tabled by Greens Ms Cate Faehrmann, and her speech is historic and bears consideration.
Expensive Out of Reach Medical Cannabis
In Australia, medical cannabis costs people upwards to $160 or $200 to just see a specialist cannabis doctor for an assessment. Most GPs are not aware of the issues nor the research, and finding a local or regional doctor is almost impossible.
Subsequent appointments cost around $90, and many of the specialist online clinics want to get people back for ongoing assessment. Then to access the product costs up to $300 a pop, according to recent estimates. You are looking at well over $3000.00 to $6000.00 per year to manage access to a natural herb that ought to be grown in your back yard. Albeit, medical products may be purified and tailored to specific conditions but we ask, at what cost?
How demoralising for people who finally find a natural plant based product that works without side effects, as compared to mainstream drugs with many side effects. You have the health promoting product dangled in your face, only to be told that this is the price, and sorry you can’t afford to buy this product. At the same time, you feel forced then to buy from the black market, that is, if you can find a source, or to grow a couple plants, if you can find the seed or a clone (a propagation cutting). There are a lot of ifs in the situation for a person with a chronic health condition forced into an illegal trade by archaic laws and even more insane regulatory conditions. How much more insane the situation becomes when you have a disability and face all of these challenges.
Just looking at cost, who in reality can afford medical cannabis? The regulatory environment is so restrictive that access let alone innovative research will not happen in this country. Big pharma wins but the Australian society does not benefit much at all.
The really big problem is that most people who need cannabis have chronic conditions and they already have high medical costs. What a burden. This forces people to access from the illegal market and/or to grow a few plants for personal use. Except in the ACT, in other parts of the country you are taking higher risks. While regional governments have different standards and may not press charges and give warnings, the federal laws are archaic and need to be repealed. Even people in the ACT are reluctant to exercise their state-sanctioned rights because as some commentators suggest the federal laws trump the local laws and can be used by law enforcement if the ends justify the means.
People with chronic health conditions, under Medicare provisions, would ideally not have to pay out of pocket fees to see a GP. While the latter depends on your surgery’s policy, the point is obvious. The supreme irony is that medical cannabis is touted as a last resort for people who are tried all the other options – which is central to the TGA individualised access criteria, which in our opinion is an unjust violation of human rights and ought to be tested in the courts.
Research will not move forward more freely until legalisation happens. We just read a fascinating paper on the role of cannabis in cardiomyopathy conditions. Anyone who knows anything about medicine will know that this signals significant advances in research as the conditions associated with cardiomyopathy are highly complex. This kind of clinical research with people in everyday life cannot happen in Australia without concerted efforts and big money spent by corporate drivers, leaving the overall research sector in the dark. Legalisation will free up options for smaller more innovative research teams, and will increase the competitive edge for health, social, business, and environmental related research projects that cannabis naturally encourages.
The Australian two mainstream parties have very poor policy development to address medicalised access and legalisation, and even less consistency. We’d say near zero educational value among the political elite of this country. It seems absurd when just the economic gains are hard to dismiss with obvious overseas evidence staring Australia in the face everyday.
In a highly detailed and layered issue like cannabis use, the ‘one size fits all’ approach has never worked, and will never work. This is perhaps the core sociological issue why prohibition has failed so miserably. This is also why an individualised health and lifestyle approach is necessary. As such, the discussion on cannabis use can expand into so many areas. But first, we would like to address the elephant in the room with respect and due consideration.
Human Rights
If anything is clear it is that our era insists on taking a human rights approach to social issues that were once taboo. This has led to dramatic social and legal changes with addressing dysfunctional social histories and systemic discrimination.
This movement is central to the core values of Australian secularisation. Unlike many today, we note that the core meaning of the word ‘secular’ in western history was actually one of two sacred domains of life. The other domain was the formally ‘religious’ or ‘regular’ lifestyle, where ‘secular’ was a word that described the sacred domain of family and society at large.
It is no mistake that contemporary social and political movements had to disengage an association with formal religion to establish a secular social ethos based in equality and human rights for all. At the same time, in our era we are seeing evidence that more and more people are awakening to the sacred nature of life within the secular. These signs include among others values giving rise to increased action on the environment, ecology, family life, post-Covid values, leaving unhappy jobs, confronting corruption, and moving forward on a spectrum of social and allied health issues.
These changes have often fought to address imbalances that in past overtly prevented social progress in issues of race, ethnicity, rural vs urban, socio-economic, ageism, biased views toward the child, religious freedom, gendered bias, same-gender marriage, sexuality, sex worker’s rights, and people with disability having access to sex workers, etc… The list is extensive.
This pathway globally and in Australia is leading to a largely allied health approach to alcohol and other drug use. The history of failed prohibition is obvious to most people nowadays. But many entrenched attitudes and social policies remain to be transformed. It is in this context that we look at the movement toward the legalisation of cannabis.
Health and Safety
Health and safety go hand in hand. Naturally, at various times people focus on one more than the other. In past and presently, social systems including government tend to side with safety over health. Safety, historically, is an area that lends itself to simplistic one size fits all measures. These usually do not work, but the overuse of safety-measures do give governments the licence to codify, sanction, segregate, prohibit, criminalise, police, prosecute, and punish.
On the other hand, healthy lifestyle and health care based values are ideally more holistic and generative, and more individualised in application. The leading edge now is individualised medicine and health care. This trend acknowledges that every principle in science and medicine needs to be applied in the context of a person’s life. Every statistical study and inference from population samples and even double-blind studies needs to be interpreted and carefully applied.
The balance of these attitudes and approaches to social issues is found in the phrase ‘health and safety’ because when these two are brought together they raise the optimal framework for sorting issues and ways forward. They imply risk assessment as well as opportunity assessment are central to every decision and every social and political policy.
Disability Sector Values
In parallel, in the disability sector we have two core values. One is dignity of risk. Dignity of risk ideally is a more health-oriented and holistic lifestyle perspective that places emphasis on personal choice and control. The other is duty of care. Duty of care is a more safety oriented perspective with emphasis on standards, professional and caring roles, and advocacy-based values.
Under the National Disability Insurance Scheme (NDIS) dignity of risk has taken strides forward under the core human rights concepts of choice and control that are enshrined in the UN Convention on the Rights of People with Disabilities. At the same time, we are seeing the need to balance these perspectives with astute advocacy and individualised planning.
As Counselling Psychotherapists, our specialist roles include providing assessments, treatment in Counselling Therapies, and detailed co-designed and collaborative planning in Behaviour Support with the application of principles in Lifestyle Medicine. We see NDIS participants who use cannabis, others who may want to try cannabis, and many others who likely have not been informed nor given the choice to use or not use cannabis.
Silence, Inaction, Avoidance
For obvious reasons, disability providers do not tend to encourage nor discuss cannabis use with NDIS participants. We suspect this is due to the perception that issues are complicated by legal, ethical, duty of care, and dignity of risk debates. Where Disability Support Workers do bridge this gap with their participants, they probably do so on a personal basis.
Part of the problem is that historically society has kept artificial rules and funding models that keep sectors apart, often forced by design or by will into fighting against other sectors for a piece of the pie. The system is rather well made as it tends to benefit the ruling class and government.
We are seeing more recent shifts with political posturing over the NDIS that continue these dysfunctional and damaging patterns. This is very sad, as the NDIS in our view presents a model that transcends many of the existing ghettos of health care vs education vs aged care vs mental health vs disability services. Will Australia as a collective consciousness ever awaken to a more integral and holistic approach to social services?
As such, it is very rare and almost non-existent for NDIS providers to articulate policies on managing substance use because these have traditionally been seen as the domain of public health and welfare systems. Current NDIS risk management frameworks, which recently took a kick from Covid-19 pandemic circumstances, have not addressed these concerns. As to the legalisation of personal use of cannabis, as well as the chronic slow pace of access to prescribed medicinal cannabis since 2016, these issues largely remain in the realm of political debate and systemic barriers.
Slow, Very Slow, Progress?
However, with the advent of legalised medical prescription-based cannabis in Australia, the pathway toward decriminalisation and legalisation seems fairly certain. What follows is the urgent need for Australian studies to look at efficacy, safety, and application of plant-based substances. Australian health care and social services need robust studies on the use of cannabis among people with disabilities. These must include population studies as well as micro-issue studies looking at specific diagnostic profiles.
For example, the Australian disability sector need studies looking at specific tailored formulations of the medicinal cannabis plant and hemp-based products and their efficacy and risk profiles among adults and children with Autism, Intellectual Disability, Down Syndrome, and in many of the more common mental health conditions including Post Traumatic Stress Disorder, Depression, Anxiety, Bipolar, and Schizophrenia.
NDIS and Cannabis Funding
Perhaps a sign of how far the Australian government has come already, and yet how far we need to go in future, the conservative space of the NDIS website has taken the leap to include discussion of funding associated with medicinal cannabis.
The NDIA advises that they will likely not fund medicinal cannabis as the medicine falls under their category of ‘pharmaceuticals’ whether obtained by doctor’s prescription as with medicinal cannabis, or over the counter as with some hemp-based products. From a page dated 12 July 2021, the NDIA states that they are not going to fund any pharmaceutical, prescribed or over the counter. They say, “We are not the most appropriate agency to fund medicinal cannabis products, as these are also pharmaceuticals.”
Given the nature of cannabis trials and studies, the NDIA further state they will not fund trials of non-PBS-listed medications. They suggest that trials are brief or time-limited interventions that are focused on improving health, but they imply this is a goal of the health care system.
Remaining Questions
As we further explore in this discussion below, it is not possible to define the complex family of plants that make up cannabis as merely a pharmaceutical. That being the case, it is uncertain whether the NDIS would ever fund any of the products in the cannabis universe except via a rather robust clinically based application under the Assistive Technology Application process. This is a time consuming process and would require a range of specialist practitioners agreement and collaboration.
Given the high costs and lack of schemes for equitable access to allied health treatments including medicinal cannabis assessments, reviews, treatment planning, monitoring, and prescription of medicines, to our knowledge the argument regarding NDIS funding of cannabis related services and products has not been tested in the courts. We are reminded that when other issues have been tested by participants through the courts, as taxing as this is for individuals who must fight for their human rights to be respected, various issues have come out siding with participant’s right to funding.
The courts have continually advanced the core values of reasonable and necessary as related to access to social and health related services. It is terribly ironic that the courts have become the leaders in upholding the NDIS Act 2013, when the agency has become a dark symbol for many people with disabilities. Not the least of these hard won victories, symbolically speaking, was the right of NDIS participants to gain relatively equal access to sex therapy and the separate use of sex workers.
Others are currently fighting for the rights to access adequate early childhood funding for complex cases. The fight for adequate equipment necessary for people and children with complex physical and neurological mobility issues continues as well.
NDIS Funded Behaviour Support and Cannabis
At one level, cannabis is a substance that, like other medically prescribed substances, could potentially be used with people with disabilities to modify mood, disposition, sleep patterns, pain, discomfort, anxiety, social phobias, anger and aggression, etc… This could happen unofficially by personal or familial use of street cannabis, or officially by use of medically prescribed cannabis.
Because the cost of medically supervised use is prohibitive, many people will use the former even while under archaic prohibition laws. In the future, when cannabis is legalised in all states of Australia, people will still have to choose medical-based services vs street-based access.
In Canada, where cannabis is legal for medicinal and personal recreational use, and where access is organised across the society by being sold at government owned Liquor Commission stores, from discussions with colleagues and others we observe that many people still use community-based sellers in part due to lower cost, along with values that support local businesses and informal relationships that have existed for decades.
As well, it is commonly perceived that people may not trust the official line of governments and the medical establishment who appear to be in jolly dance-steps with the big pharma industry of which cannabis is now a prime concern. Suffice to say, in any circumstance it is quite likely that legalisation will travel alongside diversification in community-based markets, and that black markets and local trade or bartering of products that escapes tax and other regulations will likely continue even when greatly reduced.
At another level, like many other prescriptions, where a doctor seeks the modification of anxiety or other issues for a person with disability, there are quite often layers of seeking to modify and treat behaviours of concern. Many of these cases go under reported and are not properly assessed by specialist behaviour support clinicians. This last link goes to a helpful paper (PDF) published by the NSW government that looks at the role of behaviour specialist reviews of medications among people with disabilities in Australia.
In specialist behaviour support and in counselling therapies and assessments, whether an NDIS funded clinician provides a clinical review of the use of cannabis or not depends mostly on the qualifications and experience of the clinician. It is unlikely that most NDIS funded clinicians will have this mix of health-based qualifications and experience. This is particularly true where prohibition laws have more or less necessitated that disability specialist clinicians leave drug related matters to addictions services, mental health, or mainstream health care.
Seeking Least Restrictive Options
In the current landscape, we would suggest that qualified and experienced allied health practitioners including behaviour specialists could ostensibly include a cannabis use review within a healthy lifestyle review and functional behaviour assessment. Such a review may lead to referral to a medical authority who further assess and may prescribe the more appropriate and available medicinal cannabis products.
Also, ostensibly, if an NDIS participant and their medical team wanted to prescribe medicinal cannabis for the purpose of behaviour support it is quite reasonable for a specialist in the field to examine the possible or necessary restrictive practices implied by prescribing the substance, much like we assess the least restrictive options associated with other substances including psychotropic drugs.
Also equally compelling and interesting to consider, where family or advocates or providers or medical practitioners wish to trial the use of cannabis products to help an individual get off of heavier psychotropic or related substances due to side effects or long term risk profiles, a behaviour specialist could assist to document the history of least restrictive trials toward finding a more sustainable solution.
Seeking an Even Playing Field
Unlike psychotropic drugs, cannabis cannot technically be categorised as a pharmaceutical, a psychotropic or even a psychedelic. Nor can cannabis be limited to the categories of an over the counter medicine, a herb supplement, or nutritional aid. The plant and its components and chemical make up cross many and varied categories. Did you know, you can even make bread with flour that is ground from cannabis plant stock, called hemp flour. By the way, you do not get high from hemp-flour bread.
For these reasons, even while well over 40% of people approve of legalisation, and over 30% of Australians use cannabis fairly regularly, as Australians track the hinterland toward legalisation, people will need information. Education is one thing, and necessary. But cannabis requires more than education by way of applied practice and advocacy.
Because cannabis use decisions often relate to personal health and lifestyle issues, this means that Australians are looking to their GPs and allied health professionals for help. But even six years after legalising medical cannabis, this help does not exist in most communities. At the same time, people with chronic health conditions need to discuss issues with a GP, cannabis specialist doctor, counsellor or allied health practitioner. Because of existing stigma, many people are uncertain to even raise the conversation, let alone imagining plausible dismissive or judgemental reactions from their practitioner.
In the NDIS space, for people with disabilities wanting to learn about the many issues involved in using cannabis and related products for health and lifestyle needs requires additional resources if the society is going to meet obligations under the UN Convention for the Rights of People with Disabilities. We do not yet see these factors being considered in any top-down organised, holistic, or programatic way within the contexts of the NDIS Act 2013 and Behaviour Support Rules of 2018. For change to happen in this space will more than likely rely on community-based advocacy and the voices of individuals speaking up about their experiences and needs in the political and social spheres.
In these contexts, and looking ahead proactively, people of all shapes and sizes need access to the wealth of information, knowledge, and choices that the cannabis universe embraces. Ironically, overseas legalisation happened before these educational and social movements have created resources for people to make informed choices on cannabis products. Naturally, health care professionals are conservative and reluctant to engage the public discussion and debate until there is a body of research and a social clarity on legal, ethical, moral, efficacy, and safety frameworks.
Global Turning Points and Local Struggles
Globally, however, we are now at an interesting juncture where research is being published more regularly and with ever greater urgency. Because Australians are like frogs in the pot with how slow and ineffectual political leadership tends to be, and because of past stigma and the ongoing illicit status of cannabis, most mainstream medical and allied health practitioners are not familiar with the body of research.
The history, literature, and issues are many, and at this juncture and due to the complexities it can literally take about a year for a practitioner to research and learn about the cannabis story. During this time period, a person gradually comes to terms with the applications of cannabis in health and lifestyle medicine. Now and in future years, for practitioners who are green to plant-based health, the task will be huge to come to terms with the history, evolution, science, emerging research literature, clinical applications, and recommendations.
In Australia, the help that everyday people need to make informed choices around cannabis use will likely not come immediately from GPs nor nurses. The help will not come from teachers or schools. The help will not be available from the mental health teams across the country. Even counsellors and psychologists will not be ready or prepared for this shift in society.
Since legalisation of medicinal cannabis during 2016, this country and our social services sectors have done absolutely nothing to get ready for cannabis becoming mainstream. Nothing has been done to prepare the social services sectors. To our knowledge there has been zero planning, no education and training, and even less resources developed to share information.
People in our helping professions are perhaps simply unaware. Those who are a bit more aware are likely waiting on government legislative changes, perhaps doubting the political will for change in this arena. We have certainly been among this cohort, and quite reluctant to discuss or speak up about these issues. While these doubts are well founded given the political track record is dismal, the sociology of change suggests that as people step up and share information, this will further influence the movement toward a healthy lifestyle approach to substance use. This is increasingly being understood as a human rights issue, quite apart from its obvious public health implications.
Clinical Support for a Unique Plant Culture
But thinking even further ahead… One day soon these areas of knowledge will be more common in society, i.e. cannabis will be legal and part of everyday life. What people are now realising overseas in countries like Canada, and in USA states where cannabis is legal, is that everyone needs a great deal of education to understand the types of cannabis plants available. They need help to understand the different substances within the plant that have different effects and outcomes. Individuals, families, and communities need to know about the risk profiles of different choices per each person’s needs.
In a health care future where individualised health needs are primary, cannabis is a prime example of the many dozens of choices that people will need to make as to how they use the plant and the products this industry produces. There are many choices involved in what plant, what product, and how to experience cannabis whether by smoke, vaporiser, oil, ointment, or cream. Likewise, you might want to use the active substances in the plant indirectly via cooking, eating, or drinking. For example, added to brownies, cakes, lollies, fruits, meats, soups, or other materials. Each method of interaction with the plant and its particular substances has dramatically different experiences and health-related outcomes.
The cannabis plant is not just one plant but a family of plants, all with different natures and dispositions. The family of plants that make up the cannabis mob have been extensively propagated for centuries. During the last couple hundred years the family of plants have been tailored for global consumption in an expansively individualised marketplace. However, much of the core genetic stock in the family of plants was nurtured long before modernisation and global consumption.
The emergence of an extremely organised contemporary scientific study of plant propagation, genetics, and hybrid production goes hand in hand with the global commercial production and medicalisation of the cannabis family of plants. There will be the need as time goes on for clinical expertise in cannabis related assessments associated with the integral use of cannabis in pain or anxiety management, and situating the use within everyday life, lifestyle health, and family life.
There will be the need for specialist help associated with understanding cannabis use alongside of assessment for behaviours of concern and least restrictive practices. There will be need for behaviour specialist practitioners and for disability support workers to help NDIS participants review the range of choices available, and to work alongside specialists and medical cannabis doctors and other health professionals.
In our view, the NDIS is misguided to assume that cannabis is a pharmaceutical. The plant cannot be categorised in this way alone. There is so much more to consider. Given the often dire need of people with disabilities to access sustainable alternative treatments for a wide range of issues from pain to discomfort to anxiety to chronic acute epileptic seizures, I think the NDIA will find themselves challenged by these assumptions.
Sadly for participants, who only want to have relatively equal access to services and products, which is a human right, they may feel compelled to argue the issues in court. Yet again, leaving the courts to resolve the chronic confusion that characterises the federal governance of the disability sector in Australia.
Suggestions for Support
Having said all the above, we might suggest that there are a range of approaches that need to be considered. These are based on our knowledge of current best practice approaches and circumstances. These provide basic principles to guide supportive relationships and action planning.
- Normalisation of cannabis use along with other substances appears to be taking hold across society even as associated with heavy drug use. Normalisation does not mean ignorance of risks and harm.
- Normalisation means to take a realistic attitude that weighs the benefits and costs of using a substance.
- At the same time, normalisation means that people do not judge per se, but rather seek to support people in dealing with challenges, addiction or addictive patterns.
- A healthy lifestyle model of support and treatment with substance use predominates after centuries of prohibition, even and more especially among heavy drug use and with substances that are known to be highly addictive and destructive to health.
- Taking an illicit, punitive, and stigma-driven approach does not work and the Australian community and disability services need robust assessment, treatment, and support services as of primary importance.
- Criminalisation and policing patterns further damages society, families, and communities. This is true especially among the more vulnerable populations, among Indigenous Australians, people with disability and mental health concerns, and among socioeconomic groups. This being said, affluent and middle class older Australians are among the groups whose use of cannabis and other drugs has increased in recent past years.
- Encouraging, advocating, and having access to health-based treatment options for drug over use, addiction and/or addictive patterns is essential.
- Getting one’s health back during and after facing addictive patterns of use of any substance and bringing your health back in line with healthy lifestyle and non-inflammatory diet and nutrition is also essential.
- Supporting people with disabilities in Australia to discuss, learn, and explore the circumstances and available options for medicinal cannabis use, including learning about its benefits and risks, monetary costs, and other factors, needs to be informed by the best available information.
- The human rights of people with disabilities need to be respected and upheld by balanced perspectives regarding substance use.
Featured Image Photo by Michael Fischer
