Global anthropology
University of California Press
Chapter Title: LESSONS ALONG THE PARTNERSHIP PATHWAY
Book Title: Real Collaboration Book Subtitle: What It Takes for Global Health to Succeed Book Author(s): Mark L. Rosenberg, Elisabeth S. Hayes, Margaret H. McIntyre and Nancy Neill Published by: University of California Press. (2010) Stable URL: http://www.jstor.org/stable/10.1525/j.ctt1pnmmg.11
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6 9
In a book about climbing the world’s second-highest mountain, K2 in the Himalayas, photographer Jim Curran describes the experience of seeing the peak from base camp: “There it was, unequivocal, real, present, impassive and quite monumentally huge. A great triangle that hung like a gigantic backdrop to the silent amphitheatre of Concordia. It, too, was draped in snow and its wintery vastness looked utterly impregnable, yet with a beauty and simplicity of form and balance that gave it a certain lightness that I had not expected from the many photos I had seen taken from this spot.”1 Curran’s description reminded us of the perspective of global health leaders when they set out to achieve one of global health’s daunting goals. The goal is distant, the way is risky, and success is far from certain.
This chapter lays out the key elements that contribute to success in reaching that kind of goal. We identified these elements for each stage of the Partnership Pathway: the First Mile, the Journey, and the Last Mile (Figure 5.1).
To provide an overview of all the elements, we will trace the Pathway of the Partnership Against Resistant Tuberculosis: A Network for Equity and Resource Sharing (PARTNERS) effort to address multi-drug-resistant TB (MDR-TB), beginning in the late 1990s. This project, like most partner- ships that involve a diverse group of stakeholders and a rapidly changing environment, had its shortfalls. Fortunately, when we interviewed indi-
Chapter 5 lessons alonG
the partnership pathWay
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7 0 i n s i g h t s F R o M Pa s t Pa R t n e R s h i P s
viduals who had participated, they were willing to dissect those shortfalls, to help others learn how to avoid them. “Having the experience of running this project was the most valuable experience of my life. It was an incredibly important first foray in attempting to scale up a complex health interven- tion,” recalls Jim Yong Kim, who served as principal investigator on the project and chairs the Department of Global Health and Social Medicine at the Harvard Medical School. “It made me ready for my experience at WHO.” At the same time, he recognizes, “It’s not that there’s noth- ing we could have done differently. But there wasn’t a body of scientific literature on the scale-up of complex interventions that could guide us.”2 Mark Rosenberg, who joined Kim in developing the project, admits, “It takes courage to say we didn’t always know what we were doing, but it’s necessary if we want to draw lessons from the experience.” In fact, it is often the ability of partners to adapt to external forces that allows them to succeed. Using this partnership as a reference point, we discuss each stage below, beginning with the amorphous, pre-partnership period we call the “Genesis.”
the genesis Of a PartnershiP
The Genesis of a partnership lies in the realization by individuals that they have an opportunity to make a real difference in the world. This moment of realization typically has a catalyst, such as a report that confirms cause- effect linkages or a technology breakthrough that makes treatment more viable. As we described in Chapter 3, such catalysts occur at key points in the evolution in addressing a disease or health threat, and partnerships are often born at these points. The impetus may begin with an entrepre-
GENESIS THE FIRST MILE THE JOURNEY
THE LAST MILE
Partnership pathway
figUre 5.1 Partnership Pathway. A simple diagram of a partnership’s pathway to achieving its goal allows a comparison of the complex activities and interactions that occur in each stage.
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l e s s o n s a l o n g t h e P a R t n e R s h i P P a t h w a Y 7 1
neurial individual who has a vision, a “social organization” of like-minded associates, or a donor organization that identifies a need it would like to address. It may even arise out of a group’s desire to have its voice heard. Whatever the source, a program idea emerges, and from that seed a part- nership begins to form. The Genesis of the PARTNERS project falls into the “social organization” category. Like many partnerships, it began with individuals who tapped others they had come to trust. These particular individuals, Paul Farmer and Jim Kim of Harvard Medical School, had been trying to develop a viable treatment for MDR-TB for many years. (This project took place before the identification of an even more resistant strain — XDR-TB.)
mdrtb is resistant to the two most powerful antitb drugs available —
isoniazid and rifampicin. treatment is long, complex, and costly. it requires
simultaneously administering as many as seven or eight expensive second
line antitb drugs for eighteen to twentyfour months. Partners in health
(Pih), headed by farmer and kim in conjunction with socios en salud
(ses), had begun to treat a number of mdrtb patients in Peru with indi
vidualized regimens and believed they had a successful approach. it
involved using community health workers to watch patients take the drugs
each day and support them as they experienced the intensive side effects.
the results of this approach were highly encouraging, but funding was run
ning out.
in 1998, farmer and kim approached howard hiatt, their former dean
at the school of Public health at harvard about the possibilities for funding
a new partnership. hiatt suggested they talk to another former student he
had mentored, mark rosenberg, at the task force. in turn, rosenberg
persuaded bill foege, then transitioning from the task force to the bill &
melinda gates foundation, to join their discussions. when the four met at
the task force, foege encouraged them to develop a worldwide vision,
with a goal of demonstrating the feasibility of their approach in resource
poor settings. that could set the stage for policy change at whO. excited
about the broader vision, this core group began to talk about the member
ship needed for the project.
in 1999 the gates foundation agreed to fund a feasibility project in Peru
to test their approach.
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7 2 i n s i g h t s F R o M Pa s t Pa R t n e R s h i P s
Spirits once again rose in the core team as they made their plans for the first meeting of the broader partnership. PARTNERS had entered its First Mile.
the first mile
Because of the optimism and sense of possibility that typically characterize the beginning of a partnership, the First Mile is an opportunity that does not come around again, as many global health leaders have told us. Like the base camp of a mountain-climbing expedition, this period offers a chance to consider the foundational elements and reach initial agreement about them. For mountain climbers, this is when they acclimate themselves to the altitude, agree on their roles, and prepare for the climb. For a global health partnership, it’s a chance to choose the right membership, develop a shared goal and tools to measure progress toward it, select a structure, shape a big-picture strategy, and clarify organizational roles — the foundational elements for close collaboration (Figure 5.2). (While discussions of goal and strategy might logically come before a discussion of structure, in reality, when people arrive for a first meeting, they typically want to know who will be in charge, so partnerships often prefer to resolve structure issues first.)
Below we return to the MDR-TB PARTNERS project to convey a sense of how partners can approach these foundational elements. (Chapter 6 discusses these elements in greater length.)
GENESIS THE FIRST MILE THE JOURNEY
THE LAST MILE
Key elements
• Choosing the right membership • Developing a shared goal • Selecting the appropriate structure • Shaping a big-picture strateg y • Clarifying organizational roles
figUre 5.2 Partnership Pathway: The First Mile. Like the base camp of a mountain climbing expedition, the First Mile requires partners to consider the foundational elements and reach initial agreement about them.
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l e s s o n s a l o n g t h e P a R t n e R s h i P P a t h w a Y 7 3
Choosing the right membership
The membership of a partnership may start with a core team of visionary people who have worked together on other issues. But that core team, like the PARTNERS core team, probably needs additional members for the proj- ect. Potential members include representatives of other stakeholder groups, including in-country champions of the affected population. (Chapter 6 discusses the considerations in choosing the right partners.)
As the core team for the PARTNERS project began to draft their grant proposal for the Gates Foundation, they discussed potential members. They decided the partnering organizations should be PIH/SES, the CDC, WHO, the Task Force for Child Survival and Development, and MINSA (the Peruvian ministry of health), which would all be needed to implement the approach on a larger scale. At this point they named the group the Partnership Against Resistant Tuberculosis: A Network for Equity and Resource Sharing (PARTNERS).
developing a shared goal
The second foundational element is a clear vision and goal to inspire the members and clearly define the Last Mile of the effort. Partnerships often find it helpful to begin with a vision. David Ross, director of the Public Health Informatics Institute, makes this analogy: “As in the physical world, a partnership needs a force that ‘keeps the molecules together.’ If a compel- ling story of need and urgency is not there, you are just not going to keep it together.”3 This “compelling story” is expressed as a vision — a view of what the world can be like once the partnership completes its work.
The goal itself clarifies the purpose of the partnership, and agreement on how it will be measured makes it even clearer to partners. For example, Bill Foege recalls how public health leaders in the United States defined their goal for addressing measles in the late 1970s.
there was much debate over how to reduce the impact of measles in the
United states. many wanted to select a target of reduction, such as a 90
percent reduction in cases and a 95 percent reduction in deaths. it was
finally decided that the goal would be to interrupt indigenous transmission of
measles in the United states. it was feared that a goal of reduction would
not be adequate to identify the ultimate barriers.
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7 4 i n s i g h t s F R o M Pa s t Pa R t n e R s h i P s
it seemed an impossible goal and yet it catalyzed a collaboration of fed
eral, state, and local health agencies as well as educational institutions,
pediatricians, parents, and others, with the result that one barrier after
another was identified and corrected. all measles cases in the United
states today are due to importation; indigenous transmission has been
halted.4
Through an exchange of ideas, global health leaders had sidestepped the seemingly powerful reduction goal and developed the non-numeric but ultimately more powerful goal of interrupting indigenous transmission.
As a core team of the PARTNERS project discussed their goal, they had the benefit of a visionary leader in Kim. He spoke of enabling victims to live productive lives in areas where MDR-TB was endemic. With Foege’s encouragement, he and others on the core team broadened that vision to include all resource-poor settings, with a goal of demonstrating feasibility of their approach. As the proposed partners convened for their first meeting in early 2000, they had this vision and goal as a starting point:
building on the core group’s ideas, they refined the primary goal, deciding
it would be to demonstrate the feasibility of tb control programs that
combined mdrtb with directly Observed therapy shortcourse (dOts)
to treat mdrtb successfully in resourcepoor settings. this, they believed,
would provide a model for efforts in other highburden countries. (a simi
lar effort was launched in tomsk, russia.) they also set a secondary goal
(among others) of defining and establishing the necessary infrastructure in
Peru to sustain a successful program after the grant ended.
With this shared goal and a shared vision, PARTNERS had successfully established the second of the critical elements for a strong collaboration.
selecting the appropriate structure
Structure discussions are also essential during the First Mile. “Structure” may mean deciding how the secretariat function will be carried out, defin- ing the focus and composition of work groups, or any number of things that contribute to how the work will be organized. In the PARTNERS project, for example, the secretariat was initially located at the Task Force (and later
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moved to PIH). Working groups were also part of the discussions in the first two official meetings.
the gates foundation awarded the grant in august 2000, and the partners
held their first formal meeting in november — a planning meeting with
breakout groups addressing clinical issues, populationbased program issues
(including how to arrange for laboratory services), and policy and commu
nications issues. in early 2001 the partners met again to agree on an oper
ating plan and structure the working groups.
In September 2001, PARTNERS refined the structure (consolidating nine working groups into six) and clarified their five-year objectives. The third element was in place.
shaping a bigpicture strategy
One element of structure was also part of the PARTNERS strategy. In the traditional definition of strategy as where, what, and how to achieve a goal, they knew the “where” and “what” of their strategy — they wanted to demonstrate the feasibility of using directly observed therapy to treat MDR-TB by piloting an effort in Peru. But they needed an additional ele- ment of strategy that would define the “how” of drug distribution, a major challenge.
a critical element of the strategy they agreed on was the formation of a
green light Committee (glC). made up of experts from key organizations
with experience in treating mdrtb, this committee would negotiate
lower prices for secondline antitb drugs in exchange for deliberate over
sight of their proper use.
PARTNERS, once again, had successfully shaped a key foundational ele- ment of their project.
Clarifying Organizational roles
The last key element of the First Mile is a shared understanding and accep- tance of organizational roles. With the cultural differences that characterize global health partnerships, this element is often the most difficult to build.
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7 6 i n s i g h t s F R o M Pa s t Pa R t n e R s h i P s
The cultures of various member organizations come into play; individual styles can create conflict; and even different language interpretations can lead to misunderstanding. When agreement on roles is not achieved in the First Mile, conflict is inevitable. When agreement is successfully navigated and members clearly understand those roles, partners can begin to build trust. In the PARTNERS project the grant proposal had spelled out the organizational roles (Table 5.1). With these roles clearly defined, the mem- bers enthusiastically launched the intervention.
The members of PARTNERS who spoke with us believe, in retrospect, they were relatively strong in addressing the elements critical to the First Mile. They had included the right members; the vision and goal had been shared; the structure of working groups had been clear and practical; the strategy had been on target in some ways (with the GLC being a key com- ponent); and roles had been clearly defined. The rest of the Pathway would prove to be more problematic, however.
the JOUrne y
Once members of a partnership have agreed on the foundational elements, like climbers on K2 or Everest, they begin the arduous work of moving toward the goal, dealing with hazards and obstacles every step of the way.
table 5.1 Organizational roles: PARTNERS
Partner(s) Organizational role
Centers for Disease Control (CDC) Conducting research and setting standards
Partners in Health (PIH) and Socios en Salud (SES)
Providing treatment and collecting clinical data
Peruvian Ministry of Health (MINSA)
Developing capacity for countrywide expansion and sustainability
Task Force for Child Survival and Development
Serving as neutral convener and facilitator
World Health Organization (WHO)
Implementing Green Light Committee and setting policies
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As one global health leader remarked, the experience is one of constantly dealing with opposing forces — one force field moving you forward and another countering your every movement.
During this time, management and leadership become extremely impor- tant, as the photographer Jim Curran observed when his team ascended K2. Unfortunately, the leader of the K2 team was more interested in his functional role of climbing than in managing or leading. As Curran recalls: “Al [Rouse] was first, last and always a climber; everything else paled into insignificance. . . . [He] was determined to lead from the front and was pushing himself, as always, very hard, having little energy left for organiza- tional matters.”5 As a result, an undercurrent of distrust began to emerge among the K2 team members.
The members of PARTNERS ran into a similar issue, the first sign of real difficulties ahead. Although the organizational roles had been clearly defined, members sometimes failed to fully respect those roles, and the partners never seemed to develop a cohesive energy for achieving the goal of the partnership. Alan Hinman, the representative of the Task Force during this period, reflects on the missing aspects of the partnership:
Partners in health and socios en salud were understandably concerned
with taking care of the patients standing in front of them or outside their
door. they didn’t necessarily focus on how it would lead to a nationwide
program that was exportable. CdC, meanwhile, was doing what it was
asked to do, but not spontaneously asking, ‘what can we be doing to
achieve the goal of reaching an exportable program?’ whO thought of its
role in terms of the glC — getting money to support the glC and the
mdrtb working group.6
“it wasn’t that we argued bitterly or that there was any ill-feeling. Quite the
contrary, as we drank the evenings away in the agreeable company of our hosts
in the british embassy club. but there was an underlying feeling that the eleven
of us were not yet making a team. already there was too much point-scoring
and criticism, rather than support and agreement. no one was trying to, it
just happened, and it forced people onto the defensive.”
Jim CUrran, photographer, mountain climber, and author of K2: Triumph and Tragedy
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7 8 i n s i g h t s F R o M Pa s t Pa R t n e R s h i P s
In retrospect, it’s apparent that although organizational roles were clear, some of the needed individual roles were not being filled.
The global health leaders who talked with us clarified the individual roles that are needed on any team during the Journey to their goal. In a sense all of these are leadership roles, but some of them relate more to day-to-day management, so we captured the lessons they described in two categories: bringing disciplined but flexible management and developing complemen- tary leadership (Figure 5.3).
disciplined but flexible management
Virtually every partnership we examined said they felt the need for greater management discipline. At the same time many global health leaders emphasized that management needed to be flexible to deal with the unex- pected. Some of the individuals who participated in the PARTNERS project were frank about the lack of management discipline on the project. Rosenberg recalls:
none of us foresaw how great the need would be for good management to
actually implement the decisions we had made. we thought our challenge
was to bring complex health interventions to resource-poor settings, but we
realized the real challenge was delivering complex health interventions to
management-poor settings. we didn’t realize how important management
was or how big the management deficit was in all of us.7
For example, processes for planning and communicating were conducted on the fly, and no individual partner clearly wore the hat for managing those processes.
Members of PARTNERS now see, in hindsight, that more time spent in project planning would have helped them understand such things as how much lead time would be required to build local lab capacity. Like any program in a developing country, they faced difficulties of infrastructure: patients were in remote areas, lab capacity was inadequate, systems for recording and reporting treatment needed improvement, and local health workers were scarce and needed training and equipment. Given these dif- ficulties, planning was particularly important.
Hinman remembers the lack of an effective means of communication
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among partners: “Mark [Rosenberg] and Jim [Kim] would talk, but some- times they’d forget to pass it on. Some kind of explicit communication strategy would have helped, so when the challenges came up, we could have shared ideas on what we would do about them.”8 With an early focus on planning and a continued effort to keep the members engaged in solving problems and refining their plans, PARTNERS could have saved valuable time and increased their impact.
Complementary leadership
Our research also led us to the conclusion that success depends on the ability of partners to assume complementary and essential individual leader- ship roles (as distinct from organizational roles). Members of PARTNERS assumed some of these leadership roles naturally. Jim Kim assumed the role of visionary/strategist, in cooperation with Socios en Salud, and Mark Rosenberg put his energies toward convening and team building. But because the partners never assumed other necessary management and leadership roles, the partnership was unable to respond effectively to some of the challenges along the Journey. For example, the nine working groups never seemed to get traction and were ultimately disbanded. That difficulty
GENESIS THE FIRST MILE THE JOURNEY
THE LAST MILE
Key elements
• Bringing discipline and f lexibility to management • Developing complemetary leadership
figUre 5. 3 Partnership Pathway: The Journey. The individual roles needed on any team during the Journey fall into two categories: disciplined but flexible manage ment and complementary leadership.
“there are some things you cannot take for granted; they require work and
commitment. communication is one of them.”
lOUis de merOde, consultant, silver creek associates, november 12, 2005, interview
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8 0 i n s i g h t s F R o M Pa s t Pa R t n e R s h i P s
would seem minor, however, as the impact of gathering external forces became apparent.
the l ast mile
The term “the Last Mile” is used in many contexts in global health. It often means putting in extra effort, as in “going the last mile.” Sometimes it’s used to refer to the final period in the evolution of addressing a disease. For example, in eradication efforts the last mile might be interpreted as making sure the last people are vaccinated. In this book we’re using “Last Mile” to refer to the final stage of a partnership, when achievement of the goal is in sight.
But what does that mean, in practical terms? For every partnership the definition of the Last Mile is different. For the PARTNERS project the Last Mile began when the partners realized they would soon have the data to demonstrate feasibility. For a project that involves a country rollout, the Last Mile may begin with the final phase of the rollout. For a research project it may mean trying to eliminate side effects for a drug that has oth- erwise proven to be effective. For a political advocacy project, it may begin with agreement of a key governmental group to hold a meeting focused on the subject. The keys to success in the Last Mile are adapting the approach to sustain the momentum, transferring control in a supportive way, captur- ing and communicating lessons learned, and actually shutting down the partnership when the goal has been achieved (Figure 5.4).
The Last Mile was a difficult period for PARTNERS. For any partnership this is the stage when centrifugal forces may be greatest — when membership tends to turn over and the remaining members often shift their focus to other efforts. The hard-won understanding and openness between members can vanish with such changes. Many people have told us about partnerships that were collaborative early in their Pathway but lost that quality before the Last Mile was completed.
In fact, turnover of the individuals serving on PARTNERS after the first two years did weaken those aspects of the partnership that had contributed to unity in the early days. Jim Kim, for example, left PIH to join WHO; Paul Zintl from PIH assumed the role of project manager; and Paul Farmer assumed the role of principal investigator. Many other members rotated out and were replaced, creating discontinuities that affected not only leadership
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and management but also the culture and previous understanding within the group. The collaborative spirit that had infused the beginnings of the project diminished to the point that some of the partners felt they were only going through the motions of collaboration. These changes made the partnership less resilient in finding ways to sustain momentum and transfer control when one of their greatest difficulties became a reality—health sector reform.
On a single day in the spring of 2003, the partners learned that Peru’s entire Ministry of Health was being restructured. PARTNERS had been working with individuals or entities in the ministry to develop a strategy for sustaining the effort, but now they no longer knew which individuals at the ministry would be in charge of MDR-TB. A lag in drug supplies com- pounded the problem. Unfortunately, the partners lacked the cohesiveness to respond with a single voice to help MINSA ensure that treatment in Peru would continue to move forward without interruptions in the drug supply.
While adapting the approach and transferring control in a supportive way were problematic for PARTNERS in Peru, given health sector reform, the partners were attentive to capturing lessons learned. Zintl recalls: “While working on the ground in Peru and Russia, we worked hard with our colleagues from both countries to coauthor papers and support their pre- sentations at international meetings, including those sponsored by WHO and the International Union of TB and Lung Diseases. In the face of this chorus demonstrating that DOTS-Plus worked, the skeptics were no longer able to make the case that treatment for MDR-TB didn’t work. We learned
GENESIS THE FIRST MILE THE JOURNEY
THE LAST MILE
Key elements
• Adapting approach to sustain momentum • Transferring control in a supporti ve way • Capturing and communicating lessons learned • Dissolving the partnership when the goal is achieved
figUre 5.4 Partnership Pathway: The Last Mile. While centrifugal forces may be greatest in the Last Mile, attention to key elements helps keep partnerships on track to meet their goals.
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8 2 i n s i g h t s F R o M Pa s t Pa R t n e R s h i P s
you have to work on a hundred different fronts to change policy . . . but it can be done.”9
Zintl describes the importance of other lessons he took with him in 2005 when he went into Lesotho to treat HIV/AIDS victims once the PARTNERS project had ended:
we went in there not knowing what we were going to find other than a
horrendous epidemic — but knowing that much of what we had learned in
Peru would be needed in lesotho: training and paying community members
to deliver care to impoverished patients, while also working with people at
upper levels in the ministry so that ministry budgets would provide the care
these patients needed. in Peru we worked with a community in lima norte
to show that this patient care could succeed, and then we worked with the
ministry of health so they would support that care. but it all started with
the needs in the community — you can’t start implementing health care
without knowing what it is that patients in that community most need, if
they are to be cured.10
The lessons had not only been communicated; they were being applied to other diseases.
Looking back on the PARTNERS project in Peru, the individuals we interviewed are enormously proud of the result, although they are well aware of the project’s shortcomings. Says Kim, “We went from MDR-TB being a death sentence in developing countries to a change in perception that it was a treatable disease, even in the poorest settings.” As a result of these efforts, he says, “a switch in thinking happened.”11
in the end Partners did, in fact, demonstrate feasibility. the approach
was successfully applied in estonia, latvia, lima, manila, and tomsk, show
ing dramatic cure rates for a disease widely thought to be untreatable in
developing countries. initial cure rates across these programs, excluding
chronically ill patients, ran between 61 percent and 80 percent. at the same
time costs dropped dramatically for secondline drugs obtained through
the glC. (the glC provided a method for monitoring drug use and making
drugs available only when they’re used according to specific guidelines.)
in march 2005, whO passed a resolution declaring a change in policy
to integrate dOtsPlus and mdrtb treatment, making mdrtb treat
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ment available to every patient, everywhere. the global fund to fight
aids, tb, and malaria also adopted a policy requiring that all countries
using global fund resources for treating patients with mdrtb receive
green light Committee approval on their projects.
The primary goal of the partnership had been met, and people across the world have been able to live longer and more rewarding lives. Since the proj- ect began, the GLC has approved more than 47,000 people for MDR-TB treatment across the world, some by PARTNERS and many others by organizations that built on the PARTNERS approach.
As the experience of PARTNERS and other partnerships have shown, collaboration is both difficult to achieve and easy to let slip away. While we found no magic bullet for developing and sustaining the open and trusting spirit of real collaboration, we did find the critical underpinnings that allow it to happen: first, getting the right people to the table, finding a shared goal and vision, and laying down the basics of structure, strategy, and roles; second, applying management discipline and playing complementary lead- ership roles along the way; and, finally, seeing that the partnership makes it over the goal line and hands off to the next team in a way that supports their success. (Capturing and communicating lessons learned and dissolving the partnership contribute to the success of global health in general.) As Kim explained, the “science” of scale-up did not exist when they began their work.12 But as they and other partnerships share their lessons, the “science” of global health collaboration in partnerships becomes less of a mystery.
The following chapters cover each stage of the Partnership Pathway in greater detail and draw on the insights gleaned from successful and unsuc- cessful partnerships. Of course, these insights are not a formula to solve all the problems of global health, but we hope these ideas from experienced global health leaders will help partnerships improve collaboration. As these leaders told us many times, it is worth learning to collaborate well because of the impact you can have together.
nOtes
1. Curran, K2: Triumph and Tragedy, 40. Photographer Jim Curran is not the Jim Cur- ran who heads the Rollins School of Public Health.
2. Kim, interview with the authors, March 10, 2004.
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8 4 i n s i g h t s F R o M Pa s t Pa R t n e R s h i P s
3. Ross, interview with the authors, January 29, 2006. 4. Foege, interview with the authors, August 16, 2004. 5. Curran, K2: Triumph and Tragedy, 79 and 54. 6. Hinman’s comments are from a group interview with the authors on March 10, 2004. 7. Rosenberg’s comments are from ibid. 8. Hinman’s comments are from ibid. 9. Zintl’s comments are from ibid. 10. Ibid. 11. Kim, interview with the authors, March 10, 2006. 12. Ibid.
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