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Monthly update from UNFPA in Asia and the Pacifi c JANUARY-FEBRUARY 2012

Rewarding the Heroic Work of Midwives in Afghanistan

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IN THIS ISSUE
At the Heart of Sex Selection, a Preference for Boys page 4 Teaming Up to Provide Maternal Care Following Severe Floods in the Philippines page 5 Our Human Footprint page 7 A Fruitful Trip to Seoul for UNFPA Executive Director page 9 PUBLICATION: Global Meeting on Skewed Sex Ratios at Birth page 9 UNFPA Joins the Hellosmile Global Project to Prevent Cervical Cancer page 10 VIDEO: Preventing Childbirth Injury in Nepal page 10 VIDEO: UNFPA Provides Maternal Care Following Severe Floods in the Philippines page 10

Photo: Zubaida Akbar / UNFPA Afghanistan

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Rewarding the Heroic Work of Midwives in Afghanistan
KABUL - In mid-December, Maliha walked for five days to reach Faizabad, the capital of Badakhshan, in northeastern Afghanistan, to receive her award as best midwife in the province. She felt proud as she went onstage to be honoured for her work in her community health clinic. Though Maliha is just 25 years old, she is a local hero, having delivered hundreds of babies since graduating from the Community Midwives Education Programme six years ago. With technical support from the Afghan Midwives Association, the programme trains women in rural areas that lack health clinics. In return, trainees are required to commit to returning to their villages for six years to set up a practice in a family health house, a relatively new health model in the country. The clinic is either an annex to the midwifes housing compound or close to her home. It consists of two rooms built by community labour, known as ashar, with the roofing, beams, tiles and windows provided by UNFPA as in-kind contributions. The midwives are responsible for providing round-the-clock services to neighbours within a two-hour walk from the health house. The process for setting up the clinic begins long before the midwife is trained. Community approval must be obtained so that the elders and everyone else are behind it. Once that happens, the midwifes husband, father and father-in-law will also endorse the project, making it a highly respected entity in the community. In fact, the midwives role is growing so popular that men are apparently looking for a wife who is a midwife because she can be an economic resource for the family. Competition is keen among women in the community to be trained, and they must get high test scores to be chosen. Two volunteer community health workers - one male and one female - in the family health house assist the midwife; though they also compete for the posts, they could technically be relatives, including husbands, of the midwife. Family health house model expands its reach The health house approach is critical in rural regions, where most Afghans live, often isolated up to six
Photo: Zubaida Akbar / UNFPA Afghanistan

Maliha, the first winner of the Delivering Health, Saving Lives award for Afghan midwives.

months of the year because of brutal weather. Supporters say the model will reach up to 4,000 people by 2013. To recognize the major role that midwives can play in Afghanistan, where giving birth remains a dangerous endeavour, the Afghan Midwives Association, the Ministry of Public Health and UNFPA recently created the Delivering Health, Saving Lives award to celebrate talented midwives on a provincial and national level, the criteria being those who have shown integrity, commitment and acted as positive role models for women empowerment in their community. Maliha, who received a certificate signed by the Ministry of Public Health and a portable midwife kit, was the first honouree. She and others will be recognized at a national ceremony in Kabul in May commemorating International Day of the Midwife. Lack of trained health workers It is no easy feat to be a midwife in Afghanistan, where only about 2,331 of them serve a population of about 6.4 million women of reproductive age. The combined total of midwives, nurses and doctors amounts to less than 1 for every 1,000 people, according to the State of the Worlds Midwifery 2011 study by UNFPA. That number is especially low, considering Afghanistans high fertility rate (5.1 children for each woman, according to the comprehensive 2010 Afghanistan Mortality Survey report.)

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Monthly update from UNFPA in Asia and the Pacifi c

JANUARY-FEBRUARY 2012

Remote areas report show disproportionately higher rates of maternal death than urban areas, however, since they lack infrastructure and distances to service centres are far. Infant death rates have also decreased, the Afghanistan Mortality Survey reports, as the country is making strides in improving publichealth services. In a country like Afghanistan, where women, especially in remote areas, cant really access medical facilities because they lack women heath workers, a midwife can save a womans life, said Sabera Turkmani, president of the Afghan Midwife Association. That is all the more reason to award a midwife like Maliha, who helps up to 25 women go through delivery in her village every month. It is a huge responsibility to help these women and save their lives, but I feel lucky to have this opportunity to help other women, Maliha said upon receiving her award. Intensive training Students are taught for two years, during which they gain a basic knowledge of obstetrics, neonatology, public health, family planning, prenatal care, delivery care and more. The school provides access to medical and nonmedical equipment and is linked with clinics for residencies. The cost to train one midwife is $20,000 to $25,000. Parisa, the midwife winner from Herat, noted that women in remote districts cannot afford to come to the hospitals in Herat city center. When I graduated from the Midwifery Institute of Herat two years ago, 40 other women graduated with me, she said. Right now, I know that 39 of them are working in different clinics in Herat city and districts. This is a very good sign. This means

A classroom setting for the midwives programme.

that now more women have some kind of access to a health-care provider. State of reproductive health care Cultural restrictions, low economic status, little awareness about health issues, problems of access, gender inequities and the limited number of female health-care workers challenge the already meager reproductive health system in the country, where only a quarter of all births are attended by skilled health personnel. Currently, women represent a minority of the health-care workforce. UNFPA maintains its commitment of support to the Government of Afghanistan and professional societies like the Afghan Midwives Association to address the critical issue of maternal health in Afghanistan, said Dr. Laurent Zessler, the UNFPA representative in the country. There have been improvements in coverage of key health interventions, and multiple programmes are being implemented that are contributing to this improvement, but there is much work yet to be done and donors and partners should remain engaged and committed in Afghanistan. UNFPA Afghanistans support of midwifery includes the schools of the Community Midwifery Education programme; development of a regulatory system for midwifery and policy and strategy for nursing and midwifery services; capacity building for publichealth staff and midwives at provincial levels; and support of professional associations, such as the Afghan Midwives Association. - Gaia Chiti Strigelli

Photo: Zubaida Akbar / UNFPA Afghanistan

Midwifery training programmes, organized by international agencies, national ministries and the United Nations, are addressing the need in Afghanistan for more skilled maternal care. And Afghanistan has been making important progress in reducing maternal death rates - showing a 22 per cent decline since 2000, according to the UNFPA report.

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At the Heart of Sex Selection, a Preference for Boys
technologies and a trend toward smaller families. High imbalances also indicate gender inequality in a country, a problem that can be tackled by governments placing more emphasis on empowering women and improving pensions, so parents do not think they need only sons for economic support in old age. Of the 14 countries (primarily in South Asia, South-east Asia and Central Asia) most affected by sex-ratio imbalances, the report said that almost 20 per cent of the missing girls in the world, estimated to be 39 million under the age of 20, disappear after they are Sex ratio imbalances remain throughout numerous Asian countries, including Viet Nam. born through malnutrition, infanticide and Some regions in the country, however, have leveled off to normal range. other related causes. In India, for example, it is reported that 271,000 girls have gone missing The sex-ratio imbalance that has plagued certain since birth. Asian countries has been increasing in the last few years with one exception, the Republic of Korea, The long-term consequences of demographic while a few European countries, including Albania, imbalances are still unclear, though many countries Armenia and Montenegro, are showing rises too. with high ratios will experience a marriage squeeze for men 20 to 30 years old, making it more difficult Moreover, some regions of China, India and Viet for them to find a partner. Another concern is the Nam - countries with a traditionally high sex-ratio phenomenons move to new regions, like Eastern imbalance (which is the ratio of male to female Europe. In Albania, for instance, there is a high level births in a population, with normal ranging from of violence against women, though inheritance 104 to 106) - have been levelling off or reversing. Sometimes, there are cultural quirks, and it is not just is equal and laws related to gender equity have been enacted. Until recently, the issue of sex-ratio the first-born child that is pre-selected; in Armenia, imbalance received little attention, but that has for instance, sex ratio for the first and second child changed. is regular, but for the third and fourth, it is 175. And in Nepal, groups with the lowest levels of gender Ultimately, the report suggests, more attention equality have the highest sex-ratio imbalances. should be paid to patriarchal traditions to help guide interventions. The report notes that making A workshop organized last fall in Ha Noi by UNFPA, with the Viet Nam United Nations Country Team and sex-selective abortions illegal does not solve the problem. the other partners, addressed geographic trends, shared experiences and aimed to create southMany of the affected countries are experiencing south cooperation to further combat demographic huge upheavals at institutional, economic, political imbalances. A report of the workshop, Skewed Sex and socio-cultural levels. Ratios at Birth, was recently published by UNFPA. In recent decades, ratios in some countries have jumped to as high as 130 or above, a cause of concern for governments, demographers and human rights groups, among others, who say that the root cause is son preference, though other factors play a part. These include use of new sex-selection Demographic transitions in fertility and urbanization, as well as increasing labour shortages, will also continue to influence son preferences. The continued need for further research on the dynamic should help clarify ways to prevent it in the future.

Photo: Mark Garten / UN Photo

Monthly update from UNFPA in Asia and the Pacifi c

JANUARY-FEBRUARY 2012

Teaming Up to Provide Maternal Care Following Severe Floods in the Philippines

Mindanao and Eastern Visayas regions in southern Philippines. The UN estimates some 10,000 pregnant and lactating women and around 20,000 young people aged 10 to 25 have been affected by the floods in the cities of Cagayan de Oro and Iligan and in the provinces of Bukidnon, Lanao del Sur and Negros Oriental. In total, about 135,000 families or 650,000 individuals were affected by the disaster, with 553,000 people left homeless. Some 4,600 families or 23,000 people remain in evacuation or relocation sites, with the rest seeking shelter outside the camps. The UNFPA assistance includes distribution of dignity kits to all pregnant and lactating women, clean delivery kits to women in their third trimester of pregnancy, and special medical missions designed to reach pregnant and lactating women and their infants. The dignity kits, containing 18 items for basic sanitary supplies such as soap, a bath towel, toilet paper, sanitary pads, and other items, are distributed to protect the women and their babies from disease and infection. They are packed in a covered plastic bucket that can later be used to store clean water. Blankets and additional underwear are also provided. UNFPA has also designed a personal hygiene kit for young people, with contents, such as combs, toothpaste and deodorant, that were requested by the young people themselves. The clean delivery kits, meanwhile, are intended for use in case of an emergency childbirth outside a birthing facility. These are given only to pregnant women who are in their final three months of pregnancy. Miraflor Cainoy, 31, one of the recipients of the clean delivery kits during the early phase of the humanitarian response, is now sheltered at the Calaanan Tent City. She had given birth on January 11 and happily narrated that she did not forget to bring with her the clean delivery kit she received from

Photo: UNFPA Philippines

Obstetricians providing help to pregnant women affected by the severe floods

NORTHERN MINDANAO, Philippines - In the midst of the severe flooding brought on by tropical storm Washi, Analiza Tumanda was resigned to the idea of giving birth on the rooftop of a neighbours house. But as raging floodwaters started sweeping away houses along the banks of Cagayan River, Analiza, her husband and their three children (ages 8, 6 and 3) were forced to flee, moving from one rooftop to another along with neighbours. Although she was in her ninth month of pregnancy, she hadnt expected to delivery any day soon. But the fear, anxiety and physical stress exacted their toll, and her labour pains started. It was already past midnight and I really thought I would deliver right then and there, the 30-year-old mother recalled. My neighbours were also running for their lives and trying to get help. But when they realized my condition, they prioritized getting help for me. Several minutes later, policemen arrived onboard a pump boat, and they rushed her to the nearest village health station that was still safe from the rising water. Soon after, she delivered a healthy baby girl, who was later nicknamed Sendang, the female version of the storms local name Sendong. More than 4,000 pregnant and lactating women assisted Analiza is one of the more than 4,000 pregnant and lactating women reached so far by UNFPA in its relief efforts to assist storm survivors in Northern

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services also, she said after attending the health information session. Advocating for pregnant and lactating women The UNFPA achieved a milestone in the humanitarian assistance with the creation of the reproductive health and sexual and gender-based violence prevention sub-clusters within the UNs cluster approach in humanitarian response. Through the persistent work of the sub-clusters, issues and concerns about pregnant and lactating women were mainstreamed in the humanitarian assistance. In the allocation of spaces in the temporary relocation sites called the Tent Cities, the Department of Social Welfare and Development included families with pregnant and lactating women in the list of priority beneficiaries. Subsequently, women-friendly spaces were also accommodated in relocation sites and evacuation centres. These women-friendly spaces are envisioned to be a space where women can access information and services on such concerns as maternal health and cases of gender-based violence. They also serve as a centre for initiating income-generating programmes. Discussions have begun on a cash-for-work programme specifically designed to provide livelihoods for pregnant and lactating women. Mobilizing youth volunteers UNFPA attributes the successful advocacy for the welfare of pregnant and lactating women to the partnerships forged with various organizations. Some have been around for years, while others merely started at the early phase of the emergency. In the aftermath of the disaster, UNFPA mobilized youth volunteers from the Family Planning Organization of the Philippines (FPOP) in Cagayan de Oro City and the UNFPA Youth Peer Education Network (Y-PEER) in Iligan City to identify pregnant and lactating women in the evacuation centres, which allowed the UNFPA to prepare for finely tuned response. The youth volunteers role, however, did not end there. During medical missions and distribution of next page

Photo: UNFPA Philippines

Miraflor Cainoy holding her baby

UNFPA when her husband took her to a birthing centre. Having the kit with me somehow gave me a sense of security that my baby and I will be okay. The kit was used by the doctor and midwife who assisted me during my delivery, said the new mother of a baby girl, the third child in the family. Medical missions to support reproductive health Beyond the distribution of the kits, UNFPA continues to conduct medical missions in evacuation centres and relocation sites for flood survivors. So far 23 medical missions have been conducted in Cagayan de Oro, Iligan, and in the municipality of Bubong in Lanao del Sur. As part of the medical missions, a series of health information sessions are also conducted, focusing on specific topics such as safe motherhood, prevention of sexually transmitted infections, family planning, prevention of violence against women and life skills for young people - all in the context of a humanitarian situation. When the medical mission reached the evacuation centre where Analiza and her family are temporarily sheltered, she expressed relief as she said they havent been seen by a doctor since she gave birth. Except for minor ailments such as colds, my baby is fine but I still want her to get checked. I am also worried about getting pregnant again because of our current condition so I want to avail of family planning

Monthly update from UNFPA in Asia and the Pacifi c

JANUARY-FEBRUARY 2012

Our Human Footprint

dignity kits, they continued to provide support. Rain or shine, they visited evacuation centres explaining the use of the kits, carrying the kits for the mothers, and engaging young people in focus group discussions. A broad coalition of partners Some of our members were also affected by the disaster but we are thankful that we are still standing. We can only express our gratefulness by assisting those who were hit the hardest, says Renie Paja, the youth representative of FPOP. The conduct of the medical missions was made possible through the active participation of numerous government agencies and private organizations, such as the Department of Health, Department Medical check-up performed on a mother affected by the distaster. Photo: UNFPA of Social Philippines Welfare and Development, Philippine National Police, Department of Justice, Commission on Human Rights, Philippine Obstetrical and Gynecological Society-Northern Mindanao Chapter, Integrated Midwives Association of the Philippines, Family Planning Organization of the Philippines, Iligan Society of Gynecologists, Touch Foundation, Iligan Medical Society, Save the Children, Philippine Nurses Association-Iligan Chapter, Akbayan Youth, Association of Deans of Nursing Schools in Iligan and Barangay Health Workers. Dr. Maria Imelda Carbajal, president of POGSNorthern Mindanao, said the medical missions have become part of the organizations community outreach. We conduct annual surgical and medical missions for free in various areas in Northern Mindanao. But for now, our focus will be in these medical missions for the mothers affected by the disaster, she said. In June this year, the world will meet in Brazil for the United Nations Conference on Sustainable Development or Rio+20 - twenty years after the Earth Summit in Rio where countries adopted Agenda 21, a blueprint to rethink economic growth, advance social equity and ensure environment protection. It will be one of the most important global meetings, UN Secretary General Ban Ki-moon says. He adds the vision of those who will attend the meeting must be clear: A sustainable green economy that protects the health of the environment while supporting achievement of the Millennium Development Goals (MDGs) through growth in income, decent work and poverty eradication. The statement by the Secretary General encompasses the areas of concern and work of UNFPA - in fact the MDGs were partly modeled on the UNFPA Program of Action adopted at the 1994 International Conference on Population Development (ICPD) in Cairo, which guides the organizations work. Population growth and its implications are at the heart of the concept of sustainable development which is defined as development that meets the needs of the present without compromising the ability of the future generations to meet their own needs. In October last year, the world reached the seven billion mark in terms of population growth; medical advances have ensured we are living longer as human beings and this has been rightly acknowledged by Fiji as the first Pacific island nation to launch an ageing policy. Another important consequence of an increasing population is its impact on the environment. Demographic indicators published in mid-2002 suggest that by 2025, Fijis population is expected to be one million - this is based on fertility rate (average number of children a woman can have during her child-bearing years, 15-49 years), mortality and migration.

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An environmental indicator at the time already placed threatened and endangered species at 26 for animals and 65 for plants. When you translate these to food sources and herbal medication, it can be an alarming prospect. Demands for water, trees, food and fossil fuels will only increase as world population grows. Human activity has altered every aspect of our planet, including its climate. Shortages of clean water and arable land are already a problem while species loss continues. The resilience of ecosystems - from fisheries to forests - is threatened. Impoverished people who contribute the least to climate change are likely to suffer the most from its effects - drought, floods, heat waves, tornadoes and other extreme weather disasters - and many will seek a better future elsewhere. Worldwide, some 884 million people have no access to safe drinking water and 2.6 million lack accesses to basic sanitation services such as latrines and toilets. Last December, the National Science Foundation published the discovery of the first marine disease caused by humans which is proving fatal for Elkhorn coral in Florida. The disease is white pox which causes a slowing of growth followed by white patches of tissue loss that occurs all over the coral colony. This is the first example of a human pathogen infecting a marine organism, biology professor Kathryn Sutherland said. This does not only say a lot about how inextricably linked we are but also a reminder of the potential destructive impact hidden in some of the ways we have been doing things. For Pacific island countries, another emerging issue which is already being felt is land-use. Meeting the needs of a growing population frequently requires some form of land-use change such as clearing forests for food production. Deforestation could lead to flooding and species loss or increased agricultural activities leaving cancercausing remnants of fertilizers that find its way into our water tables. UN Population Division projections suggest a global count range of between 7.3 billion to 10.7 billion by 2050. Natural resources are already strained and based on these projections, the 21st century will witness greater pressure. There is hope if recent trends of a slowing global growth rate remain; ideally the world population would peak earlier and at a lower level than initially projected, but for this to happen, family planning and related services must be available to all those who want them; that policymakers acknowledge and facilitate more girls attending and remaining in schools longer; and that more women enjoy the same socio-economic opportunities men enjoy. Population and lifestyle play a critical role in the state of our environment, which is inextricably linked to how we respond to societal issues like poverty eradication. Population impacts the availability of natural resources - as it is, most of our worlds fisheries have been fished to their maximum. Population policies are as critical to governance as they are to the protection and accessibility to land for food production. A healthy environment is paramount to developing poor nations. They will also be critical for sustainable development in the true sense of the phrase: we use only what we need for we must ensure those who follow us will have enough. Rio+20 represents a global platform to brainstorm local actions that can make a difference to our lives as world citizens. Actions to allow us to respond effectively to global situations like: 1.4 billion people presently live on $1.25 a day or less; one billion do not have access to electricity; 2.5 billion do not have toilets; and almost one billion go hungry daily. Albert Einstein once said: The world as we have created it is a process of our thinking. It cannot be changed without changing our thinking. For our collective wellbeing, perhaps it is time to change our thinking, particularly in terms of the population and environment link. - Dirk Jena

Monthly update from UNFPA in Asia and the Pacifi c

JANUARY-FEBRUARY 2012

A Fruitful Trip to Seoul for UNFPA Executive Director

SEOUL - Strengthening the partnership with the Republic of Korea at all levels - with parliamentarians, civil society, media and young people - is a top mission for UNFPA, said Executive Director Babatunde Osotimehin during his visit to the country earlier in January. I consider this visit first of many, Dr. Osotimehin said. My relationship with the Republic of Korea is one of the most important priorities to accomplish during my term. Dr. Osotimehin travelled to Seoul after attending the International Family Planning Conference in Dakar, Senegal, in late November. He shared with top Korean officials outcomes of the event, which was attended by more than 80 countries and 2,200 delegates, as he also congratulated Koreas leadership on the recent high-level United Nations meeting in Busan on aid effectiveness. Dr. Osotimehims busy schedule in Korea involved discussions with a government minister, politicians and Korea International Cooperation Agency officials, all aimed at fostering relationships between South Korea and UNFPA. During the visit, Dr. Osotimehin stressed that UNFPA is the only UN agency to work on achieving MDG 5, focusing on reproductive health, among other issues, and emphasized UNFPAs close partnership with the UN Secretary-Generals every women, every child initiative on maternal health. In addition, Dr. Osotimehin shared news from the Senegal conference that the United Kingdom, the United States and the Bill and Melinda Gates Foundation made strong commitments to family planning. The Korean officials said there may be potential for their government to join the effort, too. In Dr. Osotimehins meeting with Mr. Bong-hyun Kim, Deputy Minister of the Ministry of Foreign Affairs and Trade, he reiterated UNFPAs goal to strengthen its partnership with Korea, particularly regarding UNFPAs role in MDG5. The Deputy Minister, in turn, said he was working hard to garner more public support for increasing Korean development aid and that Korean President Lee is committed to increasing the countrys official development assistance by 2015. Deputy Minister Kim said he would also try to find ways to offer further support to UNFPA. A final meeting with Ms. Sook Mee Son, a member of the Korean National Assembly, led to Ms. Son saying that she would help create a parliamentarian group to work on MDG5. I will set up the forum dedicated to supporting MDG5, inviting not only the women parliamentarians, but also other women leaders, she added.

PUBLICATION

Report of the Global Meeting on Skewed Sex Ratios at Birth

This report provides an overview of the global meeting on Skewed Sex Ratios at Birth, held in October 2011 in Viet Nam. It delves into some key trends, determinants, consequences and responses on the issue. Challenges and recommendations are also included.
Link: http://asiapacific.unfpa.org/public/pid/9927

Addressing the Issue and the Way Forward

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UNFPA Joins the Hellosmile Global Project to Prevent Cervical Cancer
women every year, most of whom live in developing countries. In Japan, the disease still kills 2,500 women every year. As part of its work on reproductive health, UNFPA supports national governments and nongovernmental organizations around the world to scale up measures to screen and prevent cervical cancer. The Hellosmile Project features a rare, one-of-akind profile view of the iconic Hello Kitty character to draw attention to the campaigns important messages. In addition, T-shirts featuring the special Hello Kitty design are sold at UNIQLO stores around the world, with a portion of proceeds going to support UNFPAs work to prevent cervical cancer. The expected collaboration with UNFPA in 2012 includes seminars and music concerts with Tokyo FM and Sanrio, a launching ceremony of a Japan Airlines flight featuring Hellosmile logo, and other activities.

Junko Sazaki, Chief of UNFPAs Office in Tokyo (left), with members of the Hellosmile partnership at the launch

TOKYO - UNFPA has joined Tokyo FM Radio and other Japanese partners - including the Japanese Ministry of Health, Labour and Welfare; Sanrio, maker of the popular Hello Kitty products; UNIQLO, the global clothing company; and Japan Airlines - in the Hellosmile Project, a worldwide effort to prevent cervical cancer. Although preventable and treatable, cervical cancer continues to be a major killer of women. Caused by sexually transmitted infections with human papillomavirus, the disease kills more than 270,000

VIDEOS

Preventing Childbirth Injury in Nepal

UNFPA Provides Maternal Care Following Severe Floods in the Philippines

In Nepal, UNFPA and the Womens Rehabilitation Centre (WOREC) are providing treatment for women suffering from obstetric fistula and spreading the word that this debilitating injury can, in most cases, be prevented by avoiding early pregnancy and childbirth and giving birth with a skilled attendant. Video: UNFPA Nepal and WOREC
Link: http://www.youtube.com/unfpaasia#p/u/0/0gtyVLdY5dk

UNFPA provides relief efforts to assist storm survivors in Northern Mindanao and Eastern Visayas regions in southern Philippines. Video: UNFPA Philippines
Link: http://www.youtube.com/unfpaasia#p/u/0/pl1JvTlS7OI

UNFPA Asia-Pacific Regional Office, 4th Floor UN Service Building, Rajdamnern Nok Avenue, Bangkok 10200, Thailand Facebook: http://www.facebook.com/UNFPAasia, Twitter: http://www.twitter.com/UNFPAasia Flickr: http://www.flickr.com/UNFPAasia, Youtube: http://www.youtube.com/UNFPAasia Website: http://asiapacific.unfpa.org

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