Author: TSA Press

Law
schools
have
talked
about
the
“practice-ready
lawyer”
for
years.
An
aspirational
goal
that
flits
into
recruiting
materials
on
gossamer
wings
before
collapsing
under
the
weight
of
three
years
of
casebook
work.
The
legal
academy
developed
its
model
over
a
century
ago
and
it
will
cling
to
it
with
the
tenacity
of
a
lamprey
with
tenure.
And
despite
efforts
to
bring
more
experiential
training
into
the
system,
learning
the
practical
side
of
the
profession
continues
to
rely
largely
on
the
apprenticeship
model.

Trial
advocacy
ends
up
one
of
the
subjects
lost
in
the
law
school
shuffle.
Classes
turn
on
debating
the
finer
points
of
appellate
decisions,
and
trial
practice
only
shows
up
when
the
Supreme
Court
declares,
“dear
God,
whatever
you
do,
don’t
do
THAT
in
front
of
a
jury.”
That
leaves
the
finer
points
of
trial
work
to
on-the-job
training,
with
all
the
added
pressure
and
the
time
constraints
that
go
with
it.

What’s
impressed
me
about
the
MoloLamken
Advocacy
Academy
ever
since

I
first
heard
about
it,
is
that
it
stakes
out
some
middle
ground
between
the
classroom
and
the
sink-or-swim
of
being
thrown
into
a
case.
The
week-long
course
for
rising
3Ls
nestled
at
the
end
of
summer
associate
gigs
and
before
returning
to
campus,
runs
students
through
a
practical
advocacy
curriculum.
And
they
get
paid
to
do
it.

This
year’s
Academy
finished
up
last
month,
and
we
reached
out
to
some
of
the
attendees
to
get
first-hand
accounts
of
the
experience.
Off
the
top,
everyone
we
contacted
praised
the
program
and
called
attention
to
the
resources
the
firm
commits
to
the
course.
“Over
the
course
of
the
week,
partners
from
every
ML
office
flew
in
to
lead
training
sessions
and
give
detailed,
practical
feedback,”
said
Matt
Beattie-Callahan
of
Yale.
“Even
the
firm’s
two
named
partners,
Steve
Molo
and
Jeff
Lamken,
were
consistently
present
and
personally
engaged,
taking
time
to
offer
individualized
feedback
and
guidance.”

Some
law
schools
have
invested
practical
education,
but
there’s
an
element
that
no
amount
of
ivory
tower
education
can
capture.
“The
Academy
taught
techniques
that
aren’t
really
used
in
the
more
rigid
moot
court
and
mock
trial
formats,
but
I
think
will
be
extremely
helpful
in
real
litigation
settings,”
said
Daniel
Green
of
UCLA.
Law
schools,
for
better
or
worse,
impart
Platonic
ideals
with
Socratic
flair.
A
law
school
mock
trial
won’t
replicate
what
happens
when
seasoned
litigators
break
down
their
craft.
It’s
not
even
necessarily
the
school’s
fault
—
there’s
a
built-in
artificiality
that
comes
with
a
graded
environment
that
a
mentorship
program
doesn’t
bring.

And
with
that
comes
some
direct
and
honest
feedback.
After
devoting
law
school
to
overcoming
“a
hand-talker”
habit,
Avery
Newcom
of
Cornell
described
learning
to
love
the
hands.
“At
MoloLamken,
every
partner
insisted
that
I
had
to
use
my
hands.
We
even
watched
videos
of
advocates
on
mute,
and
their
effectiveness
came
almost
entirely
from
their
hand
motions.
The
Academy
taught
me
that
what
I
thought
was
my
greatest
weakness
is
actually
one
of
my
greatest
advocacy
strengths.”
Some
great
film
critics
will
tell
you
to
watch
a
movie
once
with
sound
and
once
without,
so
you
can
focus
on
the
visual
storytelling
the
audience
experiences
unconsciously.
A
jury
isn’t
any
different,
and
all
those
hand
gestures
convey
meaning,
accentuation,
and
personality.

Blending
classroom
training
with
stand-up
advocacy
exercises
—
including
surprise
“pop-up
argument”
assignments
where
students
got
short
legal
problems,
like
a
contested
evidence
objection,
and
were
asked
to
break
it
down
and
prepare
an
oral
argument
under
a
short
time
window
—
the
Academy
blends
the
law
school
class
technique
with
on-the-job
experience
with
actual
practitioners
guiding
the
learning.

It’s
a
unique
curriculum
that
anyone
looking
to
get
into
trial
advocacy
should
check
out
if
they’re
hoping
to
leave
law
school
having
fulfilled
a
little
of
that
“practice
ready”
promise.

---

Joe
Patrice is
a
senior
editor
at
Above
the
Law
and
co-host
of

Thinking
Like
A
Lawyer.
Feel
free
to email
any
tips,
questions,
or
comments.
Follow
him
on Twitter or

Bluesky
if
you’re
interested
in
law,
politics,
and
a
healthy
dose
of
college
sports
news.
Joe
also
serves
as
a

Managing
Director
at
RPN
Executive
Search.

Last
Tuesday,
Donald
Trump
sauntered
into
Joe’s
Seafood
in

occupied
Washington,
DC,
presumably
to
order
the
chain’s
$83
filet
mignon
extra-well
done
and
drenched
in
ketchup.
For
about
forty-five
seconds,
the
Dear
Leader
also
received
a
complimentary

amuse
bouche
in
the
form
of
a
handful
of
Code
Pink
protestors

chanting
“Free
DC,
free
Palestine,
Trump
is
the
Hitler
of
our
time.”

Catchy!

The
restaurant
promptly
escorted
the
protestors
off
of
the
premises,
which
it
had
every
right
to
do.
Although
perhaps
the
franchise
owners
might
have
reacted
differently
had
they
chatted
with
Stephanie
Wilkinson
first.
Wilkinson,
who

famously
tossed
then-White
House
press
secretary
Sarah
Huckabee
Sanders
out
of
her
restaurant
the
Red
Hen
back
in
2018,
says
that
standing
up
to
Trump
was
“great
for
business.”
After
Trump
trolls
flooded
the
Red
Hen
with
thousands
of
one-star
Yelp
reviews,
she
worried
she’d

go
woke,
go
broke.
But
actual
diners
voted
with
their
wallets,
and
Wilkinson
actually
grew
her
restaurant,
which
is
now
called
“Zunzun.”

“Resistance
is
not
futile,
for
you
or
your
business,”

she
says.

Joe’s
chose
Trump’s
corpulent
maw
instead
and
showed
the
nice
Code
Pink
ladies
the
door.
But
whatever
the
restaurant
served
up
failed
to
quiet
the
colicky
leader,
and
soon
he
was
frothing
at
the
mouth
about
prosecuting
“paid
agitators.”

“I’m
doing
a
great
job
for
peace
in
the
Middle
East.
I
should
get
a
lot
of
awards
for
that,
with
the
Abraham
Accords
and
everything
else,”
he

whined.
“But
a
woman
just
stood
up
and
started
screaming,
and
she
got
booed
out
of
the
place,
too.”

“She
was
a
paid
agitator,
and
you
have
a
lot
of
them,
and
I’ve
asked
Pam”
—
meaning
Attorney
General
Pam
Bondi
—
to
look
into
that
in
terms
of
bringing
RICO
cases
against
them.
Criminal
RICO,”
he
went
on,
citing
no
evidence.
“They
should
be
put
in
jail,
what
they’re
doing
to
this
country
is
really
subversive.”

And
so
Pam
dutifully
scurried
off
to
figure
out
how
to
charge
First
Amendment
protected
speech
under
the

Racketeer
Influenced
and
Corrupt
Organizations
Act
of
1970.
Luckily
she
had
her

trusty
sidekick
Todd
Blanche
to
help
out.
The
Deputy
Attorney
General,
who
was
an
actual
federal
prosecutor
at
the
Southern
District
of
New
York,
was
dispatched
to
explain
to
CNN’s
Kaitlan
Collins
that
“to
the
extent”
those
forty-five
seconds
of
chanting
were
“part
of
an
organized
effort
to
inflict
harm,
and
terror,
and
damage,
on
the
United
States,”
it
might
be
RICO.

Deputy
AG
Blanche:
RICO
is
available
to
all
kinds
of
organizations
committing
crimes
and
committing
wrongful
acts…
So
is
it
sheer
happenstance
that
individuals
show
up
at
a
restaurant
where
the
president
is
trying
to
enjoy
dinner
and
accost
him
with
vile
words?

—

Acyn
(@acyn.bsky.social)

2025-09-17T01:36:18.823Z

Todd
Blanche
knows
damn
well
it’s
not
RICO.

RICO
Suave

Trump
and
Blanche
suggest
that
anyone
who
disagrees
with
the
administration
must
be
secretly
bankrolled
by
unknown
(((wink,
wink)))
funders.
But
even
if
George
Soros
were
paying
each
and
every
member
of
Code
Pink
to
go
hang
out
in
DC-area
restaurants
shouting,
it
wouldn’t
be
a
crime.
And
it’s

doubly
not
RICO.

The
RICO
statute,
in
and
of
itself,
doesn’t
criminalize
anything,
least
of
all
yelling
at
the
President.
Instead,
it
enhances
criminal
and
civil
penalties
when
an
organization
invests
in
or
otherwise
participates
in
multiple

existing
crimes
known
as
“predicate
offenses.”

The
paradigmatic
RICO
case
involved
the

Gambino
crime
family,
where
low-level
muscle
did
the
bosses’
dirty
work.
RICO
lets
prosecutors
go
after
the
entire
org
chart,
no
matter
who
actually
pulled
the
trigger.
The
Department
of
Justice
manual

notes
that
the
“purpose
of
the
RICO
statute
is
the
elimination
of
the
infiltration
of
organized
crime
and
racketeering
into
legitimate
organizations
operating
in
interstate
commerce.”
And
although
Blanche
is
technically
correct
that
RICO
may
apply
to
any
organization
that
funds
such
predicate
offenses,
unless
your
hirelings
have
engaged
in
“a
pattern”
of
such
offenses,
it’s
not
RICO.

The
statute
(18
U.S.C.
§
1961)
lists
35
separate
predicate
offenses.
That
list
includes
the
sorts
of
things
you
would
expect
the
mafia
to
do,
like
murder,
kidnapping,
gambling,
arson,
robbery,
bribery,
extortion,
drug
dealing,
money
laundering,
counterfeiting,
and
embezzlement.
It
does
not
(yet)
include
“slightly
annoying
the
thin-skinned
President
of
the
United
States
for
less
than
a
minute.”

Apparently,
Blanche
thinks
Code
Pink’s
protest
could
be
characterized
as
some
kind
of
terrorism.
But

not
even
all
forms
of
terrorism
qualify
as
RICO
predicate
offenses.
Only

international
acts
of
terrorism,
defined
as
“conduct
transcending
national
boundaries,”
fall
within
the
ambit
of
the
statute.

So
even
if
Code
Pink
hatched
a
plot
to
spoil
Trump’s
dinner
from
Buckingham
Palace,
it

still
wouldn’t
be
RICO,
since
an
isolated
event
is
not
a
“pattern
of
racketeering
activity.”
And
a
pattern
of
saying
the
president
is
“the
Hitler
of
our
time”
isn’t
gonna
do
it.
(Which
is
a
lucky
thing

for
JD
Vance.)

If
you’ve
got
a
problem,
Ted
can
make
it
worse

But
while
it’s
fun
to
make
fun
of
Todd
and
Pam,
their
lies
about
the
law
can’t
be
divorced
from
context.
The
administration
is
vowing
to

crack
down
on
left-wing
organizations,
and
Trump’s
less-stupid
allies,
like
Senator
Ted
Cruz,
have
proposed
a

Stop
FUNDERs
Act,
an
acronym
for
“Financial
Underwriting
of
Nefarious
Demonstrations
and
Extremist
Riots.”

Cruz’s
bill
would
amend
18
U.S.C.
§
1961’s
list
of
predicate
RICO
offenses
to
add
criminal

rioting,
defined
as
a
public
disturbance
involving
acts
of
violence.
Which…
is
not
the
sort
of
thing
one
typically
associates
with
racketeering.

The
Senate
isn’t
going
to
pass
Cruz’s
bill,
perhaps
because
they
realize
it
would
have
made
criminals
out
of
the
president’s
allies
who
paid
for
buses
to
transport
his
supporters
to
DC
on
January
6.
And
even
if
Cruz’s
doomed
statute
were
codified,
it

still
wouldn’t
apply
to
Code
Pink’s
heckling.

But
all
the
hilarious
bumbling
and
mischaracterization
aside,
we
have
multiple
branches
of
the
federal
government
equate
dissent
with
terrorism
and
demanding

twenty-year
prison
sentences
for
critics
of
the
administration.
This
is
a
blatant
effort
to
criminalize
free
speech
and
intimidate
protesters.
And
that’s
not
funny
at
all.

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to
read
more
at
Law
and
Chaos….

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Torrez
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Earlier:

Todd
Blanche
Decides
Heckling
Donald
Trump
Is
Organized
Crime
Now

After
a
seven-year
hiatus,
I’m
thrilled
to
return
as
a
columnist
for

Above
the
Law,
covering
the
solo/small
firm
beat. 
So
much
has
changed
in
the
years
since
I
last
wrote
here.
In
addition
to
the
celebrity
status
that
I’ve
garnered
since
this

column
catapulted
me
to
a

guest
appearance
on
the
Daily
Show,
the
legal
profession
itself
has
experienced
its
own
glow-up. 
The
pandemic
made
remote
practice
mainstream,
artificial
intelligence
is
reshaping
everything
from
research
to
drafting,
and
younger
lawyers
are
demanding
more
humane
work
environments.
But one
concept
remains
constant:
starting
a
law
firm
is
a
radical
act.
Here’s
why.

As
the
daughter
of
a
chemist,
I’ve
always
been
intrigued
by
free
radicals.
These
molecules,
with
their
unpaired
electrons,
disrupt
equilibrium.
Free
radicals’
instability
can
cause
damage
linked
to
a
wide
range
of
diseases,
but
it
can
also
be
harnessed
to
boost
immunity
and
generate
energy.

Lawyers
who
strike
out
on
their
own
function
in
much
the
same
way.
By
leaving
the
safety
of
a
paycheck
or
the
legitimacy
of
a
firm
name,
they
destabilize
the
profession’s
status
quo.
They
create
new
client
relationships,
develop
new
practice
models,
and
expand
meaningful
access
to
justice.
Their
instability
is
also
their
power.

For
decades,
solos
and
small-firm
lawyers
have
been
treated
as
afterthoughts
—
lawyers
who
couldn’t
make
it
elsewhere.
Biglaw
was
cast
as
the
center
of
prestige
and
talent;
solos
as
routine
and
unremarkable.
But
choosing
ownership
is
not
a
fallback,
it
is
always
a
choice
(hence
the
title
of
my
book,

Solo
by
Choice). 
Launching
a
law
firm
is
a
lawyer’s
way
of
saying:
I
will
not
tolerate
inequitable
hiring,
rigid
hierarchies,
toxic
firm
culture,
or
ceding
my
talent
to
causes
I
cannot
abide. 
It’s
claiming
space
in
a
profession
that
doesn’t
always
want
to
make
room.

In
science,
free
radicals
are
powerful
because
of
their
instability.
That’s
what
drives
their
reactivity.
In
law,
instability
pushes
lawyers
to
start
firms:
losing
a
job,
clashing
with
firm
culture,
or
refusing
to
tolerate
low
pay
and
long
hours.
That
“unpaired
state”
generates
the
energy
to
try
something
different. 
And
what
looks
like
weakness
—
being
cut
loose,
being
tired
of
the
grind
—
is
actually
the
spark
that
powers
new
models,
new
niches,
new
precedents
and
new
ways
of
practicing.

Like
their
chemical
counterparts,
lawyer-founders
face
resistance.
Institutions
brand
them
reckless
or
unprepared.
But
that
pushback
only
underscores
how
destabilizing
—
and
therefore
how
radical
—
ownership
really
is.
By
choosing
independence,
solos
upend
hierarchies
that
deserve
to
be
unsettled
and
renew
and
diversify
the
profession
by
creating
alternative
paths. 

In
every
sense,
law
firm
ownership
is
a
radical
act. 
And
one
I’ll
never
tire
of
covering
—
both
at
my
home
blog,

MyShingle.com
and
once
again,
here.

---

Carolyn
Elefant
is
one
of
the
country’s
most
recognized
advocates
for
solo
and
small
firm
lawyers.
She
founded
MyShingle.com
in
2002,
the
longest-running
blog
for
solo
practitioners,
where
she
has
published
thousands
of
articles,
resources,
and
guides
on
starting,
running,
and
growing
independent
law
practices.
She
is
the
author
of
Solo
by
Choice,
widely
regarded
as
the
definitive
handbook
for
launching
and
sustaining
a
law
practice,
and
has
spoken
at
countless
bar
events
and
legal
conferences
on
technology,
innovation,
and
regulatory
reform
that
impacts
solos
and
smalls.
Elefant
also
develops
practical
tools
like
the

AI
Teach-In
to
help
small
firms
adopt
AI
and
she
consistently
champions
reforms
to
level
the
playing
field
for
independent
lawyers.
Alongside
this
work,
she
runs
the
Law
Offices
of
Carolyn
Elefant,
a
national
energy
and
regulatory
practice
that
handles
selective
complex,
high-stakes
matters.

A
new
decision
from
the
California
Court
of
Appeals
adds
an
intriguing
dimension
to
the
growing
body
of
AI
hallucination
sanctions
cases,
raising
the
question
of
a
lawyer’s
duty
to
detect
fabricated,
AI-generated
citations
—
not
in
the
lawyer’s
own
filings,
but
in
an
opponent’s.

While
the
court
did
impose
a
$10,000
sanction
on
the
attorney
who
filed
two
appellate
briefs
containing
fake
citations,
it
also
declined
to
award
attorneys’
fees
or
costs
to
the
opposing
counsel,
because
of
counsel’s
failure
to
report
the
fake
citations
to
the
court
or
even
to
detect
them.

That
makes
this
what
may
be
the
first
judicial
decision
to
touch
on
on
whether
lawyers
have
a
duty
to
detect
and
report
their
opponents’
AI-generated
fake
citations.

Fabricated
Quotations

The
basic
facts
of
the
case,


Noland
v.
Land
of
the
Free,
L.P.,
follow
a
now-familiar
pattern.
The
appeal
itself,
the
court
said,
was
“unremarkable,”
and
would
not
normally
have
warranted
publication.

But
what
made
the
decision
worthy
of
publication,
said
the
court,
was
the
plaintiff’s
extensive
use
of
fake,
AI-generated
citations
and
quotations.
“Although
the
generation
of
fake
legal
authority
by
AI
sources
has
been
widely
commented
on
by
federal
and
out-of-state
courts
and
reported
by
many
media
sources,
no
California
court
has
addressed
this
issue,”
the
court
said.

The
attorney,
Amir
Mostafavi,
used
ChatGPT
and
other
AI
tools
to
“enhance”
his
appellate
briefs,
then
failed
to
verify
the
citations
before
filing.
The
court
found
that
21
of
23
case
quotations
in
his
opening
brief
were
fabricated,
along
with
many
more
in
the
reply
brief.
Some
cases
did
not
discuss
the
topics
for
which
they
were
cited,
and
others
did
not
exist
at
all.

“Nearly
all
of
the
legal
quotations
in
plaintiff’s
opening
brief,
and
many
of
the
quotations
in
plaintiff’s
reply
brief,
are
fabricated,”
the
court
said.

Finding
that
both
California’s
Code
of
Civil
Procedure
and
Rules
of
Court
permit
an
appellate
court
to
impose
sanctions
for
filing
a
frivolous
appeal,
the
court
imposed
a
sanction
of
$10,000
to
be
paid
to
the
court
and
referred
the
lawyer
to
the
state
bar.

“Attorney
Mostafavi’s
fabricated
citations
and
erroneous
statements
of
law
have
required
this
court
to
spend
excessive
time
on
this
otherwise
straightforward
appeal
to
attempt
to
track
down
fabricated
legal
authority
and
then
to
research
the
issues
presented
without
plaintiff’s
assistance,”
the
court
said.

The
Twist:
No
Fees
for
Opposing
Counsel

Had
the
court
stopped
there,
this
case
might
seem
little
different
than
the

hundreds
of
cases
in
which
lawyers’
use
of
AI
has
resulted
in
filings
containing
hallucinated
citations.

But
what
makes

Noland
unique
is
the
court’s
explicit
decision
not
to
award
attorneys’
fees
to
the
opposing
counsel,
despite
finding
the
appeal
frivolous
and
despite
opposing
counsel’s
request
for
such
an
award.
The
court
explained:

“We
decline
to
order
sanctions
payable
to
opposing
counsel.
While
we
have
no
doubt
that
such
sanctions
would
be
appropriate
in
some
cases,
in
the
present
case
respondents
did
not
alert
the
court
to
the
fabricated
citations
and
appear
to
have
become
aware
of
the
issue
only
when
the
court
issued
its
order
to
show
cause.”

Although
the
court
did
not
elaborate
beyond
that
statement,
its
reasoning
raises
the
question:
What
is
the
role
of
opposing
counsel
in
policing
AI
hallucinations?

Put
another
way:
What
is
a
lawyer’s
responsibility
to
detect
and
report
an
opponent’s
use
of
hallucinated
citations?

The
court
appears
to
suggest
that
had
opposing
counsel
spotted
the
fake
citations
and
alerted
the
court,
they
might
have
been
entitled
to
be
awarded
sanctions.
Conversely,
their
failure
to
detect
the
fabrications
made
them
undeserving
of
compensation.

The
Broader
Implications

Before
the
advent
of
gen
AI,
lawyers
had
been
able
to
fairly
safely
rely
on
the
assumption
that
cases
cited
by
an
opponent
actually
existed.

Of
course,
that
did
not
mean
that
lawyers
could
go
without
checking
those
citations.
While
it
was
unlikely
that
the
citation
was
fabricated,
it
could
well
be
that
the
case
did
not
stand
for
the
cited
proposition
or
that
a
quote
from
the
case
was
erroneous
or
out
of
context.

So
checking
citations,
even
before
gen
AI,
was
simply
good
lawyering.
If
you
are
going
to
respond
to
an
argument,
you
need
to
explore
the
foundations
on
which
that
argument
was
constructed.

But
in
the
AI
era,
could
it
be
that
lawyers
have
a
heightened
responsibility
to
check
their
opponents’
citations?
Does
the
responsibility
now
extend
not
just
to
the
lawyer’s
clients,
but
to
the
courts?

It
is
fair
to
say,
I
think,
that
the

Noland
court’s
denial
of
attorney
fees
to
defendants
who
failed
to
spot
obvious
fabrications
hints
at
an
evolving
standard
of
professional
competence.

In
denying
opposing
counsel’s
request
for
attorneys’
fees,
the

Noland
court
appeared
to
fault
counsel
on
two
counts:
their
failure
to
alert
the
court
to
the
fabricated
citations,
and
their
failure
to
even
notice
them
in
the
first
place.

The

Noland
court’s
decision
seems
to
suggest
that,
at
minimum,
lawyers
who
spot
AI
hallucinations
and
alert
the
court
may
be
rewarded
(or
at
least
may
be
eligible
to
be
reward),
while
those
who
miss
them
may
not
be
entitled
to
fee-shifting
even
when
the
opposing
brief
is
ultimately
sanctioned.

A
Developing
Standard

While

Noland
appears
to
be
the
first
case
to
explicitly
address
opposing
counsel’s
role
in
detecting
AI
hallucinations,
it
likely
won’t
be
the
last.
As
AI-generated
fake
citations
become
more
sophisticated
and
potentially
harder
to
detect,
courts
will
need
to
develop
clearer
standards
about
what
level
of
diligence
opposing
counsel
should
exercise.

The

Noland
court’s
terse
approach
of
declining
to
award
fees
without
defining
a
bright-line
rule
leaves
the
door
open
for
other
courts
to
provide
more
guidance.

Will
spotting
AI
hallucinations
become
part
of
the
expected
professional
competence
of
practicing
attorneys?

My
guess
is
that
courts
will
increasingly
expect
all
parties
to
exercise
heightened
vigilance
in
an
era
where
fake
legal
authorities
can
be
generated
at
the
click
of
a
button.

[Hat
tip
to

David
Kluft,
assistant
bar
counsel
in
Massachusetts,
who

posted
this
case
on
LinkedIn.]

This
is
going
to
be
one
of
those
moments
where
future
generations
will
ask
how
we
didn’t
see
the
writing
on
the
wall
so
much
earlier.
For
some
reason,
the
country
laughed
off
one
of
the
first
big
rhetorical
shoes
in
the
door:
“alternative
facts.”
The
constitutional
threat
implied
by
the
phrase
“fake
news”
got
treated
as
seriously
as
“covfefe.”
One
of
the
most
lucid
“What
the
hell
are
we
doing
here?”
moments
was
when
Obama
asked
an
audience
to
imagine
the
fallout
that
would
have
happened
if
he
pulled
the
equivalent
of
Trump
blocking
a
CNN
reporter’s
White
House
press
credentials
during
his
time
as
president:


OBAMA:
“IMAGINE
IF
I
HAD
DONE
ANY
OF
THIS…
I
say
this
not
on
a
partisan
basis.
This
has
to
do
with
something
more
precious
—
who
are
we
as
a
country,
and
what
values
do
we
stand
for?”


pic.twitter.com/zSFKNzNDhR

—
The
Tennessee
Holler
(@TheTNHoller)

April
4,
2025

Funny
or
not,
these
became
the
grounds
for
deciding
which
narratives
were
state
doxa
and
which
would
fall
under
the
umbrella
of
the
“woke
mind
virus”
or
whatever
term
talking
heads
felt
like
using
to
dismiss
thoughts
that
fell
out
of
line.
The
thought
must
have
been
that
these
were
brief
detours
on
a
moral
arc
that
bends
toward
justice
or
that
free
speech
and
the
circulation
of
ideas
would
ultimately
be
the
disinfectant
best
suited
for
a
nation
dirtied
by
misinformation,
propaganda
and
fake
news.
Maybe
we
just
thought
things
would
never
get
this
bad.
But
it
is
getting
a
lot
harder
to
deny
facts,
alternative
or
not,
when
they’re
right
in
front
of
you.

A
couple
of
months
after
Stephen
Colbert
got
a
delayed
axing
for
sharing
thoughts
critical
of
Trump,
the
Jimmy
Kimmel
show
has
been
indefinitely
suspended
after
making
a
Charlie
Kirk
joke:

You
can
see
the
offending
joke
below:

The
way
this
softass
joke
resulted
in
threats
from
Trump’s
FCC
chair
and
Jimmy
Kimmel
yanked
from
air
should
scare
literally
everyone.
This
isn’t
even
a
Charlie
Kirk
joke.
It’s
a
Trump
joke.
It’s
a
Republican
joke.
This
is
censorship.
This
is
authoritarianism.
This
is
fascism.

https://t.co/KQlnZmvh2q

—
chris(tine)
(@ichris_tine)

September
18,
2025

I
know
that
it’s
easy
to
point
at
this
or
that
thing
as
partisan,
but
have
we
reached
the
point
where
you
can
get
fired
for
pointing
out
that
someone
redirecting
conversation
to
decor
changes
when
asked
about
the
death
of
a
friend
doesn’t
exactly
scream
mourning
a
deep
loss?
Will
Smith
takes
jokes
about
his
wife
better
than
Trump’s
administration
took
this.
What’s
next?
Getting
fired
for
saying
Trump
was
focused
on
the
wrong
hole
in
the
ground

because
he
went
to
a
golf
course
instead
of
going
to
Charlie
Kirk’s
vigil?
We’re
Americans
Goddammit
it
–the
right
to
speak
our
minds
without
fear
of
government
backlash
is

one
of
the
most
foundational
aspects
of
our
country’s
mythos.
And
to
think
that
all
of
this
censorship
is
coming
from
the
right:
remember
when
they
were
the
ones
screaming
that
any
state
restriction
meant
that
we
were
sliding
down
vaguely
orientalist
social
credit
scores
and
Communism?
Because
the
internet
does:

Think
what
you
will
about
Jimmy
Kimmel
—

he’ll
always
look
a
little
lonely
to
me
without
Adam
Corolla
by
his
side
—
but
what
this
late
night
comedy
show’s
“indefinite
suspension”
means
for
free
speech
is
no
laughing
matter.

one
thing
I
really
hate
abt
the
Trump
era
is
how
you
kinda
have
to
get
upset
about
the
stupidest
shit.
like
fuck
this
is
a
gross
assault
on
free
speech
and
art
in
this
country
but
also
it’s
Jimmy
kimmel.
you’re
making
me
defend
Jimmy
fucking
Kimmel
.
it’s
all
just
so
undignified

https://t.co/UJSnIMRczT

—
america’s
curdled
lounge
singer
(@KrangTNelson)

September
17,
2025

The
details
of
that
“suspension”
only
makes
things
worse.
It
looks
like
the
show
won’t
be
restored
unless
Kimmel
does
a
great
deal
of
ass
kissing
and
pays
tithe
to
Kirk’s
family
and
Turning
Point
USA:

NEW:
Sinclair
Broadcast
Group
says
it
will
air
a
one-hour
tribute
to
Charlie
Kirk
on
Friday
across
all
of
its
ABC-affiliated
TV
stations.
The
special
will
air
in
the
11:35
p.m.
time
slot
that
is
typically
reserved
for
“Jimmy
Kimmel
Live.”

$SBGI

pic.twitter.com/esTGsXjhGk

—
Matthew
Keys
(@MatthewKeysLive)

September
18,
2025

Right
wingers
have
already
taken
to
the
this-isn’t-actually-a-free-speech-issue
grift
because
ABC
ultimately
made
the
decision
instead
of
the
FCC
or
Donald
Trump,
but
the
funny
thing
about
the
internet
is
that
there
is
an
archive
of
all
the
shit
you’ve
previously
said:

Back
to
Obama’s
point
of
imagining
if
he
did
this,
here
is
JD
Vance
railing
against
the
Biden
administration
for
“encouraging
private
companies
to
silence
people
who
dared
to
utter
what
turned
out
to
be
an
obvious
truth”and
promising
that
things
would
be
different
under
Trump:

JD
Vance:
“Our
own
government
encouraged
private
companies
to
silence
people…Under
Donald
Trump’s
leadership,
we
may
disagree
with
your
views,
but
we
will
fight
to
defend
your
right
to
offer
it
in
the
public
square.”
(Feb.
2025)

pic.twitter.com/cQWAIZzCV1

—
Home
of
the
Brave
(@OfTheBraveUSA)

September
18,
2025

Quite
the
difference
a
couple
of
months
makes:

Here
is
JD
Vance
today
calling
on
Republicans
to
call
people’s
employers
and
get
them
fired
if
they
are
saying
things
about
Charlie
Kirk
that
they
don’t
like.
This
is
the
first
step
in
the
GOP’s
weaponization
of
Kirk’s
murder
to
silence
dissent.
It
won’t
be
the
last.

https://t.co/4VWvg7StjM

pic.twitter.com/j2qr5oguQu

—
(((DeanObeidallah)))
(@DeanObeidallah)

September
15,
2025

This
isn’t
just
blatant
hypocrisy
—

this
is
jawboning.
It
is
hard
to
think
of
a
better
textbook
of
example
of
quelling
speech
by
removing
someone’s
speaking
platform
than
what
Donny
Boy
is
trying
to
do
here:

Trump:
Great
News
for
America:
The
ratings
challenged
Jimmy
Kimmel
Show
is
CANCELLED.
Congratulations
to
ABC
for
finally
having
the
courage
to
do
what
had
to
be
done.

That
leaves
Jimmy
and
Seth,
two
total
losers,
on
Fake
News
NBC.
Their
ratings
are
also
horrible.
Do
it
NBC!!!

pic.twitter.com/O28JCW3T0H

—
Acyn
(@Acyn)

September
18,
2025

Despite
the
consequences
of
speaking
out,
we
(thankfully)
aren’t
at
the
point
that
people
are
too
afraid
to
speak
out
on
the
news.
That
said,
no
promise
this
doesn’t
get
CNN’s
White
House
pass
revoked
again:

David
Frum
on
Jimmy
Kimmel:
“This
is
not
cancel
culture
because
it’s
not
culture.
It’s
state
repression.
It’s
an
order
from
the
government.
Here
is
the
script,
you
must
read,
if
you
do
not
read
it,
you
will
be
taken
off
the
air.”

pic.twitter.com/RF7tiSZX4r

—
Blue
Georgia
(@BlueATLGeorgia)

September
17,
2025

You
know
things
are
bad
when
Tucker
Carlson
is
ringing
the
same
bell:


The
Earth
just
tilted
off
its
axis.

Tucker
Carlson
is
now
calling
out
Trump’s
own
regime,
accusing
it
of
using
Charlie
Kirk’s
assassination
as
a
pretext
to
abolish
the
First
Amendment,
round
up
Americans,
and
Nazify
the
country.

Yes.
He
said
that.
And
he’s
not
wrong.

pic.twitter.com/cy5oYXbJb4

—
Brian
Allen
(@allenanalysis)

September
17,
2025

Maybe
the
real
bipartisan
politics
are
the
First
Amendment
violations
we
fight
along
the
way?

---

Chris
Williams
became
a
social
media
manager
and
assistant
editor
for
Above
the
Law
in
June
2021.
Prior
to
joining
the
staff,
he
moonlighted
as
a
minor
Memelord™
in
the
Facebook
group Law
School
Memes
for
Edgy
T14s
.
 He
endured
Missouri
long
enough
to
graduate
from
Washington
University
in
St.
Louis
School
of
Law.
He
is
a
former
boatbuilder
who
is
learning
to
swim, is
interested
in
critical
race
theory,
philosophy,
and
humor,
and
has
a
love
for
cycling
that
occasionally
annoys
his
peers.
You
can
reach
him
by
email
at [email protected]
and
by
tweet
at @WritesForRent.

Nearly
all
leaders
in
the
healthcare
industry
have
a
shared
understanding
that
while
AI
will
never
replace
workers’
lived
clinical
judgment,
the
technology
can
provide
them
with
much-needed
respite
from
administrative
burden
by
handling
non-value-added
tasks,
noted
one
health
system
executive.

Terry
McDonnell,
chief
nurse
executive
at

Duke
University
Health
System,
pointed
out
that
by
handling
routine
tasks,
AI
can
free
up
clinicians
to
devote
more
time
and
attention
to
patient
care.

“I’ve
always
said
that
I
can
teach
a
nurse
a
skill,
but
I
can’t
teach
what
sick
sounds
like
on
the
phone.
That’s
lived
experience,
that’s
learned
experience,
and
that’s
what
the
clinician
brings.
And
I
think
those
are
the
things
that
we
need
to
focus
on
and
make
sure
that
people
have
the
time
and
the
bandwidth
to
really
engage,”
McDonnell
declared.

She
said
this
need
to
scale
AI-driven
task
automation
is
more
important
than
ever,
given
that
the
nation’s
rising
demand
for
care
is
colliding
with
a
shrinking
clinical
workforce. 

One
major
but
oftentimes
overlooked
bottleneck
is
the
shortage
of
faculty
available
to
train
new
nurses,
even
as
applications
to
nursing
programs
remain
plentiful,
she
added.

These
workforce
challenges
are
one
reason
Duke
has
invested
heavily
in
AI
products
designed
to
streamline
tasks
and
improve
patient
outcomes.
The
health
system
builds
some
AI
tools
in-house
while
purchasing
others
from
vendors,
McDonnell
said.

For
instance,
Duke
uses
an
in-house
AI
model
that
monitors
patient
data
from
Epic
to
flag
early
signs
of
deterioration,
giving
care
teams
the
advance
warning
they
need
to
intervene,
she
noted.

“We’re
upstream
of
it
—
we’re
not
reacting
in
an
emergency.
We’re
proactively
intervening
when
we
see
that
the
clinical
condition
may
be
changing,
and
that’s
being
driven
by
AI
algorithms,”
McDonnell
explained.

Duke
uses
another
internally
developed
AI
tool
that
focuses
on
sepsis.
It
analyzes
patient
data
to
detect
who
could
be
at
risk
and
triggers
early
treatment
bundles
before
the
condition
progresses
to
a
severe
state.

The
health
system
is
also
working
with

Artisight
to
embed
computer
vision
in
its
hospital
rooms,
McDonnell
stated.
She
said
Duke
is
installing
in-room
cameras,
which
will
work
with
AI
algorithms
to
monitor
fall
risks
and
eventually
automate
documentation
—
such
as
recording
a
patient’s
fluid
output
without
a
nurse
ever
having
to
write
or
dictate
a
note.

She
also
noted
that
Duke
recently
conducted
an
AI
pilot
with

Microsoft’s
Nuance,
and
it
rolled
out

Abridge’s
AI-powered
clinical
documentation
platform
earlier
this
year.
While
such
tools
have
proven
effective
in
reducing
burnout
for
physicians
working
in
outpatient
and
ambulatory
settings,
they
are
not
yet
fully
optimized
for
the
complexities
of
inpatient
care,
McDonnell
said.
However,
she
noted
Duke
is
currently
working
on
an
inpatient
documentation
pilot
with
Abridge. 

When
it
comes
to
the
question
of
whether
to
build
or
buy,
McDonnell
said
it
depends
on
the
problem
that
the
health
system
is
trying
to
solve.

All
AI
pilots
at
Duke
begin
with
a
problem
statement,
she
noted.
Then,
leaders
see
if
there
is
a
solution
on
the
market
that
addresses
this
issue,
or
perhaps
a
tool
that
one
of
their
partners
is
already
developing,
such
as
Epic
or
Microsoft.

If
there
are
no
well-vetted
solutions
on
the
market,
Duke
then
considers
co-developing
a
solution
with
an
external
tech
partner.
And
if
that’s
not
an
option,
Duke
sees
if
it
can
build
a
tool
on
its
own
leveraging
its
engineering
school
and
IT
capabilities,
McDonnell
said.

“We’ve
got
great
internal
strength
in
our
own
IT
and
development
teams.
We’re
really
lucky
in
that
regard
—
not
every
system
has
that
luxury,”
she
stated.

Looking
ahead,
McDonnell
encouraged
health
systems
to
balance
practicality
with
innovation
when
trying
out
new
AI
models.

“You
can’t
get
excited
about
every
bright,
shiny
toy
that
comes
through
the
front
door.
But
I
also
think
that
we’re
starting
to
learn
that
we
can
pilot
things,
try
things,
and
rapidly
learn
what’s
going
to
work
and
what’s
not
going
to
work,”
she
remarked.

To
McDonnell,
AI
success
depends
not
on
chasing
the
newest
technology,
but
on
choosing
and
refining
the
tools
that
truly
ease
clinicians’
workload
and
improve
patient
outcomes.

Photo:
Yuichiro
Chino,
Getty
Images

*
Rudy
Giuliani
owes
lawyers
roughly
$1.3
million.
[NY
Times]

*
Late
night
host
Jimmy
Kimmel
pulled
off
the
air
after
FCC
threatened
ABC
broadcast
license.
So
go
ahead
and
set
that
First
Amendment
crisis
clock
to
midnight.
[Variety]

*
Cadwalader
losing
talent,
but
not
engaged
in
merger
talks…
yet.
[American
Lawyer]

*
Go
“anti-woke,”
go
broke,
and
then
sue
blaming
Winston
&
Strawn.
[Law360]

*
The
IPO
oligopoly.
[Bloomberg
Law
News]

*
Morgan
&
Morgan
sues
Disney
to
use
Steamboat
Willie
in
test
of
public
domain
status.
[AP
News]

*
Immigration
judge
orders
Mahmoud
Khalil
deportation
as
part
of
crackdown
on
Israel
criticism.
[Reuters]

Quarterly
provincial
review
meetings
and
clinic
audits
repeatedly
flag
this
trend,
prompting
the
city’s
health
leaders
to
sound
the
alarm.

In
an
interview
with
CITE,
Bulawayo’s
Provincial
Medical
Director
(PMD),
Dr
Maphios
Siamuchembu
said
the
trend
is
as
baffling
as
it
is
dangerous.

“I
would
estimate
between
one
percent
and
five
percent
of
our
patients,
give
us
this
problem.
One
thing
that
happens
is
people
feel
better
and
they
think,
‘I
don’t
need
to
continue
this
treatment.’
But
that’s
not
the
case,”
said
Dr
Siamuchembu.

“Patients
think
they’re
cured”
– 
the
PMD’s
warning

The
PMD
said
treatment
of
TB
takes
a
minimum
of
six
months
while
treatment
of
HIV
is
lifelong.

“When
you
interrupt
that,
you’re
basically
culturing
resistance
and
it
comes
back
stronger
then
we
have
no
arsenal
to
treat
you,”
he
said.

“You
get
a
patient
who
is
admitted
to
Thorngrove
Hospital,
he
has
drug-resistant
TB
but
then
they
abscond.
They
jump
over
the
fence
of
the
hospital,
and
they
disappear.”

He
said
the
health
system
itself
is
not
blameless
as
it
has
limited
security
at
facilities
where
some
patients
literally
evade
care,
even
though
nurses
make
follow
ups
to
patients’
houses.

“You
enter
the
gate
and
they
ask
who’s
there.
You
say,
‘it’s
the
health
workers,
we
want
to
find
out
about
your
medicines.’
They
say
‘wait
for
me
outside,
and
then
they
jump
the
durawall,”
he
said.

“Some
pitch
up
months
later
in
a
worse
condition.
And
you
wonder
why
people
do
that,
because
as
far
as
we’re
concerned,
we’re
trying
to
help
them
get
better,
and
also
to
control
that
they
don’t
spread
TB
to
other
people.”

Siamuchembu
said
defaulters
often
give
false
names,
phone
numbers
and
addresses.

“We
call
their
phone
numbers
they’ve
given
us
and
it
says
this
one
does
not
exist.
We
follow
up
at
the
address
and
we
are
told,
‘we
don’t
know
this
person.’
Then
we
can’t
find
them,
and
we’re
worried
because
this
person
is
not
on
treatment.
As
you
interrupt
treatment,
these
diseases
become
worse.
It’s
a
huge
problem.”

A
hidden
threat
amid
years
of
progress

The
PMD
said,
“I
am
not
happy
with
any
defaulter.”

From
United
Bulawayo
Hospitals
(UBH)
to
Mzilikazi,
Njube
and
Nketa,
health
workers
are
recording
case
after
case
of
patients
who
vanish
mid-treatment,
often
resurfacing
only
when
critically
ill
or
not
at
all.

In
a
recent
provincial
health
TB
review
meeting
in
the
first
quarter
of
2025
(Q1
2025),
health
officials
admitted
bluntly
that
they
have
“inadequate
knowledge
on
factors
contributing
to
high
Lost
To
Follow-Up
(LTFU)
rate”
so
they
must
“conduct
operational
research
on
factors
contributing
to
high
LTFU
in
the
city.”

Defaulting
or
being
“lost
to
follow-up”
(LTFU)
in
clinical
language
is
not
just
a
statistical
headache
but
a
threatening
challenge
that
can
undo
hard-won
progress
in
containing
two
of
Zimbabwe’s
deadliest
epidemics
–
TB
and
HIV
in
Bulawayo.

Looking
at
minutes
from
quarterly
provincial
review
meetings
and
clinic
audits,
here
are
some
of
the
cases
documented
‘when
patients
disappear.

From
numbers
to
faces

The
data
is
not
abstract.
Individual
stories
illustrate
the
human
cost.

A
25-year-old
woman
had
been
stable
on
antiretroviral
therapy,
but
stopped
coming
for
reviews
after
seven
months.
The
staff
tried
to
call
her,
then
checked
the
address
she
had
given
but
it
drew
a
blank.
Her
file
now
reads:
LTFU
at
seven
months.

She
is
not
the
only
one.
In
the
same
cohort,
a
46-year-old
man
dropped
out
at
month
eight,
and
a
40-year-old
woman
at
22
months.
All
had
given
unreachable
contacts.

At
Nketa
Clinic,
a
TB
death
audit
was
described
as
a
“very
ill
patient…
ART
defaulter.”

In
other
words,
failing
to
take
HIV
treatment
had
left
the
patient
fatally
vulnerable
when
TB
struck.

The
data
reviewed
by
CITE
shows
a
persistent
pattern
across
Bulawayo’s
three
administrative
districts
–
Emakhandeni,
Nkulumane
and
the
Northern
Suburbs,
where
clinic
registers
show
loss
to
follow-up.

A
glimpse
of
the
data
shows
these
are
not
isolated
cases
but
are
symptomatic
of
a
system
where
patients
slip
through
cracks.

Together,
these
records
show
a
clear
pattern,
patients
dropping
out
of
either
HIV
or
TB
treatment
in
different
clinics,
over
the
years
and
across
districts.

The
broader
epidemiological
picture 

According
to
the
2025
HIV
Estimates
Report
for
Bulawayo
Metropolitan,
as
of
2024,
an
estimated
76
608
people
were
living
with
HIV
in
the
province.

This
represents
a
decrease
from
79
711
recorded
in
the
2020
Zimbabwe
Population-based
HIV
Impact
Assessment
(ZIMPHIA),
after
calibration
for
more
accurate
population
estimates.

Although
this
signals
a
cautiously
optimistic
outlook
for
Bulawayo,
health
officials
continue
to
address
challenges
such
as
treatment
defaulting
and
follow-up
gaps
that
threaten
to
undermine
these
achievements.

Data
from
Mpilo
Hospital
(Jan–Aug 2025)

A
fresh
analysis
of
Mpilo
Hospital’s
outpatient
infectious
disease
register
for
the
first
eight
months
of
2025
highlights
a
troubling
divide
in
adherence
to
ART.

The
data
reveals
stark
differences
between
patients
who
briefly
abandon
treatment
and
those
who
disappear
entirely
from
the
system.

According
to
the
hospital
records,
73
individuals
who
missed
appointments
eventually
returned
to
care,
classified
as
“Back‑to‑Care.”

In
contrast,
378
patients
are
listed
as
LTFU,
having
had
no
contact
with
the
clinic
for
six
months
or
more.
For
every
patient
who
re-engages,
more
than
five
slip
through
the
cracks.

The
demographic
profile
shows
a
predominantly
youthful
cohort
in
their
twenties,
which
may
mean
many
are
juggling
school,
work
and
family
responsibilities
alongside
the
demands
of
daily
medication.

Gaps
for
back-to-care
patients
ranged
from
under
a
month
to
nearly
four
years,
though
40
percent
of
returns
occurred
within
six
months
of
the
missed
visit.

LTFU
gaps,
by
definition,
exceed
six
months,
a
sizeable
proportion
extends
beyond
a
year
and
a
few
cases
stretch
past
three
years,
indicating
chronic
disengagement.

Short
interruptions
were
far
more
likely
to
be
resolved,
while
prolonged
absences
sharply
reduced
the
likelihood
of
re-engagement,
particularly
for
patients
on
second‑line
or
more
complex
regimens.

Most
patients
returning
to
care
were
still
on
first-line
ART
or
were
simply
“taking
pills
elsewhere.”

Among
those
lost
to
follow-up,
a
significant
number
had
already
escalated
to
second-
or
third-line
therapy,
suggesting
that
even
patients
on
more
complex
treatment
plans
are
disengaging.

Several
back-to-care
records
explicitly
note
temporary
relocations
to
South
Africa,
Namibia,
or
other
clinics
elsewhere.

Mentions
of
“self-transfer”
and
taking
“pills
elsewhere”
recur
in
both
patient
groups,
underscoring
a
fragmented
landscape
in
which
patients
drift
between
public
and
private
providers.

Children
appeared
only
among
the
back
to
care
returnees,
suggesting
that
caregivers
eventually
bring
them
back
to
care
after,
possibly
after
neglect,
periods
of
lack
of
awareness
or
guardian
change.

Young
women
dominate
the
LTFU
pool,
reflecting
socioeconomic
pressures,
including
transport
costs,
childcare
duties
and
the
need
to
earn
a
living,
which
pull
them
away
from
consistent
clinic
visits.

This
Mpilo
data
paints
a
complex
picture,
reflecting
that
short-term
treatment
gaps
can
often
be
corrected,
but
prolonged
disengagement
remains
a
persistent
challenge,
especially
among
vulnerable
populations.

The
data
also
shows
improved
data
systems,
patient
tracking
and
targeted
support
for
high-risk
groups
will
be
crucial
in
reducing
ART
default
and
improving
long-term
health
outcomes
in
Bulawayo.

Why
patients
default

In
interviews
as
to
why
people
default,
one
community
elder
in
Old
Lobengula,
Giyani
Moyo
said,
the
major
challenge
was
stigma.

“It’s
because
of
stigmatisation
at
the
point
of
collection
of
treatment
tablets.
It’s
how
staff
say
‘abe
TB
wozani
nga,
abe
HIV
yanini
le (TB
patients
come
here,
HIV
patients
go
there,’”
Moyo
said.

“At
clinics
it’s
prevalent,
worse
clinics
have
neighbours
and
friends
also
attending.”

A
medical
doctor
said
denial
is
another
major
reason
why
some
patients
default
on
treatment,
as
they
struggle
to
accept
their
diagnosis.

The
doctor,
who
requested
anonymity,
said
his
own
brother
was
diagnosed
with
HIV
in
2022
but
defaulted
on
medication
due
to
denial.

“In
2023,
my
brother
left
for
South
Africa,
where
his
condition
worsened.
We
later
received
a
phone
call
from
his
friends
informing
us
he
was
seriously
ill.
Since
I
am
the
doctor
in
the
family,
my
relatives
asked
me
to
go
and
talk
some
sense
into
him,”
he
said.

However,
when
he
arrived,
his
brother
refused
to
resume
treatment,
insisting
he
only
had isihlabo (pneumonia).

“Seeing
how
serious
his
condition
had
become,
I
arranged
for omalayitsha (cross-border
transporters) to
bring
him
back
home
by
force,”
he
explained.

The
brother
is
now
back
on
ART
and
picking
up.

Economic
hardships
and
Pill
Burden

Bulawayo
coordinator
for
Zimbos
Abantu,
which
runs two
mobile
clinics
in
Emganwini
and
Cowdray
Park, Charmaine
Dube,
who
has
worked
extensively
in
HIV
programming
with
various
stakeholders
in
the
district,
said
economic
hardship
and
social
realities
are
driving
many
patients
off
treatment.

“We
have
seen
a
lot
of
ART
patients
defaulting
on
their
medication.
Some
of
the
reasons
they
are
raising
are
pill
burden,
where
someone
just
gets
tired
of
taking
the
tablet
every
single
day,”
she
explained.

“Other
reasons
are
poverty,
where
people
are
struggling
to
make
ends
meet
and
to
put
food
on
the
table.
At
times,
a
person
will
prefer
not
to
take
the
tablet
than
to
take
it
on
an
empty
stomach.”

Dube
said
the
withdrawal
of
USAID
funding
has
also
exposed
serious
gaps
in
Zimbabwe’s
HIV
response,
particularly
in
urban
districts
disrupting
service
delivery
and
worsened
structural
barriers
already
facing
people
living
with
HIV.

“We
saw
some
facilities
that
were
offering
express
services
closing
down
and
people
being
referred
back
to
public
facilities,
where
there
are
longer
queues.
Most
of
the
people
are
self-employed
and
prefer
to
rather
go
hustle
than
spend
a
whole
day
queuing
for
their
medication.
That
has
resulted
in
many
defaulting,”
she
explained.

Health
system
constraints,
mobility
and
documentation
gaps 

Staff
shortages
in
public
facilities
have
also
made
the
situation
worse.

“The
other
reasons
are
the
procedural
delays
people
face.
There
are
fewer
nurses,
so
it
takes
much
longer
for
a
person
to
be
attended
to.
Those
frustrations
are
causing
people
to
default
on
their
medication,”
Dube
said.

On
the
other
hand,
medical
staff
suggest
a
mix
of
economic,
social
and
psychological
drivers
behind
the
defaulting
trend.

Sister
in
charge
of
the
Opportunistic
Infections
(OI)
clinic
at
Mpilo
Hospital
Centre
of
Excellence,
Bongani
Khumalo,
says
the
centre
currently
serves
10
836
patients
on
ART.

“The
most
common
reasons
patients
give
for
defaulting
are
people
who
go
to
South
Africa
in
search
of
work
and
fail
to
get
medications
due
to
lack
of
legal
documents,
some
give
details
that
are
not
true,
their
phones
are
unavailable
or
it’s
a
wrong
number,”
he
said.

“Adolescents
struggle
with
adherence
despite
counselling,
pill
fatigue,
lack
of
disclosure
to
partners,
especially
in
new
relationships,
and
mental
health
issues.
Others
tell
you
they
had
no
transport
fare.”

From
his
observations,
the
crisis
has
a
youthful
face
and
also
cited
how
stigma
remains
a
persistent
factor.

“Some
youth
or
teenagers
have
been
taking
ART
for
their
whole
life
since
birth
and
are
now
fatigued,”
Khumalo
said.

Stigma
and
discrimination

Meanwhile,
some
patients
avoid
clinics
because
they
fear
being
recognised
by
neighbours,
said
Moyo,
the
community
leader.

Others
conceal
their
status
from
partners
and
families,
leading
to
hidden
struggles
with
adherence.

This
was
corroborated
by
National
AIDS
Council
(NAC)
provincial
manager,
Sinatra
Nyathi,
who
said
stigma
and
discrimination
continue
as
a
problem.

“We
do
have
the
stigma
index
report,
which
talks
about
where
we
are
in
terms
of
stigma
and
according
to
the
current
report,
we
are
not
going
down
in
terms
of
stigma,
but
actually
going
up,”
she
said.

A
2022
report,
the
Zimbabwe
People
Living
with
HIV
Stigma
Index
2.0,
revealed
that
despite
major
progress
in
HIV
treatment
access,
stigma
and
discrimination
remain
widespread.

The
study,
which
was 
cross-sectional
and
conducted
in
all
Zimbabwe’s
10
provinces
with
1
400
participants
found
that
the
most
common
forms
of
discrimination
faced
by
people
living
with
HIV
(PLHIV)
include:

• Exclusion
  from
  social
  gatherings
• Gossip
• Verbal
  abuse
• Physical
  abuse

Stigma
was
reported
across
multiple
spaces,
including
families,
health
institutions
and
communities.

At
the
same
time,
the
report
indicated
Zimbabwe
has
made
remarkable
strides
in
treatment,
with
close
to
100
percent
of
respondents
reporting
access
to
HIV
care
services,
noting
strong
resilience
among
PLHIV,
which
is
vital
for
their
physical
and
psychological
well-being.

“Looking
into
the
future,
HIV
programming
in
Zimbabwe
should
prioritise
creating
an
enabling
environment
to
reduce
stigma
and
discrimination
against
PLHIV
to
sustain
and
enhance
their
health
outcomes
and
quality
of
life,”
the
report
concluded.

Danger
of
defaulting

The
NAC
provincial
manager
said
there
was
a
huge
danger
of
defaulting.

“You
need
to
understand
that
HIV
attaches
itself
to
your
T-helper
cells
in
order
to
infect
you.
If
that
attachment
doesn’t
happen,
infection
cannot
occur.
That’s
why
studies
have
shown
that
some
people
with
certain
cell
deformities
are
resistant
to
HIV,
it
simply
cannot
attach.
This
is
also
how
ARVs
work,”
Nyathi
said

“Different
ARVs
target
different
stages
of
the
HIV
life
cycle.
Some
prevent
attachment,
like
in
PEP,
which
is
given
soon
after
possible
exposure
to
stop
the
virus
from
entering
the
cells.
Others
target
multiplication
inside
the
cell,
preventing
the
virus
from
bursting
out
and
spreading.
These
drugs
are
specialised
to
fight
HIV.
That’s
why
we
use
a
combination
of
three
drugs
-to
block
HIV
at
multiple
points.

“If
you
stop
treatment,
you
give
the
virus
a
chance
to
multiply
quickly
and
attack
more
cells.
That’s
when
it
becomes
dangerous.
Many
people
stop
treatment,
feel
fine
for
a
while,
then
return
when
it’s
too
late.
The
virus
will
have
multiplied,
invaded
more
cells,
and
often
mutated.
HIV
mutates
very
fast,
and
once
it
changes,
the
drugs
you
were
taking
may
no
longer
be
effective.

“That
is
why
adherence
is
critical.
Staying
on
treatment
keeps
the
virus
suppressed
and
gives
you
a
much
better
chance
of
living
a
healthy
life.”

According
to
the
2025
HIV
Estimates
Report
for
Bulawayo
Metropolitan
province,
looking
at
the
treatment
progress, 
95
percent
of
people
living
with
HIV
know
their
status, 
98
percent
of
those
who
know
their
status
have
been
initiated
on
ART.

Among
those
on
ART,
96
percent
have
a
suppressed
viral
load.

Viral
suppression
remains
a
challenge,
largely
due
to
poor
adherence,
according
to
Mpilo
Hospital’s
Centre
of
Excellence
medical
director,
Dr
Nkazimulo
Tshuma.

Dr
Tshuma
said
starting
a
patient
on
ART
does
not
automatically
mean 
their
viral
load
will
be
suppressed.

“We
can
give
one
medication,
but
it
is
now
up
to
the
patient
whether
they
take
it
properly
or
not.”

She
pointed
to
several
factors
that
contribute
to
inconsistent
medication
intake.

“There
are
issues
drug
to
drug
interruption
some
people
have
different
boxes 
when
they
come
to
us
they
don’t
tell
us
they
have
other
conditions
and
we
wont
know
they
are
on
other
medications
so
ARvs
can
also
interrupt
with
other
medications
that
they
are
taking
causing
them
not
to
suppress
the
HIV
properly,
that
is
one
of
the
reason
why
people
are
not
suppressing
their
load,”
Dr
Tshuma
explained.

However,
Dr
Tshuma
stressed
that
the
main
reason
remains
poor
adherence.

“People
are
not
taking
medicine
properly
because
of
many
other
factors.
We
know
generally
we
are
all
undergoing
challenges
here
and
there,
some
people
when
they
go
through
challenges,
tend
to
stop
taking
medicines,”
she
said.

Dr
Tshuma
said
while
health
facilities
are
performing
well
in
terms
of
ART
supply
and
record-keeping,
achieving
viral
suppression
requires
more
than
providing
medication.

“So
medicines
are
being
supplied,
interestingly,
those
people
come
for
their
reviews,
monthly
or
every
six
months
or
they
collect
but
keep
them
at
home.
In
terms
of
us
supplying
ART
record
wise
we
would
have
done
very
well
but
come
to
viral
suppression,
sometimes
we
are
not
doing
so
well,”
she
said.

The
2025
HIV
Estimates
Report
for
Bulawayo
Metropolitan
Province
shows
that
the
city
continues
to
bear
a
significant
portion
of
the
national
burden
of
AIDS-related
deaths.

According
to
the
report,
approximately
946
people
living
with
HIV
in
Bulawayo
died
from
AIDS-related
causes
in
2024.

The
city’s
figures
represent
5.7
percent
of
Zimbabwe’s
total
16
723
AIDS-related
deaths
recorded
nationwide
during
the
same
period.

Adherence
push

Ward
26
Councillor
Mpumelelo
Moyo,
interviewed
at
a
mobile
clinic
in
Emganwini,
warned
that
men
who
default
on
HIV
and
TB
treatment
are
putting
their
own
lives
and
the
wellbeing
of
their
families
at
risk.

“Men
default
because
naturally
they
are
risk
takers,
but
where
they
take
risk
is
a
danger
to
their
lives,”
Moyo
said.

“They
should
be
continuously
educated
on
the
importance
of
taking
medication.
For
TB,
one
must
take
pills
until
the
course
is
completed,
and
for
HIV,
pills
are
taken
for
life.
Men
must
realise
it’s
their
health
that
is
at
risk,
and
stopping
treatment
could
leave
their
families
vulnerable.”

The
councillor
highlighted
his
role
in
encouraging
adherence.

“It
is
my
responsibility
as
a
councillor
to
encourage
men
wherever
I
go
to
take
pills
continuously,
not
to
default
and
be
there
for
their
families,”
he
said.

The
PMD,
Dr
Siamuchembu
also
warned
on
how
defaulting
is
a
“big
problem”
particularly
for
TB.

“If
I
am
on
treatment
and
default,
I
develop
TB
resistance,
which
I
can
give
to
you.
The
person
infected
doesn’t
have
to
do
anything
but
just
has
to
be
close
to
me
to
get
TB.
We
then
end
up
spreading
a
drug-resistant
TB,
which
we
can’t
afford.
This
is
a
problem
for
the
country
because
we
will
not
be
able
to
contain
it,”
he
said.

“We
want
to
treat
everyone
whom
we
can
treat,
cure
them
and
make
sure
they
don’t
spread
it.
It’s
the
same
thing
with
HIV,
except
that
with
HIV
most
of
the
time
you
have
to
consent
to
have
sex
and
to
get
it.
But
with
TB,
you
don’t
have
to
do
anything
but
be
close
to
a
person
with
TB.
Even
if
you
don’t
know,
you’ll
get
it.
You
see
that?
We
want
to
cut
those
numbers
down.
We
want
to
get
rid
of
TB
and
HIV,
as
public
health
concerns
by
the
year
2030.
We
only
have
less
than
five
years
to
do
this.
So
we
want
to
accelerate
that.”

Emerging
solutions

As
a
response,
hospital
staff
at
Mpilo
said
they
are
updating
record
keeping
systems
and
the
rollout
of
an
electronic
health-record
(EHR)
platform
is
expected
to
improve
tracking
across
facilities,
flag
duplicate
prescriptions
and
support
patient
retention
for
those
who
move
between
clinics.

Health
authorities
said
they
were
also
pushing
differentiated
service
delivery
(DSD)
models
to
reduce
barriers
but
this
has
been
affected
by
the
foreign
aid
funding
cuts.

Under
this
model,
families
were
allowed
to
send
one
member
to
collect
ART
for
everyone.

In
some
rural
areas,
patients
linked
to
Community
ART
Refill
Groups
(CARGS)
took
turns
collecting
for
each
other.

In
cross-border
communities,
the malayitsha system
evolved
where
these
informal
transporters
ferry
both
goods
and
medical
records
between
Zimbabwe
and
South
Africa,
collecting
ART
on
behalf
of
patients
working
in
the
diaspora.

“The malayitsha is
also
taught
how
to
maintain
those
drugs,
make
sure
they
are
packaged
well.
It’s
very
safe,”
Nyathi
said.

NAC
Programmes
Officer,
Douglas
Moyo,
said
the
fact
that omalayitsha were
organising
themselves
and
taking
turns
to
collect
medication
shows
real
commitment.

“They
have
sustained
that
arrangement
for
a
long
time.
If
you
want
to
see
the
success
of
the omalayitsha system,
go
to
Tsholotsho
rural
clinics.
Most
of
their
clients
are
actually
in
Botswana
and
South
Africa,
not
in
the
villages.
It’s
a
very
successful
model,
though
not
well
documented
and
it’s
proving
to
be
very
effective
in
rural
areas,
even
in
places
like
Plumtree.”

Despite
these
innovations,
staff
acknowledge
gaps
and
funding
challenges.

Follow-up
systems
often
fail
once
patients
give
false
addresses
and
mental
health
services
remain
thinly
stretched,
leaving
many
untreated
for
depression
and
substance
abuse,
both
linked
to
defaulting.

Khumalo
said
the
OI
clinic
tries
to
cushion
patients
with
support
groups,
peer
counselling,
telehealth,
free
lab
services
and
even
cervical
cancer
screening.

“To
keep
patients
on
ART
we
must
provide
individualised
care,
address
client
concerns,
and
monitor
progress,”
said
the
sister
in
charge.

The
coordinator
for
Zimbos
Abantu
Bulawayo,
concurred 
community
engagement
and
support
groups
are
critical
in
keeping
patients
on
track.

“There
should
be
strategies
like
community
support
groups,
where
people
are
encouraged
and
empowered
to
take
up
their
health
more
seriously,”
Dube
explained.

“Traditional
methods
where
people
have
been
grouped
in
groups
of
10
or
20,
maybe
it’s
an
ART
or
TB
support
group
where
those
recipients
of
care,
share
experiences
of
what
they
are
facing
and
how
they
are
tackling
challenges
and
encourage
each
other
to
continue
taking
up
health
education
also
work.”

Dube
also
highlighted
the
importance
of
addressing
nutritional
challenges
that
often
affect
adherence.

“We
have
also
opted
that
people
don’t
focus
on
the
most
expensive
food
but
the
basics
like umfushwa,
which
is
more
accessible,”
she
said,
adding
that
“growing
gardens
at
the
back
of
their
homes
so
they
get
something
to
eat
as
much
as
they
are
facing
economic
challenges,”
helps
people
stay
on
treatment
without
compromising
their
health.