in_effect

In government offices which are sensitive to the vehemence and passion of mass sentiment public men have no sure tenure. They are in effect perpetual office seekers, always on trial for their political lives, always required to court their restless constituents.

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The answer was that in Burundi, having a clean bill of health has taken on a very particular meaning: unless and until you have paid for your hospital treatment, you simply can't leave, you are in effect a captive.