January 5

Happy New Year!

Apart from working at the maternity this week—and getting to celebrate the arrival of 2013 with laboring women and their new babies—I’ve been busy completing the list of HIV+ women who have been lost to follow-up.  From March of 2009 until November of 2012 there were 240 women who started receiving HIV care at HIC, but now no longer are doing so. I really hope that the social worker and the community health workers will make use of this list and that some of them will be found and restarted with their HIV care. I am however, not incredibly optimistic that many women will be located. The social worker and community health workers are already very busy and to try to track down 240 women—with little more than their names, dates of birth, and possible addresses—seems very ambitious. But I feel that if even one or two women are found and are restarted in care that my work on the list was worth it. 

Along with the lost to follow-up list I’ve also been working on an “opposite” list—collecting information about those women who are still receiving HIV care at HIC. The hope is that with both lists, providers at HIC will have a better sense of whether or not there are differences between those women who are lost to follow-up (LTF) and those who are active. Maybe it’s the timing of enrollment in the HIV program, or whether or not a woman gives birth at home or in the hospital, or her age that is a significant factor in whether or not she stays in care. With that information the providers at HIC may be able to modify certain aspects of their program (i.e. enrolling women earlier if that was shown to make a difference) or focus on certain “at risk” women (i.e. if older age is show to have increased LTF risk, providing more education/support to those in that age range), thus—hopefully—decreasing the programs LTF rate and ensuring more women (and their babies) receive the important HIV medication and care.

This week I also went into the capital and had the pleasure of meeting a woman who is running GHESKIO’s Nurse Practitioner program. (GHESKIO stands for the Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections, and was the first institution in the world dedicated to the fight against HIV/AIDS. It has provided continuous free medical care in Haiti since 1982) I talked to her about what can be done to better define the role of an NP in Haiti—to distinguish NPs from the nurses and doctors, and to make sure that the doctors don’t worry about NPs “taking their jobs”. I also got to meet three women who have already graduated from GHESKIO’s NP program who are working as NPs at GHESKIO. All of the women that I met were amazing. They were all very motivated and open to improving the NP program and striving to provide the best care they possibly can for their patients. 

 

December 28

As I mentioned in my last post I’ve struggled with practicing as I’ve been taught and believe is best while also trying to respect how my Haitian counterparts were taught and what they believe is best practice.

There was a woman who came in in labor this week and when the doctor examined her he said that she would need an episiotomy (cutting the perineum to make the vaginal opening bigger) in order to give birth (this was long before the baby was even close to being at the perineum when something like that could really be evaluated). I had labored for most of the evening with this woman and thought of her as “my patient,” and was more than a bit frustrated at the prospects of her having an episiotomy. I told the nurses I was working with that I didn’t think she needed an episiotomy—and explained that in the U.S. the literature shows repairing lacerations is better than repairing episiotomies—and that if I caught her baby I wasn’t going to perform one. Needless to say, I was not allowed to catch the baby and she got an episiotomy (and actually had quite severe post-partum bleeding, I believe in part as a result of her episiotomy).

I know that the nurses where just doing what the doctor ordered them to do (as is appropriate), and that they believed that performing an episiotomy was best practice, but it was still very hard for me to watch. I however, see no easy way to reconcile our differences in practice. Although I’ve tried to talk to the nurses about why we in the U.S. don’t perform episiotomies (and various other practices), at least in this type of society behavior change needs to come from the top (i.e. the OB/GYN chief) and not the bottom (i.e. night nurses). And although I feel very strongly about the issue I’m reticent to go to the head of the OB/GYN department and try to lobby for such a change. Part of that that is me being scared and non-confrontational, but it’s also hard given that this is what is believed to be best practice and still taught in the medical/nursing schools, and I’m “just” a visiting foreign new midwife lucky enough to have been allowed to work at HIC for these 2.5 months. So, I’ve done nothing—except never perform an episiotomy and have had many moms with no lacerations (when I was told an episiotomy would be needed) or well repaired ones. I know that’s not enough and that I’m not serving my patients as best I can, but it’s all I feel comfortable with doing at this point. 

*I’m in Rwanda this week representing Hope Through Healing Hands with Dr. Paul Farmer, Partners in Health Rwanda, and Harvard Medical School. These dispatches from the road are my personal journal–recording what I’ve seen and learned on this trip. See my pre-trip thoughts, and blogs from MondayTuesday, and Wednesday

Today we went to see some of Rwanda’s natural treasures: mountain gorillas.

Rwanda has a long history of gorilla conservation. Dian Fossey, author of Gorillas in the Mist, founded the Karisoke Research Center in Rwanda in 1967 and studied gorillas in the Virunga Volcanoes until her death in 1985.

We were hosted by Gorilla Doctors, a mountain gorilla veterinary project supported by the UC Davis Wildlife Health Center and dedicated to saving the mountain gorilla species one gorilla patient at a time. Gorilla Doctors serve the mountain gorillas throughout the Virunga Volcano Mountain Range that spans Uganda, Rwanda, and the Democratic Republic of Congo (DRC).

With Gorilla Doctor guides, we spent six rainy hours trekking through Volcanoes National Park looking for the Titus family of 10 gorillas—including one silverback and one 3 month old newborn. We finally caught up with them at about 9,000 feet.

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These incredible creatures are monogamous vegetarians. Each mother has 4-5 children during her lifetime, starting when she’s about eight years old. They can live to be 43 years.

At one point, the gorilla population here was down to 250 animals. When I visited in 2008, there were 750. Today, Gorilla Doctors estimates that there are 880 gorillas.

But gorillas are not quite the departure from human health that they may seem.

Dr. Jan Ramer, regional manager of the Mountain Gorilla Veterinary Project, explained that Gorilla Doctors approach their work from the “one health” perspective, a belief that the health of one species is inextricably linked to that of its entire ecosystem, including humans and other animal species.

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It’s easy to see how closely the species connect.

The number one killer of gorillas is trauma. On our walk we came across three rope and wire snares. Though meant for antelope, gorillas, especially infants and juveniles, sometimes get caught in these snares. Gorillas may lose limbs or digits to snares, or die as a result of infection or strangulation. Gorilla Doctors respond to reports of gorillas in snares and work to treat their wounds and release them.

The number two killer of gorillas is infectious diseases, and humans and gorillas are susceptible to the same diseases. In fact, the most common infection in gorillas is respiratory disease, which can range from a mild cold to severe pneumonia, in individuals or in whole groups. These diseases are often passed from human to gorilla.

I’ve worked with these animals before, even doing some gorilla surgery, but seeing them in their homes never gets old. Amazing creatures.

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*I’m in Rwanda this week representing Hope Through Healing Hands with Dr. Paul Farmer, Partners in Health Rwanda, and Harvard Medical School. These dispatches from the road are my personal journal–recording what I’ve seen and learned on this trip. See my pre-trip thoughtsMonday’s blog, and Tuesday’s notes.

This morning we met with patients and physicians at Centre Hospitalier Universitaire de Kigali (CHUK), the urban hospital equivalent. For the past few days we have explored Paul Farmer’s vision of taking health care to the people in rural areas, so often neglected around the world.  Today we looked at health care in the city.

CHUK is the primary teaching hospital, located in the heart of Kigali. With 25 departments—17 clinical and 8 administrative—CHUK provides training, clinical research, and technical support to Rwanda’s 39 district hospitals.

Again we were able to meet patients and hospital staff. I was particularly impressed with this three-year-old little firecracker. He fractured his hip falling out of tree, but that wasn’t keeping him down! I also had the honor of meeting this dedicated woman. She’s served as a nurse in all of CHUK’s departments over the past 11 years.

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Over and over I’m impressed with how much Rwanda, with PIH and other groups, has accomplished.

For instance, Rwanda has one of the highest vaccination rates in the world—a status they have achieved through very hard work over the past eight years.

Vaccines for children here are a series of six individual vaccines that begin at birth over the first two years of life. In a country with about 11.5 million people—the majority of whom are very poor, a 94% vaccination rate has been achieved through national campaigns centered in communities. The vaccines are administered through community health centers in each of the villages. This is really, truly remarkable.

Breast and cervical cancer have been on the rise in Rwanda, so in 2010, a national campaign to vaccinate schoolgirls against HPV began that is gradually making it across the country through community health centers. The hospital at Butaro—where we were yesterday—is participating in research and the collection of data around this vaccine.

It works; it’s a great vaccine. For cervical cancer it’s very important. And Rwanda is taking a leadership role. As you can imagine, cancer is not treated well in the developing parts of the world. So it’s pretty remarkable that both a vaccine program and cancer care are coming together here.

Of course Rwanda’s remarkable progress is contrasted by the genocide that took place here 20 years ago.

This afternoon we visited the moving Kigali Genocide Memorial, where the history of genocide worldwide is powerfully presented. It was a return visit for me, but no less humbling.

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Last time I was here, a bipartisan group of Senators laid a memorial wreath. This time, I considered what Rwanda has accomplished in those 20 years:

  • a dedicated nurse spending 11 years caring for the sick;
  • Partners in Health Rwanda’s work over the past nine years;
  • a nationwide vaccine program against polio, tuberculosis, and measles, for the past eight years; and
  • the PIH Women’s and Girls Initiative training women for the past six years.

But these are only the beginning.

Maybe the most hopeful thing I saw today was the work of Human Resources for Health (HRH). We had the privilege of meeting physicians from this innovative Rwanda-U.S. joint partnership to strengthen the Rwandan health care system.

Harvard Medical School, USAID and other US government programs are funding about 70 to 100 clinicians and administrators and planners through the Rwandan Ministry of Health to develop the clinical service infrastructure.

These are inspiring mid-career physicians from Harvard-affiliated hospitals who are changing the world. Our tour was conducted by an American orthopedic surgeon who is dedicating a period of her life to serving the hospital and the training program of young Rwandan physicians.  They are all heroes.

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The program, funded by the American Taxpayer and in its second year of an eight year commitment, is a tremendously powerful and smart investment in the future.

What is needed in Rwanda—and globally!—is a long term plan. HRH is building up infrastructure which is so badly needed to lift up the health sector here. But equally importantly, their work will make health care in Rwanda sustainable and prepared for the future.

*I’m in Rwanda this week representing Hope Through Healing Hands with Dr. Paul Farmer, Partners in Health Rwanda, and Harvard Medical School. These dispatches from the road are my personal journal–recording what I’ve seen and learned on this trip. See my pre-trip thoughts, and Monday’s blog

Who says you can’t treat patients suffering from cancer in the poorest, most rural parts of the world?

I’m writing on my iPhone on a bumpy dirt road that I am told will be paved next year. It winds for two hours through gorgeous green mountains sculpted with terraced plots of land and scattered homes stepped up and down the hillside.

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But 30 minutes ago I was on a mountain top in a cancer ward listening to the heart sounds of a 6-year-old boy with leukemia and examining the slowly disappearing lumps on the chest of a 20 year old man with non-Hodgkin’s lymphoma—both being treated with state of the art intravenous chemotherapy.

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Butaro Hospital, based in Burera District, Northern Province, is a PIH-supported facility and home to the Cancer Center of Excellence, a cancer-referral site for all of Rwanda. The cancer ward was opened up in this rural district hospital two years ago. As we toured the wards, we saw children with leukemia, women with breast cancer and men with bowel cancer.

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Paul Farmer introduced to the world the fact that HIV treatment does not have to be expensive and that it can be successfully treated in the poorest parts of the world. No one believed him at first. But he proved them all wrong.

Now he is doing the same for cancer diagnosis and treatment. If it can be pulled off in rural, mountainous, and hard-to-reach Burera, it can be done anywhere.

One third of the patients come from the local district, a third come from outside the district, and a third from around the country and even neighboring countries.

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The hospital has only the essentials: a simple plain film x-ray machine, one ultrasound machine, and basic blood chemistries but nothing like blood cultures. There are no pathologists there—photographs or iPhone pictures can be sent to partner hospitals in Boston, Brigham and Women’s and Dana Farber Cancer Center, when needed.

But the staff is Rwandan and they have been trained in concert with Partners who place a heavy emphasis on fact-based science, research, and clinical training with certification. Pride among the staff bursts forth. People are living and have hope where they were dying in despair.

It’s truly an amazing thing to see.

Kigali, Rwanda

Why are we in Rwanda? What makes it a unique place to learn about health policy, and health care delivery? What will we learn that can make us smarter as we address health issues back at home?

I thought through these questions on the flight to Rwanda, and I had plenty of time. It’s been a long series of flights—Aspen to Denver to Chicago to New York to Amsterdam to Kigali. But the real journey began today as we saw our first health facilities.

Today (Monday), the delegation piled into a Land Rover after breakfast for the 2.5 hour drive to our first stop: the Partners in Health (PIH) headquarters at Rwinkwavu. We toured the Rwinkwavu District Hospital & Health Center, which was funded in part by the Rwandan government, PIH, and Bill & Melinda Gates.

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Formally, I’m here as the Chairman of Hope Through Healing Hands, the global health nonprofit I founded. Having been both a surgeon and a public servant, I am convinced that health and medicine are the best currency for peace and healing worldwide. I started Hope Through Healing Hands to put that belief into action.

It’s a vision that is shared by Dr. Paul Farmer, PIH’s founder and director. Paul has been a friend and like-minded champion for global health for years. He has always had the vision to see things that others could not, the audacity to dream big, and the commitment, dedication, hard work to make his visions–whether a nursing school, hospital, outpatient clinic, or even an entire medical school–a reality. It’s an honor to tour Rwanda with him, and see the progress being made.

When I was last in Rwanda, in the summer of 2008, I was impressed to see how diligently international funds were used (in that case, PEPFAR funding focused on HIV, malaria, and tuberculosis care and prevention). I said then, I wish all Americans could join our delegation to see how wisely their contributions have been spent, and with accountability.

I have seen the same today in the Rwinkwavu District Hospital.

When Rwinkwavu District Hospital first opened, Paul planted several trees there on the property. Standing in their shade today, they are a visual reminder of the growth and progress that PIH—and Rwanda as a whole—has made.

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With Paul Farmer under the trees he planted.

The district hospital is in Southern Kayonza District, one of three that PIH serves. The 110-bed Rwinkwavu District Hospital and its eight health centers are in remote, rural area, and yet it is delivering care to the poor with both compassion and excellent science.

The highlight of my day was meeting the young researchers at Rwinkwavu who were learning how to conduct sophisticated clinical studies that are and will continue to be published in peer-reviewed journals. They are pushing medicine forward not only in their hospital, but globally as well!

Increasingly the hospitals in Rwanda are seeing surgical disease including cancer. For so many years, the African continent has concentrated on infectious diseases. Now that most of those are under control, the most dramatic emergence is of chronic disease of the heart and lung. In addition, there is a huge need for trauma treatment centers, which are generally nonexistent.

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After our hospital tour, we visited the PIH Women and Girl’s Initiative, a wonderful artisanal cooperative that had been started specifically for teenage girls, ages 12 to 18, an age group that has been neglected a bit in Rwandan society. The 20 young women that we met had dropped out of school for various reasons, but had banded together to start a cooperative and learn about small business. They manufacture purses, robes, aprons, gloves that are truly magnificent.

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While the medicine being done compels the surgeon in me, from a global health perspective, the most exciting thing about PIH’s work in Rwanda is that it truly is being taken up by the Rwandan people.

Initially, PIH was a health care provider in these hospitals and health centers. But increasingly, PIH has transitioned into more of an advisory role. PIH now supports the Rwandan government in providing services to more than 865,000 people at Rwinkwavu District Hospital and two other hospitals and 41 health centers, with the help of 4,500 community health workers.

At dinner I had the opportunity to sit beside Dr. Agnes Binagwaho, Rwanda’s Minister of Health. Dr. Binagwaho and I have met several times on my previous trips. She’s been championing public health in Africa since 1994. Tonight she, I, and David Vreeland, discussed the role of information technology in healthcare and the transformation it promises. Rwanda has made outstanding progress implementing health IT to support clinical decision making–a challenge we struggle with in the US as well.

This is the power of global health diplomacy—empowering a community to achieve health, healing, and peace, and seeing incredible gains for the entire global community.

Tomorrow we head North to another province, another hospital, and a cancer center of excellence. I’m excited to see what we learn there.

December 22

As the providers at HIC (i.e. the nurses) have become more comfortable with me and my abilities I’ve slowly begun to help teach the nursing students who are present during my shifts. This week I got to help a couple of the students do deliveries, which were rewarding experiences, though ones I’m not (yet) totally comfortable with. In many ways I still feel like a student myself—I graduated from nursing school in May 2012 and this is my first job practicing as a “real” (as opposed to “student”) midwife—and so it’s a bit odd for me to already be put in a teaching role. That said, I really do enjoy guiding the students and helping them grow more confident with and skilled in catching babies.

One of the hardest things about trying to teach here is that there are some birthing practices that are standard in Haiti that aren’t viewed as best practice in the U.S./developed world (i.e. they always clamp and cut the cord immediately, in the U.S. it’s recommended to typically wait at least 2 min, they perform perineal massage while pushing, in the U.S. that’s not recommended, they perform episiotomies very frequently, most midwives in the U.S. perform them very rarely). So although I may be coaching a student through a delivery, advising her using recommendations from the U.S., often times one of the nurses will “correct” the student and tell her to do something very different than what I’ve just said. So that is sometimes frustrating for both the student and me. I’ve now started saying, “in the U.S. we do this” and trying to explain why I recommend doing something “my” way versus the “Haitian” way. And after hearing my explanations and watching me practice, some of the providers/students are slowly adopting at least the delayed cord clamping, which I’m happy about.

This week I was doing the admitting paperwork on a woman who came in in labor. I know how to ask some basic questions in Creole (How old are you? What’s your name? How many babies do you have? etc.) and so went through those with her.  For the more “complicated” question (Where were you born?) I switched to French, hoping she knew how to speak it—which she did. Her reply—Jamaica—surprised me, and prompted for me to ask her if she spoke English—which she did also. So throughout my night laboring with this woman we had conversations in a mix of Creole, French, and English, which made me smile. I know for Haitians and most people around the world speaking multiple languages is nothing exciting—and I mélange French and Creole normally with all my patients—but having that English thrown in (with her great accent to boot) was a treat.

 

I was in Aspen earlier this week working on some of the challenges facing healthcare and the health industry in the US, but it’s time to switch gears.

From my 2008 trip to Rwanda with the ONE Campaign

Sunday, I leave for Rwanda to lead a one week group trip with my friend Dr. Paul Farmer to see some of the work being done byPartners in Health (PIH) in the country. I haven’t been in countrysince 2008, and I’m anxious to see the progress PIH and other groups are making in health.

Since the spring of 2005, Paul’s PIH organization has been in Rwanda working closely with the government and the Ministry of Health to reach the rural, underserved areas of the country. PIH began by focusing on HIV/AIDS work, but has now expanded to full healthcare offerings. Today, over 800,000 people are served by PIH’s 40 health facilities.

But the health challenges in Rwanda are still vast! Next week with PIH we’ll be considering many aspects of health in Rwanda, but one in particular that I’ll be looking at while I’m there is nutrition.

I firmly believe–and have seen firsthand!–that global health diplomacy works as a real and powerful currency of peace worldwide. And a healthy start to life–a mother enjoying a safe and healthy pregnancy leading to a safe birth and healthy infancy–is crucial to building a foundation that leads to stable communities and global peace.

Food insecurity and malnutrition account for more than half of the deaths of children under 5 in developing countries, and Rwanda has had its fare share of nutrition challenges. In 2005, 18% of children in the country were underweight.

But Rwanda’s government has made real progress in child nutrition since 2009. That year, a Presidential Initiative launched to address malnutrition. The country also joined forces with the US in the Feed the Future initiative.

A 2010 health survey showed that chronic malnutrition and stunting affect 44% of children under the age of 5 in Rwanda.

In September of last year, the Right Honorable Prime Minister, Dr. Pierre Damien Habumuremyi launched a 1,000 Days Campaign, focusing on food availability and a balanced diet for pregnant women through the first two years of life of their babies.

The first 1,000 days may seem like such a small window of opportunity for global change, but the data are clear that childhood undernutrition has long-lasting consequences.

WHO models estimate that over half of adults in the prime working age group–20-29 year olds in Rwanda–have been affected by childhood stunting. Many of these adults wear the visible badges of malnutrition: shorter height or lessened muscular development. And for just as many, malnutrition has exacted a mental toll as well, diminishing the cognitive function of the working age population.

Along with the rest of what we’ll see–including a bit of gorilla trekking and possibly gorilla surgery–I’m anxious to see what progress Rwanda’s 1,000 Days Campaign has made, and the returns realized on nutrition investment.

I’ll be sure to keep you updated.

November 30

Yesterday and today I participated in a training called “Helping Babies Breathe” (HBB). The training materials are produced by the American Academy of Pediatrics, and our training was put on by a number of American doctors who do HBB trainings all over the world. I was lucky enough to be able to also participate as a trainer in the training, which was a lot of fun. There were about 40 people at our training—mostly nurses, though there were also a couple of doctors (but sadly no midwives). I had 6 women (all nurses) within my small training group.

The HBB curriculum teaches participants how to resuscitate a baby in resource-limited settings (i.e. all of Haiti). Using a Neo-Natalie blow-up baby I taught my group the basic steps of drying a baby, suctioning his/her mouth and nose, performing stimulation, and using a bag and mask to perform ventilations—all in hopes of resuscitating a baby who is born not breathing.  We practiced various scenarios including: a baby born with clear amniotic fluid, with meconium, with the baby crying right after having been suctioned, and with the baby not crying or getting a high heart beat after correctly being ventilated for a number of minutes.  Each of the participants were given training materials to use back at their specific clinics/hospitals to train additional staff, as well as a number of bags/masks and bulb suction devices to now use to resuscitate babies.

It’s amazing to think that such inexpensive/relatively low-tech products like a bulb suction device and a bag/mask can have such a dramatic difference on a baby’s outcome. It’s also very sad to think that without the proper training even in the presence of such devices, many providers here don’t make use of them.

I’ve had to resuscitate a number of babies at HIC, and each time I’ve been the only provider helping with the resuscitation. Often the nurses have told me that a baby looks dead—and why should I try to save him/her? When I have responded that the baby has a heartbeat, and is in fact not dead—which is why I’m working to get him/her to breathe again—they have laughed and thought me foolish. That mentality however, I think—I hope—is slowly changing. As the nurses I’ve consistently worked with have seen the fact that with proper resuscitation a baby can be brought “back to life”, they are at least telling me that they now see the utility in not automatically giving up on a baby, but instead trying to work to make him/her breathe. 

No one from HIC came to the HBB training—despite the hospital having received a number of invitations—which is sad, but the training has inspired me to use any downtime during my night shifts to train the nurses I work with. Hopefully with such training—and seeing my example of resuscitating every possible baby—the night shift nurses will learn the HBB techniques and will be able to pass it on to the other maternity nurses, and save lots of babies lives in the days/months/years to come.

Likewise, I hope that the providers who were trained in the past two days go back to their institutions and train others—or at least serve as an example and spark some discussion—and in doing so help babies who might otherwise not been given a chance.

 

Motherhood is a dangerous journey to take in most of the world. Nearly 300,000 women die each year from complications due to pregnancy, and 99 percent of those women are in the developing world. In Malawi, an estimated 510 out of 100,000 women will die giving birth. But Chief Kwataine, a former English teacher, has become well-known in the country for his work developing safe motherhood activities for nearly the last twenty years.

Watch this short, two-minute video to learn more about how women's (and children's) lives are being saved in Malawi. It's well worth your time.

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