We’re Not Ready for Winter – We Need to Be!

The winter hasn’t even hit us yet. But it will and it’s going to hit us hard. Harder than we know. Harder than we are prepared for. Do you remember January 2015, with queues of people lying in corridors in our Emergency Departments, and a high spike in winter deaths? One of the people I respect most in the world of Public Health, Prof Dominic Harrison, highlighted to me this week, that it was a three-fold, intertwining cord which led to the devastating outcomes: an ineffectual flu vaccine, high staff vacancies in the NHS, and high staff sickness rates. But here’s the thing – this year we have more factors (Covid-19, incoming Influenza, staff gaps in the NHS, people having to self-isolate and sickness levels rising – this week our surgery had 14 staff off with C-19) and although, so far we haven’t seen the spike in deaths associated with the rising number of Covid-19 cases (thanks to better treatments), our hospitals are filling up fast, whilst the mantra remains, that the NHS must get back to pre-Covid levels of operation. This is going to be a tough winter. And it’s going to be worse, as it always is in our most deprived communities, which will further widen the health inequalities gap. And people are going to die, not only of Covid and influenza, but of other preventable things like heart attacks, strokes and suicide, in higher numbers than usual. What am I, a prophet of doom? Well…..I hope not! But this is a wake-up call.

 

It’s no surprise that so many people feel a smouldering sense of anger towards the government. There is no doubt that things could and should have been handled differently from the beginning. It’s no use saying – well….we didn’t know what we were facing, we weren’t prepared for this….. the government didn’t even follow their own advice from their preparedness exercise three years ago, they have outsourced test and trace to companies with no track record or expertise in the world of public health to the tune of £12billion and it doesn’t even work effectively. They have given contradictory advice to different regions of the UK, they have continued to allow foreign travel, they have failed to adequately explain the reasons for certain policies which key members of their inner circle haven’t even followed, they have briefed key city leadership teams through the press and failed to win the public’s trust – something which is so crucial at such a time as this. They have “followed the science” and then not followed the science…..it has been a shambles and it’s no wonder that people are disengaged.

 

HOWEVER – this is not the time to let our cynicism get the better of us! What we have to face is that we are where we are and we’re heading into winter, and our anger towards these various failings is in danger of causing us to embrace apathy or rebellion – both of which will have terrible consequences. So right now, we need to keep our heads and we need to take a deep breath. There will come a time for the government to answer serious questions about how they have handled this pandemic and the decisions they have made. But it is not now. Now, we need to look ahead and be really pragmatic about what we’re about to face together.

 

Firstly, I would implore the government to listen to the wisdom of Prof Devi Sridhar. As the youngest ever Rhodes Scholar and fiercely respected Professor of Global Public Health, she is worth listening to. She has not been shy in her critique of where the government have made mistakes. But she is also speaking with a real sense of pragmatism and kindness, as she draws on lessons from across the globe to develop a roadmap for the way ahead. Her advice to government is as follows:

  • Ensure the Test, Trace and Isolate system is robust. Test results need to be back within 24 hours, 80% of contacts must be traced and strict adherence to the 14 days isolation is vital. The current system still isn’t working effectively enough, despite an eye watering bill with no sense of accountability or responsibility for it’s failure. It is not too late to ensure that local directors of Public Health can lead this work heading into winter and ensure that all available labs are put to effective use.
  • Solid, consistent and clear public health messaging needs to go to the public through every means possible. There needs to be rationale and helpful explanations about why certain measures are being chosen.
  • We need strict border measures to stop the virus from re-circling.

Secondly, as the public we need to take whatever responsibility we can to ensure we continue to do all we can. Conspiracy theories are not even vaguely helpful right now. And although it’s true that death rates have been lower than expected, there are other things to consider. This is still a dangerous virus – it will lead to many extra admissions to hospital through the winter period, especially linked with Respiratory Illness and it will affect unsuspecting and previously healthy people with the effects of long-covid – I have seen the effects of this in my (young and previously fit) patients and friends and it is truly debilitating. With all the other things we have to cope with this winter, we can’t afford to let our guard down – not now. We know from public health data that the vast majority of spread is between family, friends and neighbours. We also know that it won’t just be Covid-19 that kills people this winter. Higher than normal deaths from other illnesses/conditions are expected across the board. So, here are some sensible things we can all do to try and stay well:

  • Have a flu jab if you’re in one of the ‘at risk’ groups
  • Take worrying symptoms seriously! Don’t ignore chest pain (especially if it’s worse when you exert yourself), or new lumps and bumps – especially in your more private parts, or bleeding from somewhere you don’t normally bleed from, or unexplained weight loss. See your GP!
  • Wash your hands regularly
  • Wear a face mask when out and about
  • Spray and wipe down surfaces
  • When you cough or sneeze, do so into your elbow crease
  • Keep 2 metres apart from people who are not in your household, and wear a facemask if you have to get closer
  • Keep within your household bubble – the vast majority of spread is now happening between family, friends and neighbours – we can’t be blazé about this!
  • As far as possible (recognising that choices are significantly reduced for many of our communities), make good choices for your own physical and mental health:
    • Eat well – be determined to fuel your body with good nutrients – if you’re trying to get to a more healthy weight then significantly reduce salt, alcohol, sugar and carbohydrate in your diet. Consider taking a vitamin D supplement through the winter – 1000units daily – only about £1 for 60 tablets from most pharmacies.
    • Exercise – this doesn’t have to be anything unrealistic or intense – stop looking at other people’s sculptured bodies and feeling crap about yourself. You are beautiful! Just take a walk, if you’re able, every day – whatever the weather, and get some fresh air. If you’re unable to walk, try some gentle chair-based exercises – it doesn’t have to be anything heroic – something is better than nothing. Do more if you want, but let it become enjoyable, rather than a chore – something you’re choosing in order to make life better and more happy.
    • Be grateful – everyday, when you wake up and before you sleep – try and think of three things you can be grateful for that day.
    • Breathe deeply and use breathing techniques to calm yourself down, like box breathing (breathe in for 4, hold in for 4, breathe out for 4, hold out for 4).
    • Connect with people – even if it’s via zoom, facetime or the phone – whatever it takes – connect with other human beings around you. Social isolation is literally a killer. We must take care of each other. Ask people how they are and genuinely care enough to listen. Some people are going to tell you they aren’t sure they want to carry on living. Ask them if they are thinking about ending their life. If they say yes – ask them if they have made any plans. Either way, take this seriously. Help them get help. Ask them if they have phoned their GP yet. Tell them you’re going to to keep walking with them through this tunnel. Reassure them that there is a light even though they can’t see it right now.
    • Learn something new – a language, a skill, whatever you fancy – give it a go.
    • Relax – seriously switch off the 24 hours news cycle, disconnect from too much social media and take time to do things which are good for your soul – sing, dance, read, play games, take long baths, whatever helps…..
    • Sleep – our bodies and our minds regenerate when we sleep. Sleep is good!
    • Above all – keep love and hope alive. We’ve got to dig deep to keep loving each other – being kind in our attitudes, even towards our enemies. And keep on keeping on hoping. If you’re not sure how, this podcast with Brené Brown and Michael Curry will help!

 

Thirdly, the NHS is not yet ready. Yes – there have been some remarkable things which the NHS has done to respond to the first wave of Covid. Contrary to some misleading articles about General Practice, we are and have always remained open and available to our patients. We are triaging all patients via the phone to work out how we can best help and employing loads more technology to help us do this. It’s so much better for a young mum of three kids to be able to have quick video-call about one of her children’s rashes than have to lug them all down to the surgery. It’s great that we can now supplement a phone/video call with an advice sheet sent to your phone. It also means that we can prioritise who really needs seeing face to face and keep our premises as Covid-secure as possible. Many community staff were redeployed from their usual work, such as Speech and Language Therapists, Occupational Therapists and Physiotherapists, into the Nightingale and Rehabilitation hospitals, meaning they were taken away from their usual work, with a huge amount to now catch up on. This was not without cost to families who needed their support or were awaiting a diagnosis, and added to the strain in General Practice also. It was tough. But it was worth it. And we’re so grateful for the way the public were overwhelmingly understanding towards us as we tried to flex our services to cope with the demand.

 

However, we need to take a radical stocktake of where we are and again put into motion some very different ways of operating over the next 2-4 weeks. It will allow us to work in a way that is safest for the public and will provide a sense of reassurance. Although I welcome the reopening of the Northern Nightingale Hospitals – as usual, the focus is far too much on the Acute Hospital sector and not enough on how we can help people stay more well in the community and prevent admission, particularly in our economically poorest communities. It’s important that the public understand that we need to reorganise our services in the community again in order to try and enable as many people as possible to stay well through this winter, particularly in our poorest communities, where admission to hospital and early death rates are always significantly higher.

 

I have nothing but compassion and camaraderie with GP colleagues as they cope with a huge surge in demand, (just indeed as I do with all NHS workers and carers right now, whatever their role). What I believe we need to do NOW though is change the way we’re working so that we can give real focus into the areas which are likely to affect people’s health most significantly over the months ahead, support our community colleagues to focus on various aspects of their work more effectively and enable our teams to be resilient and stay well themselves through the winter, whilst serving the communities with their usual brilliance. Here are my suggestions, which we are exploring in more depth across Morecambe Bay and indeed our Integrated Care System across Lancashire and South Cumbria (though important to note that this is more about function than form, so might ‘look’ different in each locality):

 

  • accept now that we cannot get back up to pre-covid levels of activity, for example in routinely scheduled operations, and if we try to, it will lead to more unnecessary deaths. This is a big ask for people who are waiting for their hip to be replaced, or their hernia to be repaired, but we have to be realistic about what is possible with the resources we have available.
  • re-focus and align existing capacity in order to ensure a more coordinated approach to addressing demand.
  • target additional resource to mobilise capacity where it will have the most impact.
  • use data and evidence of risk and vulnerability from COVID-19 in a more systematic way to inform a response that is scaled appropriately.
  • In order for this to work practically, we must create a model which makes this possible. Perhaps one way is by reorganising into a model of Red, Amber and Green Community Hubs, supported by a co-ordination centre, which pulls together the data and brings aid when practices are struggling, could work in the following way and allow us to work as effectively as possible (recognising that this may vary according to Primary Care Network/ICP/MCP need and capability/capacity):

Red Hubs (which can be remote in terms of triage) staffed by Paramedics, GPs and Nurse Practitioners, to deal with COVID-19, Flu, and Acute Respiratory Illness (i.e. anyone with a fever, cough or breathlessness). It may be that out of hours providers may already be in place to supplement and support this model.

Amber Hubs – a remodelled care co-ordination team approach led by the General Practice Team with proactive support from community (including mental health) teams.  They would use an asset based community development model of Population Health Management and work WITH communities to:

  • Focus and drive on proactive long-term condition management AND other acute illnesses that don’t fit the criteria for the red hubs.
  • Have a driving focus on proactive long-term condition management with particular emphasis on conditions more vulnerable to poor outcomes from COVID-19.
  • Be supported by redeployed medical specialities.
  • Fund and support the Community Voluntary Faith Sector to partner with Primary Care and Community Teams to create a really resilient partnership in doing this work together, recognising the HUGE impact the 3rd sector makes to this work and how fragile they are in terms of adequate resources.
  • Be sited so as to ensure accessibility to residents within the 20% most deprived communities within each ICP/MCP.
  • Have attached to them place based multidisciplinary assertive and active case management and care co-ordination teams (think spokes) as outlined previously. These teams would have a focus on the “priority wards” and groups experiencing higher levels of social isolation.
  • Take a “more than medicine” approach by having active in reach from other partners reflecting broader, social needs that are barriers to improved health and wellbeing; social prescribing, housing, employment and more as informed by the data.
  • Cardiovascular Interventions
    • Hypertension – we have too many patients with a BP >150/90 (current guidance shows we should be aiming for <135/85 for the general population and <130/80 for those Diabetes or known heart disease). We will best prevent MIs and CVAs by being much more proactive in this area.
    • Atrial Fibrillation – ongoing protection work by ensuring appropriate anticoagulation in those with a Cha2ds2vasc score of over 2.
  • Diabetes (and Cancer)
    • focus on healthy weight, driving down BMI where possible, through targeted interventions and
    • reducing HbA1c in people through targeted lifestyle interventions and medication where necessary.
  • Respiratory Disease (and Cancer)
    • Stop Smoking interventions
    • Weight loss programmes
    • Winter warmth schemes in homes and damp removal – this will be vital in keeping admissions down
  • Cancer – Getting a real focus on 2 week wait referrals with appropriate messaging to the public
  • Mental Health – Suicide Preventions
  • Mental Health reviews
  • Targeted messaging to the public to help them understand why and how things are changing
  • Suicide awareness training
  • Frailty and Care Home work – ongoing support and focus on the frail and those in care homes

 

Green Hubs – these will focus on:

  • Musculoskeletal problems – physio first and possible redeployment of Orthopaedic Surgeons and Pain Specialists, to run clinics and provide joint injections in the community rather than surgical procedures, to see people through the winter period
  • Other day to day, essential General Practice issues – baby checks, smear tests, dermatology, rheumatology, ENT, low level mental health etc – run by a reworked and repositioned team

 

 

The model above won’t work for all, but the principles are important. It might all seem a bit radical and it’s true that there would need to be a significant amount of resource and support flowing into the community to enable this – however, if we don’t do something like this, then it’s like knowing an earthquake is coming and not bothering to take aversive action. We don’t have the personnel we need right now, but partnering with the voluntary sector (with appropriate resource allocated) and ensuring we have the right data help and support will make this more possible. Finances must be freed up to support this model and NHSE need to give the ICS teams across the nation some slack to take this more proactive approach. It will actually lead to huge savings (of lives and money).

 

We’ve already lost a lot of people to Covid-19. We’re heading into a serious economic catastrophe and a winter of discontent. Good public health and good health care IS good economics. If the government heed the warnings, if the public take this seriously and work with us, if the NHS can reorganise, even at this late stage, then we will significantly improve our chances of getting through this winter well together. We won’t have another opportunity to ‘get this right’. I hope we will act now and find that we really can make it through together.

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Should The Schools Go Back on June 1st?

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Is the decision to send some of our children back to school on June 1st the right one? What are the factors that have been considered and how has the decision been made? I”ve been asked these questions a number of times and they bother me at several levels. They bother me as a Dad (and believe me I have an even deeper respect for teachers and the magic they do every day!), as a GP, as a School Governor of a Primary School, as a Trustee of a Multi-Academy Trust, as a Co-Author of a book about Adverse Childhood Experiences and as a local leader in the NHS as Director of Population Health in Morecambe Bay. So, I come to the questions with several different hats on and feeling conflicted in how I think about the issues involved. To be absolutely clear, this blog is written from a personal perspective and I am not writing in any of my official capacities, as with any blog on this site. I was having a conversation the other day with a friend of mine, who spent years working as a solicitor. We were talking about judicial reviews and the probity of any given decision. The vital test is this: has everything been taken into account that should have been; has anything been taken into account that shouldn’t have been? In other words, it’s not about the decision but about HOW the decision is arrived at. If the test is satisfied, it’s a good decision.

 

Firstly, I want to focus on the process of decision making. Over the last few years, working with the Poverty Truth Commission and using the ‘Art of Hosting’ as a framework for how to encourage wider participation, I have been greatly impacted in how I think about this process. In the PTC we follow the basic principle that ‘no decision about me, without me, is for me’. When the government made the decision to open schools more widely on June 1st, did they talk to the unions first? Did they discuss the ideas, concerns and expectations of many teachers prior to their announcement? Was there any discussion with children or young people about what they might feel about returning to school and what their priorities might be? Was there even an announcement to the house of commons so that the idea could be debated and discussed before deciding on the June 1st date? I think the answer to each of those questions is ‘no’. So, in terms of probity, it seems impossible to say this is a good decision without having taken into account such vital opinions and voices. I absolutely recognise that being in government at such a time is no easy task. If the government, here in the UK, continue to act without involving wider participation and conversation, it is less likely, especially at a time of such national anxiety and uncertainty, that they will be able to take the public with them. We need the government to choose to be listening, inclusive and honest about the complexity of the issues involved. If they do this, they will find national collaboration much easier to achieve.

 

Secondly, we keep being told by the government that we are being “guided by the science”. This statement alone poses so many questions! When Sir Jeremy Farrar, (watch from 10:30) CEO of The Wellcome Trust, and member of SAGE was humble enough to admit last week that it was a mistake not to have been far more on the front foot with testing and contact tracing here in the UK, something which has been shown to have an extraordinary benefit in Kerala, South Korea, Taiwan, Iceland and Germany (as just five examples – there are plenty of others from Africa and Oceana also), it felt like there was a collective sigh of relief across the country. Finally, someone actually publicly stated that things have gone wrong. Since that time Prof Tim Spector has warned us that because the UK has been listing only a limited number of possible Covid-19 symptoms, there are probably between 50000 and 70000 people who currently have the disease and are not self-isolating. He, along with Deputy Chief Medical Officer, Professor Jonathan Van Tam have both also insinuated that the ‘tried and tested’ method of physical contact tracing through local public health teams is much more trustworthy than a centralised app-based model. Without this, the ‘R’ number is very limited in it’s ability to predict much at all, as we’re really in the terriotry of good guess work, rather than more real time data which we can interrogate and probe more thoroughly. The danger with this approach therefore is that we are 3-4 weeks behind with the actual numbers and looking at death rates doesn’t necessarily help us much either when considering the rate of spread. To make matters more complex, the (inaccurate) R number has significant regional variation, which again makes the case for more locally led and connected decision making. Furthermore, the UK Pariliament’s Science and Technology Committee, chaired by the Rt Hon Greg Clark MP have detailed ten significant findings and concerns with recommendations attached, whilst recognising the complexities involved. Of particular note, we’ve had 10 weeks in which woefully insufficient testing, contact tracing and isolation has been the reality. Today, the WHO reported the largest number of new cases of Covid-19, worldwide. With our airports still open and an increase in travel emerging, we put ourselves at major risk of an early second wave, especially if we do not have the necessary systems in place to prevent this. Boris Johnson is still adamant that things are steaming ahead nicely but other government ministers say their new track and trace system will not be ready for roll out on June 1st. This is different to having a fully operational system in place. There are questions that still demand answers! Many expert voices are calling for a much more locally driven, joined up approach, led by our brilliant Directors of Public Health, supported by joined up working across the public sector and supported by General Practice. There are plenty of voices asking us to pause and think again.

 

Thirdly, we need to know if it safe for children to go back to school? The government are confident and clear that it is. It is interesting, however, that allegedly every member of the current cabinet sends their children to private schools, none of which will be opening until September. The answer to this question is not straightforward and there are several things to consider and we should be honest about that.  Are children likely to become unwell from Covid-19, if they have no underlying health conditions? No – they are very likely to only suffer very mild symptoms, though there are some concerns regarding some children having rare sudden respiratory symptoms. But what about the impact on those who will need to continue to be isolated at home? Can children have the virus without showing symptoms? Yes. Can they therefore be spreaders of C-19? Yes they can, and because we have not been doing effective testing, contact tracing and isolation, this could be problematic. If the government’s testing and contract tracing system, run by Deloitte’s and supported by the national app is up and running by early June, will this make it safer? Probably, but there is great cynicism in the world of Public Health that this approach is desirable. As stated above, the tried and tested model of this all being run by the Directors of Public Health and their teams in each geography, supported by local GPs is deemed to be much more effective. Local knowledge and guidance would, I believe, give local teachers much more confidence with more readily available advice where needed. Should staff be wearing face masks? There is varying advice on this. Our local authority currently says no, but Prof Trish Greenhalgh from Oxford University advises that they should, on the basis that face masks reduce the spread of C19 and can perhaps offer some protection for the wearer also.

 

What are the risks of not opening the schools? Well, we know that 10% of all children in the UK (and this is not dependent on social class, so kids at private schools are at just as much risk) are likely to be suffering from 4 Adverse Childhood Experiences. The impact of this kind of trauma on them can be absolutely huge in the long term and schools and key relationships with teachers/TAs can be significantly protective factors. Schools also play a very important role in tackling food poverty and ensuring many children get 2 or even 3 good meals. So Steve Chalke is right that not opening schools could appear like a middle-class luxury. But will putting kids who need security and love, into an alien situation with facemarks, social distancing and a very different kind of day to usual, actually compound the sense of trauma? We don’t know yet, but we will need to watch this carefully, if and when the schools do go back. Perhaps headteachers could prioritise those children most at risk, over the 4 and 5 year olds, who it will be very hard to keep socially distanced. What I will say though, is that headteachers are not the ‘bad guys’ here. I don’t know one headteacher who doesn’t want anything except the best for the children in their school and genuinely wants to be able to have them back.

 

Without effective or sufficient testing and contact tracing, we do put ourselves at risk of an early second peak. This is a risk – are we prepared to take it in the face of what we know about the rise in domestic violence, childhood trauma and growing mental health issues? Will 6 weeks back at school before the summer really be worth it? Should we mitigate the risk by not opening and ensure that we are more sure of the necessary processes being in place first? The decision ultimately belongs with each head teacher with support from their governing body, as to whether or not to open on June 1st. It is dependent on what is practicable in their given location and with the staff and facilities they have at their disposal. The government guidance is difficult to implement in many settings. So let us be kind to each other. Let’s be honest about where we are and just how complex this is. For those who want to dip their toe in and give it a go, we must ensure that guidance is followed as closely as possible, especially hand washing, cleaning of surfaces and physical distancing, where practical. For those who decide to wait, fair enough. But whatever happens, let us be determined to build an education system that is fit for the future. Let us rebuild education based on love and kindness and let’s be brave enough to redesign the curriculum around the needs of humanity and the ecology.

 

So, in summary:

 

  • These are my own opinions
  • Is it safe for children and teachers to go back to school? Possibly, but without satisfactory testing, contact tracing and isolation in place and with growing evidence that this will not be adequate by June 1st and with an inaccurate R number due to an incomplete list of symptoms for testing people, there is a risk to the wider public that we could enter an early second peak. It would be prudent for the government to seriously reconsider their centralised approach to this, when empowering local government and public health teams to lead this process will be far more effective. It may be safe for children to begin to return to school (I think), but maybe not for wider society.
  • At what point then, would it be safe for schools to reopen? Perhaps once we are more sure that the protective public health systems we need to be fully operational are in place and running effectively. But we do need to return to school soon, so we need to find a way through – that way is unlikely to come through centralised command and control but will rather require a participatory and inclusive approach. So the answer is maybe but maybe not quite yet – better to get it right than to risk getting it horribly wrong by rushing it.
  • If schools choose to reopen, due to the concerns about issues like trauma, mental health and hunger, what are the issues they need to consider? The current government advice on social distancing is impractical and schools may need to look for community partners, who may be willing to help with other local premises (e.g. churches, mosques and local halls) to enable this to be possible. They will also need to ensure good hand washing, cleaning of surfaces and consider what they want to do about face masks AND we need to re-emphasise this advice to the wider public. Schools will also need to think about how they staff the recommended ‘bubbles’ and whether or not they will need community DBS-checked volunteers to help out. On top of this they will need to consider who they initially prioritise how they support the emotional and mental health of our children, young people and staff in a very different kind of setting. And they will need to remain inclusive of those children and young-people who cannot return to school due to having underlying health conditions themselves or in their households.
  • Whatever happens, let’s ensure a more participatory and inclusive conversation about the path ahead of us. Schools need to be involved in the process.
  • Let us also have a wider conversation about the kind of education system we need for the future. Lots of good thinking on this already across the UK and some podcasts coming soon.

 

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Reimagining Health and Care – An Apocalyptic Moment?

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Good Grief

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Metamorphosis

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4 Things to Do If You Are ‘Isolated’ at Home Because of Corona Virus

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Corona Virus Update

Tweet As the national guidance changes, here in the UK, I’m updating my advice and practical suggestions of what we can do to be prepared, stay well, support each other and be good neighbours. I hope you find this next instalment helpful!   Share This:

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Corona Virus Advice – Time to be Serious

Tweet Corona Virus or Covid-19 is not something we can be laid back about. We have to take mild symptoms of cough or fever really seriously. I hope you find this video helpful:   Share This:

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