Health workers and the weaponisation of health care in Syria: a preliminary inquiry for The Lancet–American University of Beirut Commission on Syria

The conflict in Syria presents new and unprecedented challenges that undermine the principles and practice of medical neutrality in armed conflict. With direct and repeated targeting of health workers, health facilities, and ambulances, Syria has

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  Health Policy   Published online March 14, 2017 1 Health workers and the weaponisation of health care in Syria: a preliminary inquiry for The Lancet –American University of Beirut Commission on Syria Fouad M Fouad*, Annie Sparrow*, Ahmad Tarakji, Mohamad Alameddine, Fadi El-Jardali, Adam P Coutts, Nour El Arnaout, Lama Bou Karroum, Mohammed Jawad, Sophie Roborgh, Aula Abbara, Fadi Alhalabi, Ibrahim AlMasri, Samer Jabbour  The conflict in Syria presents new and unprecedented challenges that undermine the principles and practice of medical neutrality in armed conflict. With direct and repeated targeting of health workers, health facilities, and ambulances, Syria has become the most dangerous place on earth for health-care providers. The weaponisation of health care—a strategy of using people’s need for health care as a weapon against them by violently depriving them of it—has translated into hundreds of health workers killed, hundreds more incarcerated or tortured, and hundreds of health facilities deliberately and systematically attacked. Evidence shows use of this strategy on an unprecedented scale by the Syrian Government and allied forces, in what human rights organisations described as a war-crime strategy, although all parties seem to have committed violations. Attacks on health care have sparked a large-scale exodus of experienced health workers. Formidable challenges face health workers who have stayed behind, and with no health care a major factor in the flight of refugees, the e󰁦ect extends well beyond Syria. The international community has left these violations of international humanitarian and human rights law largely unanswered, despite their enormous consequences. There have been repudiated denunciations, but little action on bringing the perpetrators to justice. This inadequate response challenges the foundation of medical neutrality needed to sustain the operations of global health and humanitarian agencies in situations of armed conflict. In this Health Policy, we analyse the situation of health workers facing such systematic and serious violations of international humanitarian law. We describe the tremendous pressures that health workers have been under and continue to endure, and the remarkable resilience and resourcefulness they have displayed in response to this crisis. We propose policy imperatives to protect and support health workers working in armed conflict zones. Introduction This Health Policy presents preliminary results from an inquiry of The Lancet  –American University of Beirut Commission on Syria: Health in Conflict . 1,2  Health workers a󰁦ected by the Syria conflict face serious short-term and long-term threats. In this paper, we examine the experiences of health workers inside Syria, and the hazardous situation and precarious conditions these workers face. The srcins or evolution of the Syria conflict are not described in this paper, nor the associated impact on populations and health outcomes discussed. Rather, the paper focuses on four analytical themes: attacks on health-care facilities and targeting of health workers as part of a broader pattern of systematic violations of international humanitarian law, the attrition of health workers, the challenges facing health workers in di󰁦erent areas, and the evolving roles of health workers. Examples include the expansion in health-care provision of single-speciality to multiple specialities, whether in medicine, surgery, public health, or all three, as well as role expansion beyond direct health care into administration of hospitals or health directorates, development of non-governmental organisations for aid delivery, coordination of vaccine campaigns, cooperation with UN and other international aid organisations, and finally, advocacy. We build on this analysis to develop policy options to ensure that health workers a󰁦ected by the Syria conflict, and others elsewhere, receive the essential attention needed to protect them, and to prevent threats to their neutrality and impartiality (panel). Health workers under attack In this paper, we propose the idea of weaponisation of health care to capture the phenomenon of large-scale use of violence to restrict or deny access to care as a weapon of war. Weaponisation is multi-dimensional and includes practices such as attacking health-care facilities, targeting health workers, obliterating medical neutrality, and besieging medicine. Through large-scale violations of international humanitarian laws, weaponisation of health care amounts to what has been called a “war-crime strategy”. 3  Weaponisation of health care in the Syria conflict is manifested most notably in the targeting of health workers and facilities. The historical context is important to understand. Global context: protection of health workers under international humanitarian law The imperative for unobstructed humanitarian aid during armed conflicts is well established. 4   The importance of allowing health workers to treat sick and wounded combatants led to the creation of the International Committee of the Red Cross (ICRC) in 1863 and drove the development of the humanitarian principles of impartiality, independence, and neutrality underlying the first international humanitarian law in 1864. 5  The four Geneva Conventions, codified in 1949, define the obligations of nation states engaged in armed conflict. 6  The Fourth Geneva Convention, which requires warring parties to refrain from hostile actions against Published Online  March 14, 2017  Online/Comment*These authors contributed equally Faculty of Health Sciences (F M Fouad MD, M Alameddine PhD, Prof F El-Jardali PhD, N El Arnaout MPH, M Jawad MBBS, S Jabbour MD) , Global Health Initiative (F M Fouad) , Knowledge to Policy (K2P) Center  (Prof F El-Jardali) , and Center for Systematic Reviews on Health Policy and Systems Research (SPARK)  (Prof F El-Jardali, L Bou Karroum MPH) ,   American University of Beirut, Beirut, Lebanon;   Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA  (A Sparrow MBBS) ; Syrian American Medical Society (SAMS), Washington, DC, USA  (A Tarakji MD, A Abbara MBBS) ; Department of Sociology (A P Coutts PhD) , and Department of Politics and International Studies  (S Roborgh MSc) , University of Cambridge, Cambridge, UK; Imperial College London, London, UK (A Abbara, M Jawad) ;   Multi Aid Programs (MAPS), Bekka, Lebanon (F Alhalabi MD) ; and SAMS, Zahleh, Lebanon (I AlMasri MD)Correspondence to: Dr Samer Jabbour, Faculty of Health Sciences, American University of Beirut, PO Box 11-0236, Riad El Solh, Beirut 1107 2020, Lebanon For more on The Lancet -American University of Beirut Commission on Syria: Health in Conflict  see Online  for infographic  Health Policy 2   Published online March 14, 2017 civilian populations, established distinct protections for health and humanitarian workers who provide aid to wounded combatants of any side and to civilian populations. 7  These protections under international humanitarian law confer treaty obligations on all signatory nations. Every country in the world has signed and ratified the 1949 Geneva Conventions; however, not all nation states have signed or ratified the Additional Protocols to the Geneva Conventions that expand and clarify the protections for medical and humanitarian personnel and civilian populations. 8  These protections are recognised as a matter of customary international humanitarian law, which means even governments that have not ratified the relevant treaties are required to respect them. 4 Finally, recognition by UN rights bodies that international human rights law and international humanitarian law provide for access to health care in wartime is increasing. 9–11 The ability of people in need to access health care depends on state and non-state armed groups respecting international humanitarian law provisions that protect health workers. Yet several of today’s armed conflicts and resultant humanitarian crises are taking place in settings in which both state and non-state armed groups have shown disregard for the safety and lives of health workers, flagrantly violating applicable international humanitarian law with impunity.Findings from studies 12–14   have emphasised the need to better understand the plight of local and international health workers in conflict. The bulk of attacks occur in ongoing conflicts in Afghanistan, Somalia, South Sudan, Syria, and Yemen. 15  National sta󰁦 are the most exposed and the most common victims of attacks. 16  When international organisations are forced out of an area, not only are local humanitarians the only groups that remain active, but the UN and other international non-governmental organisations also rely on them as implementation partners. Despite research e󰁦orts to document their plight, knowledge and evidence remains scarce. Particular violations of international humanitarian law in Syria The Syria conflict has seen large-scale aerial bombing of civilian areas, committed by the government and its allies. The pattern of government attacks on civilian areas suggests that the government deems all civilians, including those providing medical care, living in opposition-controlled areas to be a󰁩liated with terrorism, and hence as legitimate military targets. But, as international humanitarian law makes clear, even that designation is no justification for the Syrian Government’s war crime of deliberately bombing civilian homes; attacking infrastructure vital to civilian life such as schools, bakeries, and markets; and forcing the displacement of over half the country’s population. Nor does international humanitarian law permit the Government’s attacks on health workers who provide care for civilians or injured fighters in these areas. Human Rights Watch and Amnesty International describe all of these practices by pro-government forces as war crimes. 17,18 Evolving practices in the weaponisation of health care Targeting of health workers by pro-government forces was identified as a problem early in the Syria conflict, well before any substantial militarisation. 19–21  Doctors practicing in areas which witnessed protests were forced to treat patients injured in such protests in secret for fear of being arrested. 22,23  The first documented execution of a doctor by pro-government forces occurred in March, 2011. 24   In April 2011, Syrian forces began arresting doctors, patients, and paramedics in Douma and other areas of eastern Ghouta where protests took place. 24   In September, 2011, the first intentional attack on a clearly-marked ambulance occurred in Homs. 21  In July, 2012, the Syrian Government passed a counter-terrorism law Panel:  Literature review and data collection We define health workers as doctors, midwives, nurses, dentists, pharmacists, physiotherapists, paramedics, ambulance drivers, other emergency response personnel, allied health technicians, medical and allied health students, public health professionals, and civil defence personnel providing volunteer health aid such as first aid and frontline rescue. We focused on these groups because of their prominent roles in conflict settings and in accordance with the definition of medical personnel, as an equivalent term under international humanitarian law.We collected information about health workers from multiple sources. • Literature review: we did a thorough scoping review to present a broad overview of the evidence, irrespective of study quality, to examine areas that are emerging, to clarify key concepts, and to identify knowledge gaps. We included all study types and news items. We searched five English language databases (MEDLINE, PubMed, Embase, Human Resources for Health Global Resource Center, and WHO Global Health Library with two search terms “Syria” and “health workers” for articles published between Jan 1, 2011, and Jan 12, 2017. We also searched grey literature through browsing of websites of organisations reporting violations, government and UN agencies tracking the situation of health workers and facilities, and international organisations involved in provision of care in Syria, such as the websites of the organisations Physicians for Human Rights, WHO, Syrian American Medical Society, Human Rights Watch, World Bank Group, Médecins Sans Frontières, United Nations Office for the Coordination of Humanitarian Affairs, International Committee of the Red Cross, Union of Medical Care and Relief Organizations, Amnesty International, and Union of Relief and Development Associations. To enhance the comprehensiveness of our strategy, a Google search was also done with a combination of keywords such as “Syria”, “health attacks”, “health workers”, and “health professionals”. • Data on health workers and care were provided by organisations and researchers.• Information from experts were provided during consultations, such as a consultation held in November, 2016, with Syrian practitioners including those working in government, rebel, or refugee areas, and meetings convened by The Lancet –American University of Beirut Commission on Syria: Health in Conflict. • Testimonials of health workers, including one from the authors of this Health Policy.• Collation of data sources with cross-checking of data from all sources to strengthen accuracy and synthesis.  Health Policy   Published online March 14, 2017 3 e󰁦ectively criminalising the provision of medical care to anyone injured by pro-government forces in protest marches against the government. 25  The passing of this law was an e󰁦ort to justify the arrests, detention, torture, and execution of health workers despite explicit and customary international humanitarian law protecting health workers from punishment for acts in accordance with medical ethics in international and non-international conflicts. Notably, Serbia enacted a similar law during the 1998–99 war in Kosovo. 26 Targeting of health workers largely by pro-government forces has continued and takes many forms (appendix): attacks on health facilities, executions, imprisonment or threat of imprisonment, unlawful disappearance (ie, kidnapping), abduction, and torture sometimes leading to death. The perpetrators are primarily government forces. Abuses by non-government forces have also been reported. 27  As a consequence of the targeting of health workers, hundreds of health workers have been killed. Whereas data from single sources are commonly reported, we have collated data from several sources including Physicians for Human Rights (PHR), Syrian American Medical Society (SAMS), Syrian Network for Human Rights (SNHR), and Violations Documentation Center in Syria (VDC) to minimise possible reporting bias (table 1). Although all these sources confirm targeting and associated deaths of health works as a major problem, variations in reporting exist, reflecting di󰁦erent methods of classification and verification. This illustrates the di󰁩culty of accurate documentation of attacks from within a conflict area.PHR report that 782 health workers were killed, in violation of medical neutrality, from   March, 2011, through to September, 2016 (figure 1). 28  Shelling and bombing accounted for 426 (55%) deaths, followed by shooting (180 deaths; 23%), torture (101 deaths; 13%), and execution (61 deaths; 8%). The Syrian Government and allied forces are responsible for 723 (92%) of these deaths. Doctors were the most targeted group of health workers, accounting for 247 (32%) of those killed. 176 (23%) nurses and 146 (19%) medics have been killed. Medical, dentistry, veterinary medicine, and pharmacy students were also targeted, accounting for 9% of those killed. Between Oct 1, 2016, and Feb 28, 2017, our review of data from SNHR, SAMS, and VDC indicate that at least an additional 32 health workers were killed, which brings the total number of health workers killed in acts of war crimes over the 6 years of the conflict to 814.Over time, targeting of health facilities emerged as a key feature in the weaponisation of health care and became more frequent (figure 2), more conspicuous, and more widespread. 33  This practice was so flagrant that it led the UN Security Council to condemn attacks on health workers and facilities in conflict in resolution 2286 on May, 2016. 34   With the military surge that began in late September, 2015, when Russia joined Syrian Government forces, 2016 marked the worst year of the conflict to date in terms of attacks on medical facilities. SAMS documented 194 verified attacks, an 89% increase since 2015. SNHR reported 289 attacks on medical facilities, ambulances, and Syrian Arab Red Crescent bases, 96% of which were by Syrian or Russian forces. 31  Notably, although PHR data for 2016 is only published up until July, and reporting only 54 attacks for 2016 (of a total of 400 attacks since March, 2011) PHR only reports on attacks against medical facilities that are protected in accordance with international humanitarian law, using a three-point corroboration methodology. PHR stresses that their numbers are highly conservative, that numbers are an underestimate as only those attacks and deaths 2011201220132014201520162017 Physicians for Human Rights 28 *4819018017710777†..Syrian Network for Human Rights 29 ‡3487110118§112104¶12Violations Documentation Center 30 3623224214870825 *Excludes three deaths for which the year was impossible to ascertain. †January to September, 2016. ‡Included medical and civil defence personnel. § May to December, 2014. ¶Excludes 63 health workers who were not deliberately killed. 31 Table 󰀱 : Health workers killed in the Syria conflict, 2011–17 Figure 󰀱 : Profile of a war-crime: health workers killed in the Syria conflict, 2011–16 Adapted from Harvard Public Health magazine based on data from Physicians for Human Rights (updated March, 2017). From March, 2011, to September, 2016, at least 782 health workers have died in attacks on health-care facilities and in targeted attacks on individuals. *Veterinarians and veterinary students killed while treating people. Turkey   I  r  a q    J o r d a n        I    s     r    a    e       l  S a u d i A r a b i a C y p r u s      L   e     b   a   n   o   n AleppoIdlibHamaHomsDeir ez-ZorRif Dimashqal SuweidaDaraaQuneitraDamascusTartousLattakiaRaqqaHassakeh SYRIA Gaziantep      2  4    7     D  o  c   t  o  r  s    1    7   6     N   u  r  s  e  s    1  4   6    M  e  d   i  c  s    7  4       P    h  a  r  m  a  c   i  s   t  s    3    8    M  e  d   i  c  a    l   s   t   u  d  e  n   t  s    2  4    A  m    b   u    l  a  n  c  e    w  o  r    k  e  r  s   2   0     V  e   t  e  r   i  n  a  r   i  a  n  s   *   1   9     D  e  n   t   i  s   t  s    1  4     D  e  n   t   i  s   t  r   y   s   t   u  d  e  n   t  s   1   0     V  e   t  e  r   i  n  a  r   y   s   t   u  d  e  n   t  s   *   8     P    h  a  r  m  a  c   y   s   t   u  d  e  n   t  s   6     L  a    b    t  e  c    h  s   Type of health personnel     D   e   a    t    h   s Reported deaths 117–14588–11659–8730–581–29 ATTACK SOURCECAUSE 723Syrian Governmentand allied forces72Non-state armed groups(ISIS or opposition)1Kurdish forces16Unknown forces426Shelling orbombing180Shooting101Torture61Execution14 Other orunknown See Online  for appendix  Health Policy 4   Published online March 14, 2017 with su󰁩cient evidence to be considered are counted. SAMS declared UN Security Council resolution 2286, passed in May, 2016, a failure after reporting a minimum of 172 attacks from June to December, 2016, with the Syrian Government and its allies responsible for almost 98% of the attacks. 32 The pattern of attacks on health facilities suggests intention to target, which is a war crime. To the best of our knowledge, the frequency and extent of targeting of health care is not known to have occurred in any previous war.Examination of attacks since 2012 on health facilities has revealed a distinct pattern of weaponisation. 35  Analysis of attacks over several years in important opposition-held areas of Aleppo, Hama, Idlib, eastern Ghouta, and Homs reveals a pattern of repeated targeting with intention to shut access to health care, whether to impede opposition forces or to force civilian displacement (figure 3). M10, an underground fortified hospital in eastern Aleppo, was attacked 19 times in 3 years, including 13 times between July and October, 2016, shutting it down with the last attack in October. 38  A cave used as a specialty hospital in Kafr Zita, Hama, has been bombed 33 times since 2014, including six times to date in 2017. 39  Orient hospitals throughout Idlib were targeted at least 20 times since 2013, forcing the closure of almost all hospitals by 2016. Hospitals in Idlib city itself, under Government control until March 28, 2015, have been targeted dozens of times since, at least 15 times in 2016. 36  In Homs, Al Rastan hospitals and clinics have been attacked at least 25 times since 2012. Attacks on hospitals and ambulances in Douma, eastern Ghouta, under siege since November, 2012, have been steadily increasing. This targeting of health facilities is so e󰁦ective that some areas, such as eastern Aleppo, lost all functioning hospitals and almost all health workers as of November, 2016. There are no longer any health facilities in eastern Aleppo, and health workers number in single figures. Attrition of health workers and its effects Facing danger, insecurity, and economic meltdown, many health workers either fled or voluntarily emigrated. With the number of health workers already depleted by so many detentions and deaths, these departures leave an enormous human resource gap. Estimates of loss vary widely and reliable data is scarce. In 2009, there were 29   927 doctors. 40  In 2015, PHR reported that 15   000 doctors had left, 41  and in 2016, a high-ranking UN o󰁩cial stated that 27   000 of 42   000 doctors had left. 42  The Ministry of Health and WHO data on trends in the distribution of health workers in public hospitals and data from the Syrian Medical Syndicate, both of which can be used as proxies of attrition, have not been made public. Although attrition a󰁦ects the whole of Syria, the situation is very di󰁦erent between government-controlled areas and non-government-controlled areas. In the non-government-controlled area of eastern Aleppo, the ratio of doctors to residents in 2015 was roughly one physician for every 7000 residents, compared with one physician for every 800 residents in 2010. 43 The e󰁦ect on the population is profound as reported by the Syrian Center for Policy Research, based on the only population-based survey done during the conflict, in which informants were asked to rate health care as su󰁩cient (ie, adequate number of appropriate health workers). 44   Based on data from 2100 key informant interviews in 698 subdistricts in both government-controlled and non-government-controlled areas, only 42% of the population live in areas that are likely to have su󰁩cient health workers, whereas 31% live in areas where health workers are insu󰁩cient and 27% live in areas where health workers are completely absent. All areas without health workers were either a󰁦ected by or experienced active conflict, and most were under military siege and restriction of mobility (Alsaba K, Mehchy Z, Nasser R, Syrian Center for Policy Research, personal communication). Figure 󰀲 : Attacks on health facilities over the course of the crisis, 2012–16 Data for years 2012–15 were from PHR, findings as of July, 2016. 28  Number of attacks in 2016 was calculated by summation of the 27 attacks reported by PHR 28  from January to May, 2016, and 172 attacks reported by Syrian American Medical Society 32  from June to December, 2016. PHR=Physicians for Human Rights. 20122013201420152016050100150200250     A    t    t   a   c    k   s   p   e   r   y   e   a   r Years916686122199 Figure 󰀳 : Recurrent targeting of health facilities in the Syria conflict, 2012–16 Data are from Syrian American Medical Society, 32  Assistance Coordination Unit, 36  Physicians for Human Rights, 28  Syrian Network for Human Rights, 31  Violations Document Center, 37  and United Medical Office in Deir Ezzor and eastern Ghouta (independent research and field trips since 2012 by one of the authors AS). 2012–13201420152016048161220     A    t    t   a   c    k   s   p   e   r   y   e   a   r YearsKafr Zita Specialty Hospital, HamaM10, AleppoAl Rastan, HomsDouma, eastern GhoutaIdlib city hospitals, IdlibOrient hospitals, Idlib  Health Policy   Published online March 14, 2017 5 Health workers working under different systems inside Syria Health workers face di󰁦erent challenges in areas under di󰁦erent authorities. A key challenge to our ability to devise policy and practice interventions is the scarce and disparate information available about the realities of work in di󰁦erent areas.In non-government-controlled areas, the challenges facing health workers and innovations devised in response are yet to be fully described, but observations from various sources collected in this inquiry provide key insights. Unmanageable demands under extreme conditions Across many non-government-controlled areas experiencing regular attacks, health workers report having to deal with influx of trauma victims, severe shortages of medical supplies and human resources, epidemics of infectious diseases, chemical attacks, living under siege, and breaches of medical neutrality, sometimes simultaneously. Other reported practice challenges include working in basement hospitals that have been hit by bombs and using mobile (cell) phone lights to illuminate operations during electricity outages. 44,45  Government targeting of health facilities forces decentralisation of hospital services, so that specialties and expertise are not concentrated in a single facility at risk of attack—for example, emergency rooms are separated from operating rooms, which in turn are separated from intensive care wards. 46 Siege medicine An estimated 1 million people are currently living under siege, largely by the government, which also a󰁦ects life and practice of health workers in these areas. 47  The Syrian Government rarely allows surgical supplies, dialysis kits, or essential medicines in convoys to besieged areas. The few areas besieged by non-state armed groups receive medical supplies through airdrops. 48,49  The Government has blocked implementation of public health measures such as water chlorination and vaccinations. 50  Whether cancer or complicated antenatal cases, children with meningitis, or victims of airstrikes, patients are rarely allowed to be evacuated to access required health services unavailable within besieged areas. Health workers are forced to make di󰁩cult choices between the severe and more severe cases, which jeopardise patients’ lives while undermining health worker morale. Patients and health providers have resorted to unusual measures. For example, as intravenous fluids are routinely removed from aid convoys, health workers devised a method to make normal saline. There is now an underground factory in eastern Ghouta near Damascus producing normal saline. Denied blood bags for the collection and storage of blood, urine bags with anticoagulants added are used. Homemade external fixators are used for orthopaedic surgery. Fearing the deliberate attacks on health facilities, many women have to schedule caesarean sections to avoid exposure to targeted attacks on hospitals during long hours of labour. An ultrasound in early pregnancy is used to reliably plan the date of the C-section, given the dearth of neonatal incubators, ventilators, oxygen, and other fundamental resources needed for the survival of premature infants. This practice results in unusually high rates of caesarean deliveries, which are as high as 70% in eastern Ghouta. 51 The need to do it all The combination of criminalisation of care to civilians in opposition to the government and the attacks on large health facilities has led to the need to create field hospitals in homes, schools, basements, mosques, and even caves to treat casualties on-site and to stabilise patients so they can be safely transported to permanent medical facilities. 52  Many challenges complicated this strategy. 53  The dwindling number of providers in non-government-controlled areas and exodus of older and more experienced doctors has left critical gaps. Smaller numbers of providers who are younger and less experienced than those who have left, many of whom are medical students or early residents, are forced to fill these gaps. Some of these health workers report the need to learn how to do everything, from the full range of medical conditions to war trauma. Treatment of patients with war injuries poses a serious problem because Syria’s medical training system did not include specialisation in trauma management, intensive care, or emergency medicine before the crisis. Thus providers must learn on the job. 48 Interrupted training Extensive anecdotal information from informed observers 54   and doctors who have provided medical care in Syria is available. All indications are that care provided by young health workers remaining in non-government-controlled areas has been indispensable, but comes at a high cost. To compensate for shortage of qualified providers, many medical students and early-grade doctors were forced to cease their training to provide health care, despite the fact that they did not have full qualifications. This portends an important gap in supply of skilled medical doctors in coming years. More immediately, as many such providers worked beyond their training and skills, taking on more responsibility without the usual training and mentorship, patients are obviously at risk, particularly when health workers are forced to manage war trauma and chemical attacks. Poor outcomes, including surgical complications and in-fections, have become more common. Managing public health challenges The restrictions by the Syrian Government on the flow of aid, supplies, and expertise to non-government-controlled areas not only endangers medical care, but
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