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Health Care Expenditures and Life Expectancy – What is this picture really telling us?

HealthCareSpendingLifeExpectancyI keep staring at this picture, which appeared on “Economist’s View” last March and wondering exactly what I’m supposed to learn from this, aside from the obvious fact that health care in the US is too expensive.

We have known that health care in the US is too expensive for a long while now. We are also pretty sure of the reasons why, none of which are easily solved.

But we shouldn’t assume that there is a causal relationship between health care expenditures and life expectancy. The message here seems to be that other countries increase their health budgets and their citizens live progressively longer, but for some reason it doesn’t work in the US. Well, I don’t think it works anywhere.

There’s no evidence to suggest that extra spending this year will increase life expectancy this year. If anything, it is long past expenditures and improvements to health care that will increase life expectancy today. I think that if we looked at overall economic growth and life expectancy, we would see the same trend. Most of us will live longer, because we were born under better conditions than our grandparents, not because of government spending for health care, the vast majority of which goes to the elderly.

What this tells us, though, is two things: one, that health care in the US costs too much and seems to be increasing without bound (math talk). Second, that life expectancy in the US is shorter than these other countries. This is true, but the US is a fundamentally different place than any of the countries on that list, some of which has to do with social problems (racism) and some of which likely has to do with the fact that we take in larger numbers of immigrants from countries which have low life expectancies than any country on that list.  These places aren’t comparable. While solving the problem of racism is noble, I don’t think that many people (except our President and his bigoted minions) want to suggest that we increase US life expectancy by deporting immigrants or closing the door to people from, say, Africa.

But we should be careful not to take home the message that there is an intrinsic relationship between spending and lifespan because that would be just misleading in my opinion.

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“Homicidal Snakebite in Children”

Currently, I’m doing a research project on snakebites and found this gem in the literature, of which there is little:

“Snake bites are common in many regions of the world. Snake envenomation is relatively uncommon in Egypt; such unfortunate events usually attract much publicity. Snake bite is almost only accidental, occurring in urban areas and desert. Few cases were reported to commit suicide by snake. Homicidal snake poisoning is so rare. It was known in ancient world by executing capital punishment by throwing the victim into a pit full of snakes. Another way was to ask the victim to put his hand inside a small basket harboring a deadly snake. Killing a victim by direct snake bite is so rare. There was one reported case where an old couple was killed by snake bite. Here is the first reported case of killing three children by snake bite. It appeared that the diagnosis of such cases is so difficult and depended mainly on the circumstantial evidences.”

When does a person “ask” someone to “put his hand inside a small basket harboring a deadly snake?” Does that ever happen? Apparently so.

Apparently a man killed his three children using a snake.

It gets better:

“In deep police office investigations, it was found that the father disliked these three children as they were girls. He married another woman and had a male baby. The father decided to get rid of his girl children. To achieve his plan, he trained to become snake charmer and bought a snake (Egyptian cobra). The father forced the snake to bite the three children several times and left them to die. At last, he burned the snake.”

Paulis, M. G. and Faheem, A. L. (2016), Homicidal Snake Bite in Children. J Forensic Sci, 61: 559–561. doi:10.1111/1556-4029.12997

Kenya 2017 Election Violence: Some Data Analysis

I’m getting used to the new version of ArcGIS (which is a vast improvement!) and gave it a test run on some data from the ACLED (Armed Conflict Location & Event Data Project) database, specifically on this years round of violence surrounding the Kenyan election. ACLED keeps real time data on violence and conflict around the globe, the latest entry in 2017 is Nov 24, just five days ago.

KenyaViolence2017

The first election occurred on August 8th, 2017. The opposition contested the results of the election, claiming problems in vote tallying by the IEBC, resulting in a nullification by the Supreme Court. A new election was called and was to be conducted within 60 days of the nullification. Raila Odinga, the opposition leader, claimed that the election again would not be fair, dropped out of the race and called for a national boycott. The election went ahead as place on October 26, 2017 and Uhuru Kenyatta was declared the winner.

NairobiViolence

 

 

There was violence at every stage of the process, both by rioters in support of the opposition and by the police and military who were known to fire live rounds into groups of demonstrators. Opposition supporters were known to set fire to Kikuyu businesses. Local Kikuyu gangs were reported to be going house to house rooting out people from tribal groups from the West and beating them in the street. Tribal groups in rural areas were reported to be fighting amongst one another. The police response has been heavy handed and disproportionate leading to a national crisis.

As of now, though not nearly as violent as the post election violence of 2007-08, the violence has not yet abated.

In the database, there were 420 events logged, including rioting, protests and violence against civilians by the state, police and local tribal militias. There are 306 recorded fatalities in the data base, but this number should be approached with some caution. There were likely more. The database is compiled from newspaper reports, which don’t count fatalities and don’t cover all events.
ViolentTSI made two maps (above), one for Nairobi, and the other for Kenya. They include all non Al-Shabaab events (a Somali Islamist group the Kenya Defense Force has been fighting for several years.) I also included a time series of both events and fatalities.

Some excerpts from the notes:

“Police raided houses of civilians in Kisumu, beating civilians and injuring dozens. Live bullets were used on some civilians, including a 14 year old boy. Of the 29 people injured, 26 had suffered gun shots.”

“One man was found dead in a sugar cane plantation one day after ethnic tensions between the Luo and Kalenjin communities got into an ethnic clash. The body had been hacked with a panga.”

“Rioters started throwing stones at the police in the morning, protesting against the elections to be held the next day. The police responded with teargas and water canons. The rioters were mostly from the Luo ethnic group and they took the opportunity to loot several stores, attack residents and to burn a store owned by an ethnic Kikuyu. One woman was raped.” *This was in Kawangware, not far from my apartment. I was eating at a local bbq place when this happened. 

 

 

“Police forces attacked supporters of the opposition that went to the Lucky Summer neighbourhood to check on a ritual of beheading of a sheep that was taking place (suspectedly by the Mungiki sect). The police shot at the civilians. The police confirmed that it shot a man and that the group performing the ritual had sought protection.”

“As a revenge to the previous event, the Kikuyu joined forces and attacked the Luo. The ethnic tensions and violence led to one severely injured person. Residents claims three were killed and dozens, including three school children, were injured.”

Links I liked

Scarlet fever is back (link)
Lake Chad’s humanitarian disaster (link)
Mapping the drug overdose epidemic (link)
Undernutrition in TZ. Only 8% young kids are adequately nourished (link)
Inverse distance weighting in R (and resizing maps) (link)

And some music from Lucas:

Waning interest in the development industry in Kenya?

I was reading Chris Blattman‘s blog this morning where he had a cool post on the increasing use of  development jargon in published material. Words like “impact,” “stakeholder,” and “capacity” are all over the place here on the continent.

These terms are so pervasive, that people drop them in everyday conversation, almost creating a language on their own.

Honestly, I’m not really sure what “capacity” is supposed to mean, let alone am I able to identify who is and who isn’t a “stakeholder.” The cynical me says that a “stakeholder” is a person who is able to scrape off development funds into their own pockets, which seems to be a national pastime here. “Capacity” is as condescending as it sounds. Who decides who has the “capacity” to do things anyway? Are people who lack skills “incapacitated?”

The most annoying to me are “self help groups” which are, in essence, simply small business cooperatives. Not sure why their existence has to be treated as writing some past individual wrong. Given that it is mostly illegal to have a business here in Kenya (due to onerous laws on trade left over from the Brits and overzealous bureaucrats looking for bribes), it is possible that a “self help group” simply avoids many of the most costly permitting laws but more likely that a development group felt the need to give a fancy name to something completely normal.

That, however, is an aside.

If Google Trends is to be believed, interest in the development industry is waning in Kenya. I searched for trends in four terms, “capacity,” “sustainable development,” “stakeholder,” and the almighty “per diem.”

Development organizations often pay people to attend “seminars” on this or that topic in the form of “per diems” which are often not small. A fairly educated Kenyan can make a decent wage from attending these seminars on a regular basis. Harry Englund of Churchill College wrote a cool book on the subject called “Prisoners of Freedom.”

Anyway, here’s the graph. I found it kind of reassuring. Countries like Kenya can’t claim independence while holding out their hands waiting for development money to come through. Kenya is not a poor country. It doesn’t need many of these development projects when it is perfectly able to stand on its own. If these trends are to be believed, there is reason to be hopeful.
development

Snakebite follow up in Mbita, Western Kenya

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A staged picture. With Paul Diela, our team manager in Mbita.

As I’ve noted in previous posts, we’re doing some research on snakebites in two areas of Kenya. I came out to Mbita in Western Kenya to do some routine management things for the demographic surveillance system that I run. This gave me an opportunity to go out and visit some houses of people who had indicated that someone in the family had been bitten by a snake in the past.

 

Today brought us to the Gembe East area of Mbita District in Homa Bay County, an area most associated with malaria transmission (of which I’ve written papers on). The Usao area we visited today is probably the poorest area of Gembe East. Roads are almost non-existent and the cell network is even harder to find. Among kids, skin infections are common, as are untreated wounds and eye infections. One kid has an eyeball so swollen that he couldn’t blink.

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Discarded ACT (malaria medication) pack

Discarded Coartem and Artefan packs litter the area. When I’m in the villages I always check the trash. It’s a great indicator of the public health situation. I often think that people should give up on surveys and just start mapping drug waste out here. At least we wouldn’t need to go through any (or at least few) bureaucratic hurdles.

 
We hired a single staff member at the last minute, assisted by a graduate student from Japan, hired a car and took off this morning to get here.

To find the snakebites, we compiled a list of houses where people had reported snakebites and then coordinated with our DSS staff to find them. Our registration system allows us to easily find houses in our survey areas, a real asset when one is doing these kinds of follow up surveys.

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Survey work.

The first house we went to was vacant, everyone had taken off to do their daily chores. I became worried at this point since this area is so challenging to get to. Our list indicated that the neighboring house had a snakebite victim so we went over there and found the lady more than willing to talk.

Her son had been bitten ten years earlier by a puff adder in the space between her house and the water. Fortunately he didn’t suffer any permanent damage, but given that two houses right next to one another both experience snakebites, the area has to be considered somewhat dangerous.

She didn’t take the child to a clinic, instead enlisting the help of the local witchdoctor. Local practitioners treat snake bites by making small cuts around the wound, ostensibly to cut off routes that the venom can use to spread, then they apply a salve containing local herbs. The nature of the herbs is unknown. I plan to try and find one of these guys and see what it could possibly be.

Giving up, we returned to the market area, and suddenly several people came out of the woodwork claiming to have been bitten in the past. Some of them were in our list. Lucky day.

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Puff adder wound, note scaling of the skin.

One gentleman had been bitten on the leg several years previous. He didn’t suffer any major damage, but the skin surrounding the wound is now scaly and tend to come off. Again, the culprit was a puff adder. The locals claim that the snake causes a persons skin to become snake-like, even shedding occasionally, just as a dog bite (rabies) causes a person to bite like a dog (it’s disconcerting how familiar people are with the symptoms of rabies here).

Our regular DSS survey worker pointed out that many people don’t want to report snakebites, presumably because of the associations with witchcraft. He also noted that when people hear about other people reporting bites, they tend to want to report them too. We had one lady who claimed that she hadn’t been bitten, but today was eager to talk about it. Just about everyone has some story about a snake, it appears.

After doing about six surveys, almost all of which were puff adder bites, we moved on. Most of the wounds we saw were minor. Some wasting of the legs, some skin problems, but no paralysis or debilitating long term issues.

A 12 year old boy, however, had been bitten on the hand by a puff adder about three years ago. Fortunately, his mother took him to the clinic immediately. He spent a month in the hospital, likely on intravenous antibiotics because the venom had destroyed most of the tissues in his left arm. Amputation was avoided, but he no long has full use of the arm and the hand is permanently deformed.

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Puff adder wound, three years post envenomation

The survey worker tried to get the child to identify the snake by showing him a picture of other many kinds of snakes, but it had all the hallmarks of a serious puff adder bite. Clearly there was rotting of the tissue all the way up to shoulder and the joints were permanently bent. The elbow no longer moves due to the lack of muscle tissue and cartilage. The kid otherwise is a normal 12 year old boy. He is lucky to be alive.

Only two of the ten surveys today indicated that people went to a clinic for treatment. Someone noted that getting to the clinic is nearly impossible unless you have a motorcycle, and most of the people here just don’t have the means to call one. They opt for the witchdoctors, who make snakebites a principal part of their practice. Whether it is effective or not is unknown. Likely many minor bites might have resolved themselves on their own. Serious bites likely result in death so we’ll never know.

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A cow. 

 

 

An incredibly boring and rambling post about yesterday’s journey to Mbita, Kenya that no one should read.

I have no money. I haven’t had more than a few dollars at a time for the past few weeks, and this pattern has been repeating itself for at least the last few months. Nairobi is a terrible place to live if you have no money. Now I can see why most people are so pissed off and mean a lot of the time.

It is incredibly stressful, but you learn ways of getting by. Eggs are cheap. If you are willing to walk a bit and aren’t picky about the taste, beans and a chapatti will only set you back about $.50. If you stock up on rice in the rich times, you can eat a reasonable dinner and stay full for a while.

Not leaving the house, ever, really helps. Every venture outside will cost you money you don’t have. Aside from the problems of having to run the gauntlet of people constantly demanding money… cause you’re white. And white people have money. And why don’t you have any money? You greedy bastard.

Whatever you do, don’t get pulled over. You might be able to plead your case and convince them of the truth, that you really have no money, but, if not, you’re going to jail, because you are a white guy and all white people have money somewhere.

But that’s not what I was going to write about. Because I have no money, I scheduled a trip to Mbita. I can get the per diems out here and at least eat and not feel horribly fucking poor. So it was a grand plan. Go on the road and not feel poor and ashamed like I did when I was in high school.

Was going to take the bus because I feel guilty about using my employers money, but had to get here by noonish so I just took the damn flight. It was only $40 more than the bus. Maybe they could spend that $40 on something useful and not me, but fuck it, I’ll fly.

The problem with coming out here is that you fly into Kisumu, then have to travel about 90km to the ferry and take a one hour ferry ride to Mbita. Though you are constrained by the ferry schedule. So you have to wait a while. The whole trip can take as long as the bus if you do it wrong.

The cab from the airport to the ferry is $80. Yes, the cab is more expensive than the flight. I think these guy s are ripping us off. So I hate them. I don’t want to use them. So I decided not to, aside from the bigger issue of having to front the money for the cab (money I don’t have) and fight to get reimbursed. Too much trouble.

So, I elect to take a matatu (bus). I run the gauntlet of cab drivers, one recognizes me, I tell him I have no money and have to take the bus, which is true. Kenyans first look at you like you are lying, then they look at you as if you are greedy, then there is some glimmer of understanding when they think about who they are talking to…. At that point, they just think you are pathetic.. like the KCs (perjorative for white Kenyans), some of whom really are dirt poor.

Loser.

Oh well. I walk past and go out to the road. A matatu comes by, I tell him I want to go to the Luanda Port, he says get in. I do. We roll along. At some point we pass by a familiar junction and pass it. “Why didn’t we turn?” I think. I ignore it and roll along with the ride. We are riding. They gave me the front seat.  I’m not recognizing anything at all.

After an hour, we get to Luanda. Luanda Town. Not Luanda Port.

Fuck. “Nimesema Luanda Port, si Luanda Town! Nataka kuende ferry port, harafu naende Mbita Town. Sijui?”

When Kenyans realize they fucked up, they kind of shut down. It’s weird. Like even apologizing or offering to help you get out of your predicament are admissions of guilt and inherently dangerous. There’s really not a whole lot you can do at that point.

I saw a shop selling drums. Maybe there’s something good. If I’m going to be lost, I might as well check it out. I run the gauntlet of Luos screaming “Mzungu!” Don’t they teach these people manners?

The shop is just curio crap. Wood giraffes and other assorted junk. Giraffes aren’t even out here. Not sure why it matters to create cheap carvings of them. Maybe they should carve hyacinth which is starving the lake for oxygen and light or even tilapia. Or cholera. I don’t know. Giraffes don’t make a whole lot of sense out here. For all their talk of “culture” in Kenya, the face they present to tourists is remarkably incongruent to anything resembling local culture. Now, I’m complaining.

Maybe an NGO taught them what to carve at one point and they just did it because it seemed like a good idea. No clue. That’s usually how it works.

I’m wondering what the hell to do. Go back to that junction we passed? Seems reasonable. A bus is there. I tell the tout I want to go to the port. He says, OK, take this bus and get off at Ramulu, then change to a cockroach.

A cockroach is a Toyota ProBox which has been converted into a taxi. It normally seats ten. If you are lucky, you can sit in the hatchback, which is the cheapest seat, but the place where no one wants to sit because only the truly poor sit back there. The downside is that you’re locked in so if there’s an accident, you can’t get out. The upside is that you are the only dude back there for the whole ride.

The other seats are usually crammed four to a seat. As the Kenyan diet gets more and more calorie rich, people are getting bigger. You can imagine what it’s like to sit four across in the backseat of a ProBox. I’ll take the boot Er.. the hatchback. We’re British here.

OK, so I do all that. Just like the dude says. I look at Google Maps. We pass a road that goes right down to the port. Should I get out? I figure that the road might be bad. That’s why he’s passing it. Yes, that must be it. Yes. No need to fear. It’s only 25 km to the town where I have to get in the cockroach.

I continue.

We get to the town, I get out, he shows me the cockroaches. I need food. I go and buy some chicken. Animal Planet is one the TV. Reptiles are eating one another. It is an apt analogy for Kenya, perhaps. At least at election time. Maybe it’s an apt analogy for the US. I don’t know.

 

The chicken isn’t bad. Better than that terrible Nairobi chicken from those farms where they use hormones, which cause chickens to grow into full adults within an hour and give people breasts. At least that’s what taxi drivers tell me.

I go toward the cockroach. A guy is approaching me hoping to rip me off. I speak Swahili. He repels and yells loudly to his friends that I speak Swahili. They leave me alone. I must be a lost cause.

The cockroaches are waiting. Here, cockroaches wait until the car is full before they embark. Unless you have stuff to carry, it’s stupid to wait because you’ll be sitting there all day long. If you walk down the road for a while a rogue cockroach will come by and pick you up. Those guys are hated by the guys at the stages waiting for customers. They look at them as bottom feeding trolls. No pride.

I start walking. The cockroach guys complain.

The boot is open so I get in, and promptly fall asleep. I got up at 5 am to get to the airport and have already spent two hours in vehicles. A bag of maize makes it more comfortable.

Eventually we stop at the “Port.” It’s a dusty nothing town in the middle of nowhere. Not the port.

“Hapa si port!”

“Hapa ni Port Victoria.”

Good god. Luanda didn’t work for me. Now Port isn’t working for me. This just isn’t my day.

“Port Victoria” sounds like it should be some old British outpost or something, with grand houses and a nice place to drink tea on the water. What it is a dusty, waterless town in the middle of nowhere. There’s a non-sandy beach somewhere nearby though it isn’t part of the town.

Google Maps can’t generate a route from it since there’s no road, technically. I’m 100 km from the “port” I want to go to. I start walking. Then stop. I look around for someone reasonably educated to avoid making all the mistakes I’ve been making all day long.

Out here, most people aren’t all that well educated and aren’t used to dealing with non-locals. A bad mix.

I find a guy with shiny shoes. He speaks educated English.

I explain to him that I want to go to ferry port. He proceeds to give me a route with six changes. It’s complicated by not undoable, and spares me having to go all the way back to where I came from.

First, I I’ll have to take a motocycle taxi 20 km to a neighboring town, then change to a cockroach, then to few buses. The motorcycle guy tries to make conversation with me about mundane topics. I’m too annoyed to engage him. I stop replying.

Feigning happiness gets exhausting. At this point, I’ve been in motion for nearly four and a half hours. Just drive. He is ripping me off. 700 for this trip is just way too much.

We get to Siaya, home of the nyatiti. There are no nyatitis to be seen anywhere. Of course. Because even in Siaya, people don’t care about it.

I didn’t have any expectations of seeing people playing nyatiti on the streets of Siaya. For the record.

There’s a cockroach there. He tells me I can take it.

“Are you leaving now?” “We are waiting for a few more people.” The car is empty. I start walking. I can hitchhike it to Bondo. I note that there are no cars. It’s hot. 3 pm is the hottest time of the day. I have no water and Bondo is 20 km away. I can do this.

Cars come by, they ignore me. Eventually, a preacher picks me up and drives me a kilometer or so. He is friendly and wants my number. I give him a fake number.

I keep walking and cars keep passing me by. The cockroach still hasn’t appeared and I’m 10 km in. On foot. Which means he is still waiting over there.

I get another ride from an electrician who says he’ll take me all the way in to Bondo, saving me a lot of trouble. He’s nice enough and doesn’t talk about Jesus, which is cool. Not talking about Jesus is a sign of character to me. Trump never talks about Jesus but he’s an awful individual. Hm.

Now this post is rambling. No one is reading this. I can write just about anything at this point.

Dude negotiates a price for me on the matatu, which is kind of unnecessary, but he gets it to a real price of $.50. At least I have some backup if they try to rip me off. Sure enough, the guy tries to rip me off. I call him on it and he coughs up the money.

The lady next to me compliments me on saying “asante” as if I’m straight off the boat. For some reason, this annoys me. Generally, at this point, anything could annoy me, but after arguing with the matatu tout over a few coins in Swahili, you’d think that I would be able to say thank you.

Most whities that come out here are religious people. They capitalize on dumbness, it helps them do what they do because there are people who are just midline educated and have no work prospects and want to feel as they have control over some particular space. So having a semblance of power over white people, however benign, is a premium. “He doesn’t know ugali. The poor guy. I will teach him.”

I find this type of pandering annoying, and find the ways in which white religious people exploit it to be offensive. It’s the little things that count.

For the whities, it’s a cash cow. They take some pictures of them “helping” poor people, then go around to churches in the states to raise money for their “projects” but the cast majority of the money goes to supporting the missionaries themselves. The smiles and feigned ignorance of the ways of the savage are simply a means to an end.

But I digress. I run into so few missionaries in Nairobi that they always stick out to me here in Western Kenya.

I go on, get out at a stage and realize that if I don’t drink water anytime soon, I’m going to suffer heatstroke. The bus is ready to go to the port. I casually tell the guy to wait without indicating what I’m going to do. I go buy some water, chat with the lady and drink some. When I come back out, the bus is still there full of people.

“Twende” and we’re off.

We’re driving for a while and the tout taps me on the shoulder for money. I have him 50 bob and he just stairs at it. “How much is it?” “200” he says.

“That’s too much. Pesa mingi sana.” People laugh. I think he’s trying to rip me off and stew on it for a while. I realize at some point that the port is significantly farther away than what was described to me. It was probably a fair price.

I’ve now been on the road for seven hours and have spent more that $15 of money I don’t have. I was hoping to take a nyatiti lesson this weekend but have spent it all on this stupid trip through Nyanza.

I go to get a soda at the hotel across the street from the port and ask a guy what time it is. A full hour till the ferry comes. By the time we hit Mbita it will be dark and I’ll miss the sunset by the lake, which, aside from work and money, is why I come here. Again, I stew on it, annoyed.

The watch guy asks me if I’m going to Mbita. He says he can get me a spot on the boat matatu that’s leaving now. “It’s faster. You can get there by six.” For 200 schillings. I already bought my ticket for the ferry but screw it, let’s go.

The boat matatu is fast. We are there in a mere 15 minutes. The ferry is absurdly slow. We see it crawling on the way. It was 5:30 and it had just left port. I wouldn’t have gotten to Mbita until well past 7:30. This was a good plan.

They at least give us life jackets but the ride is fairly scary nonetheless. No one here can swim to I’d probably die trying to save someone. I always think about these things.

After more than 10 hours of travel by plane, matatu, bus, motorcycle, foot and boat, I finally arrive in Mbita, run another gauntlet of motorcycle taxis and hit the gate before it closes.

Now, finally, I sit here by the lake and watch the sun go down.

Coming out here is complicated. I am reminded of a time of my life where things really weren’t so bad, compared to now, where things really can’t get much worse. Oh well.

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