Public Health and Welfare (_Depletion and Abundance_ Book Excerpt)

Sharon May 20th, 2008

I’m short on essay constructing time right at the moment, and I thought it might be nice to include an actual excerpt from _Depletion and Abundance_. 

One of the central arguments I make in the book, an argument probably familiar to most of my readers, is that the things we most need to prioritize in adapting to difficult times are the things that most people say they care about most already – education, healthcare, basic security issues.  So my approach, when I wrote about health care was not to try and comprehensively answer what we should do about medical care, but to a. make the argument that this needs to be a much bigger priority in discussions of peak oil and climate change and b. say that it is possible to create a “shadow” health care system that would serve not just our needs in a future crisis, but the needs of millions of Americans who have no access to health care now.  I don’t claim to answer every question about how X condition can be dealt with, or what might or might not be available to many people, but I do try and get the ball rolling, and ask that we bring health care to the center of our discussions of the future.

It is a long chapter, so I’m going to break it up into several pieces.  Bear with me if something you think is important isn’t here yet – it may be coming up in a later post.  Enjoy!

___________________________-

If you are going to deal with the issue of health in the modern world, you are going to have to deal with much absurdity. It is not clear, for example, why death should increasingly be looked upon as a curable disease, an abnormality by a society that increasingly looks upon life as insupportably painful and/or meaningless. — Wendell [ad1] Berry

“I’ve been in hospitals,” I said. “They take away your pants. Then they hurt you and starve you and expose you to disease. Then they bill you for it. A lot.” — Spider Robinson

As I mentioned in the first chapter, many Peak Oil and Climate Change activists have, as much as everyone else, tended to think that the biggest energy consumers in our lives are the places we most urgently need to focus our attention. This reasoning has led us to emphasize things like transportation and energy replacement. This is a reasonable assumption, of course. You look around and think “Where do the fossil fuels go at present?” and it seems reasonable to associate large usage with the most important sectors of our society. But if you rethink the problem, and truly get your mind around the fact that the future really is going to be very different from the present, we can begin to think about it in terms of optimization — the places where we get the most quality of life out of our fossil fuel inputs. That is, I believe we have, thus far, been asking the wrong questions about what matters.

If we were to ask “Where do we need energy the most?” we would get a very different answer. Perhaps the most bang for our fossil-fueled buck comes in health care. In fact, when anyone suggests moving to a much lower-energy society, the most disturbing and frightening thing for them to imagine losing is usually health care. When we talk about the changing economy, the question that most immediately jumps up is “What will we do about health insurance?” The shift here — from medical care to insurance — is a telling one, because right now medical care is so costly that almost no one can afford to pay for it outright. And yet, medical care in and of itself does not have to be as expensive as it is for us. The French, who arguably have the best medical system in the world, spend only half what we do.

In the coming changes, the most important things will be making sure that people can live simpler, lower-energy lives without unbearable costs. That means keeping infant mortality low and lifespans long. It means stabilizing population. As we’ve seen, to a large degree decisions about how many children to have are based on expectations of those children’s survival. In a society with a great deal of uncertainty about the future of children, we can expect rising, rather than falling birthrates.

Along with access to education and basic social welfare programs such as support for the elderly and disabled and food price stabilization, I would argue that one of the most urgent projects we can engage in is in finding a way to maintain the benefits of modern medicine in a low-energy society. And as I research this problem, I increasingly believe that this can be accomplished, that we have the resources to create a low-energy national health care — or, if our government will not lead on such a project, that states, regions or even communities can enable such a health care model.

I am not claiming that we can reproduce modern health care as we know it, or that the change will be without cost or difficulty, but I do believe it is possible to integrate a lower-energy health care system into our existing models, and that the project of doing so, besides preparing us for a crisis, might also improve the lives of the 40 million Americans currently without access to health care.

Now, just as I am not a demographer, an economist, a nutritionist or any of the other things I’ve presumed to do research on and offer analysis of, I am not a medical professional. My intent here is not to offer specific medical advice, but to jumpstart the conversation about what kind of low-impact, low-energy medical infrastructure we can have. My goal is not to end the conversation, but to begin it, and to pass on my thoughts to those who can take it further.

The Myths of Medicine

It is difficult to begin to triage the current medical system without first evaluating our assumptions about how the medical system works. I think many of us are carrying three false beliefs about medicine. They are:

1. More health care is better, and good health care must be expensive.

2. The benefits of modern medicine always outweigh the costs

3. Social good programs like health care are things you get to later rather than sooner.

The first assumption seems fairly obvious — in a world where billions of people, including millions of Americans don’t have access to health care, it would seem that if you could get all the health care you wanted, that would be better. But in fact, the data are more complex than that. For example, a recent article in The Atlantic by Shannon Brownlee, author of Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer[ad2] , includes the telling quote by a Dartmouth Medical School professor: “If we sent 30 percent of the doctors in this country to Africa, we might raise the level of health on both continents.”

That is, even something that seems to be as obvious a good as a large number of doctors isn’t necessarily so under the current system for a host of reasons, including the fact that multiple specialists attending to treatment often lead to confusion and errors, and that doctors tend to concentrate in wealthy areas, so that more doctors doesn’t mean better distribution of health care.

Americans spend about twice as much money on health care as Europeans do, but our lifespans are no longer and often shorter. We take more drugs than they do, endure more medical interventions at the end of our lives, report lower levels of satisfaction and happiness with our health and suffer more from anxiety and depression than people with lower levels of health care. It is also true that our present medical system is not about “health” so much as treating disease, and that a system that actually focused on preventive care, health and wellness — all much lower-input practices than our present one — might work better with less energy.

In his book Aging Well Dr. George Valliant describes tracking several groups of men over more than 50 years, including Harvard graduates and inner-city, lower-class Boston men, and notes that among all these groups access to health care was not the defining factor in quality of life or health in the senior years — basic self care and staying away from doctors was. That is,

…being able to afford better doctors, hospitals, and healthcare is unrelated to their health or longevity. “It’s not economic at all,” he asserts. “People [ad3] who go to hospitals are sicker than people who don’t. Having better doctors and hospitals is a bit like locking the barn after the horse is out. The trick is not going to hospitals in the first place.” (Valliant )

[ad4] 

Though it is obviously important that sick people have access to health care, at present only three out of every 100 dollars spent on health care in the US go to any kind of help maintaining good health, rather than to the treatment of medical problems. For example, midwife Kathy Breault observes that an increase in Caesarean sections is tightly linked to an explosion of gestational diabetes in women, which often causes very large babies that cannot be delivered vaginally. The increase in gestational diabetes is almost entirely a product of our industrial diet and sedentary lifestyle, and yet while health insurance will pay for a C-section, it will only rarely fund nutritional education or cooking classes and never pay for a babysitter to allow an expectant mother to cook a meal, shop at a farmer’s market or get some exercise.

It is important to realize that Americans have similar lifespans to average Cubans, and higher infant mortality rates, despite the fact that Cuba is a vastly poorer nation and spends about $186 per person annually on health care — compared to $4500 per person in the US. In Kerala, a state in India, lifespans are not quite the same as in the US, but they similar to those of inner-city African Americans. Kerala infant mortality rates are lower than mortality rates for infants in Cleveland or Baltimore’s inner city. That is remarkable because Keralans use one seventeenth the resources we do to maintain health.

There are other examples of “low income, high well being” nations that spend very little on health care, demonstrating that neither energy use nor expenditure is the determining factor in long lifespans and low infant mortality. What does matter is making health care and its corollary, education (the ability to obtain and make use of health information is tied to literacy levels to a large degree), a major social priority, even to the exclusion of other projects if resources are limited.

The Amish are another important example. Amish people in the US have a number of factors that would seem to place them at risk of higher infant mortality rates and lower lifespans — they receive little preventive care, eat a high-fat diet, have no health insurance, use herbal and home remedies first, and give birth to most of their children at home, using lay midwives. And yet the average Amish lifespan is virtually the same as that of the average non-Amish American, despite their spending one fifth or less on health care.

All of these examples demonstrate the simple truth that, although hospitals and medical care are energy intensive, it is not impossible to dramatically reduce our need for expensive, energy intensive medical care by prioritizing health and general welfare.

Whenever I talk about going to lower-energy usage, a percentage of people shout out something like “But that would mean going back to the stone age, to lepers walking the streets and people throwing their feces out the window on our heads!” (Okay, I exaggerate a little for effect.) But I think it is fair to say that variations on “Without power, life would be intolerable” is a common assumption, and that it is tied to myth #2 above, that modern medicine is an unmitigated good.

Now, do not mistake me — I believe that much of medicine is good. But everything comes with a price, and sometimes we simply choose not to see the price of things clearly. That is, often when we worry about the dangers of losing modern medicine and society, we see clearly the costs of not having easy access to high-technology, high-energy medical care, but don’t see, because we have assimilated into them the high costs of the medicine and the society that makes it possible.

____________________________

 Next time…more on evaluating the costs and benefits of energy intensive societies.

 Sharon

20 Responses to “Public Health and Welfare (_Depletion and Abundance_ Book Excerpt)”

  1. Kerr says:

    I have a hard time understanding the last sentence… is something missing?

    Good chapter. A hard one for me to swallow.

    Inner city African Americans have comparatively poor life expectancy, and since you mentioned the life expectancy of people in Kerala is similar, I would have liked to see you deal a bit with the contributions the unequal distribution of medical care makes to that situation. If it’s not true that across national boundaries access to medical care makes for longer life expectancy, it seems to be correlated across racial boundaries within the US. Most of the explanations I’ve seen that haven’t relied on unequal access have seemed predicated on inaccurate assumptions. I have a hard time believing that in a drastically fuel-reducing society, African American people and other people who experience racial discrimination won’t be “triaged” out of health care and other vital systems. I think that’s an important thing to be thinking about.

    The neighborhood I live in is predominantly white and Asian. There’s a neighborhood just south of me that is predominantly Black and Hispanic. It’s mostly a poor area but there are places where by income alone you would expect people to have the average standard of living for the region. But health care needs there are dire. There’s much less access to care and almost no one has coverage. Possibly more importantly there’s much less access to FOOD. There are no grocery stores anywhere in this neighborhood, only liquor stores where the healthiest thing you could pick up is a bologna sandwich on wonderbread and a bag of chips. This is because grocers see this neighborhood as a high crime risk—despite the fact that the crime rate is similar to the neighborhood where I work, which has two “natural” grocery stores and a nearby weekly farmer’s market. I bet this happens all over the country.

  2. Sharon says:

    You are right, Kerr, there’s a comma missing after “them” – good thing I’ve got another go ’round in the editing process still there. Clearer now?

    Well, it is worth remembering that Cuba and Kerala both have good health care access and much better diets – it isn’t what we spend on it, but if you can’t get at it at all, that is a problem. That’s why my proposed shadow system.

    I will get to the inequity issue, but remember, I’m breaking up an otherwise large chapter. But there are also going to be huge number of things I don’t deal with simply because this is a chapter, not a book. There needs to be a book, or many books, but I don’t really have the qualifications to write one, and wouldn’t try. I’m hoping to push other people forward on this.

    Sharon

  3. shitbrain says:

    Now, do not mistake me — I believe that much of medicine is good.

    Actually, all medicine is poison. In some small percentage of cases, their use may be a lesser evil. But generally speaking, they should be avoided like the plague that they are.

  4. jase says:

    shitbrain – your name is accurate.

  5. Anonymous says:

    If pointing out typos is still helpful at this stage, then I’ll say that in this sentence – “In Kerala, a state in India, lifespans are not quite the same as in the US, but they similar to those of inner-city African Americans.” - you’re missing the word “are” between “they” and “similar.” Sorry, it’s not something I would nitpick about in a regular blog post, but I thought you might want to know about it for the book.

    Very thought provoking post – thank you.

  6. Leila in PA says:

    Thanks for pointing out that an equivalent level of health can be reached with far fewer $$s than what is spent today. I think there is a lot of overhead and waste in our system. And insurance administration is a big part of that. If my employer did not cover my insurance I don’t think I would have it at all, and just keep a large cash reserve. There’s probably also a lot of unnecessary spending happening at hospitals. Home births are far cheaper, for instance, and have equal outcomes in healthy pregnancies. But oftentimes the cheaper options are overlooked in favor of the ultra modern high tech ones, which may not necessarily be better at all.

    But I must say that many Amish I’ve seen are missing teeth, so I don’t know if their health is entirely equivalent. They’re also far less sedentary than us, so I’m sure that helps.

  7. olympia says:

    I’m curious as to just how Peak Oil aware the medical community might be. As it is, I see health care providers and patients both becoming overly reliant on a multitude of drugs, c-sections galore, etc., with very little apparent awareness that these treatments don’t take place in a vacuum. It’s of dire importance that the medical community be educated on the medical ramifications of Peak Oil.

  8. Sharon says:

    I think generally the medical community is not aware of PO, or if they are, of its implications for health care. There are a few people doing this work, but not enough – and that’s one of the reasons I’m so concerned about it.

    As I understand it from the Amish near me, dental work is generally considered to be non-essential and cosmetic, and isn’t encouraged – many Amish have all their teeth pulled and replaced with false teeth in their 30s and 40s, I gather (note, I’ve done no research on Amish dentistry). I think that this is wrong and that keeping one’s teeth will be rather more important than their estimate, but my claim isn’t “we should all be Amish” but that the Amish have equivalent lifespans and infant mortality rates despite rather different levels of care.

    Sharon

  9. Bess says:

    That bit about gestational diabetes has gotten me thinking about the entire maternity care system in several ways.

    First of all, I do not believe that GD is responsible for the cesarean epidemic. Doctors start talking about a baby being “too big” for the mom’s pelvis when an ultrasound (accurate to +/- 25% for weight of a baby) indicates a weight somewhere around 8-8 1/2 pounds, and start talking about scheduling a cesarean. But a lot of babies who seem “too big” for a woman lying flat on her back in bed, tethered there by the fetal monitor, or an epidural, or an iv, all of which are very common interventions, in a position which closes down her pelvis, might easily be able to birth that baby if she were able, encouraged, and supported in moving and assuming positions that can create as much as 2 cm more diameter in the pelvic opening, such as squatting or hands and knees. GD might be responsible for the occasional truly huge baby that really can’t fit through the mother’s pelvis, but I know of many cases where a woman had a cesarean for a “too big” baby who went on to have babies a full pound or more bigger vaginally.

    Many studies have been done, and I can get you the statistics if you want, that show that for a low risk pregnancy, birthing at home or in a birth center with a trained midwife is safer for both mother and baby than birthing in a hospital, particularly with an OB. (And lower energy and less expensive) If we are going to restructure the health care system to be lower energy and less expensive, we must take birth out of the hands of doctors, making midwives responsible for the vast majority of cases, and OBs only taking the high risk cases. This system is in place in several other industrialized countries — countries that rank significatnly higher than we do in terms of maternal mortality and morbitity and infant mortality. Some women really do need that high tech care and some cesareans truly do save lives — there is an appropriate time and place for every intervention — but they are all grossly overused in the current system. I don’t have numbers on this, but I suspect that childbirth is just about the most common reason for hospitaliization for women in this country, since something around only 10% of births occur anywhere else (again, I don’t have this number in front of me), so it would definitely make a huge difference. Part of the problem is the model of care in most hospitals is based on the premise that childbirth is a disaster waiting to happen, as well as incredibly inconvenient and time consuming, and must be managed so that it happens in a predictable way, as opposed to a model of care in which childbirth is a normal and natural life process which often needs time and patience. Yes, emergencies do happen, and I am in no was advocating unattended birth, but for the most part, if birth attendants sat back and watched, most babies would be born all on their own.

    I could rant about the current system of maternity care for ages, but I won’t. I think I’ll leave it at that, for now.

  10. Sharon says:

    Bess, I think you’ll find that in the section on birth and death I say pretty much the same thing ;-) .

    Kathy’s point about GD is that it is entirely preventable, and yet they won’t allocate the comparatively few dollars needed to prevent it, but will pay for the C sec, simply because the “wellness” model isn’t really considered part of health care.

    Sharon

  11. Squrrl says:

    Actually, last I knew, which was recently, only about 1% of births in the US took place outside of hospitals…and, as a pp pointed out, the statistics indicate that a homebirth at the end of a healthy pregnancy is _safer_ than a hospital birth, not just _as safe_. Also, very relevant to the discussion at hand, the homebirth of my daughter cost a fraction of what a similarly uncomplicated birth would have cost at the hospital, and the highest technology needed was a flashlight.

    The last four times my family has gone to the hospital, they did a few pointless tests, told us what we had already told them, gave us treatment we could–and would– have done ourselves, and then charged us hundreds of dollars. Can we do better, even with less? God, I should think so. Do I want to make sure that when I really need the hospital, it’s still there and functioning? Yes! That means not wasting resources on xrays when you already know it’s nursemaid’s elbow, as a not-so-hypothetical example.

  12. Delpasored says:

    Amen to Bess and Squrrl’s comments on the typical American birth. I work at a large urban hospital with a very high Cesarean rate. The high rate is not because of poor health of mother or baby, but the hospital policy of only allowing women to labor for a certain amount of time before diagnosing “failure to progress”. Doctors manipulate a woman’s labor to fit in with their office hours and other time contraints. Anytime a doctor tells you that they attend 90% of their patients births or they refuse to let a doula attend your birth – run like the wind!

  13. olympia says:

    Speaking of home birth……my sister, who had her last baby at home, and plans to do so with the one she’s expecting, told me that she has to pay extra, above and beyond what insurance covers, to deliver at home. How screwed is that? She pays the extra, because she finds home birth preferable to hospital delivery. I was present at all her labors, and I have to say her home birth did seem a lot more relaxed and generally better than her hospital births. I loved the way, at her home birth, her midwife was sending my sister’s older children to look for cookie sheets on which to put her tools- I mean, how cool is that?

  14. Kiashu says:

    The main difference in health care spending vs results for all the different countries and areas mentioned is doctors’ salaries.

    The average doctor in the US gets $165,000. Cuban doctors get about $3,000. That’s one reason Cuba can spend much less on healthcare but get better results than the US.

    US doctors have to be paid so much because of the high cost of malpractice insurance. And of course, because people pay so much for healthcare if they don’t get the results they want they’re much more likely to sue the doctor for malpractice, which puts the doctors’ insurance premiums up, which makes them demand higher salaries, and…

    High salaries also come from ensuring that not enough doctors are trained. For example, from 1997 to 2003 New York’s 41 teaching hospitals were paid $400 million to reduce the number of doctors they trained, according to the New York Times. When supply is low and demand is high, price goes up.

    High salaries also come from the high cost of medical school. Because we the public begrudge contributing $100,000 over seven years for the cost of training a doctor, we end up paying $50,000 extra every year for that same doctor.

    The second factor is profiteering by US and EU pharmaceutical companies. That heart pill did not actually cost them fifty bucks to make.

    Take away large doctor’s salaries and pharmaceutical company profiteering, and healthcare becomes very cheap.

    Here Down Under we have the same sort of thing happen – public healthcare covers our whole body except for our teeth and eyes. So we get things like a young man with an abscessed tooth, he’s unemployed so he can’t afford the $190 for a consultation let alone $1,000 or more for the surgery, so instead he waits until half his head swells up, then goes to the public hospital – and wakes up in intensive care, the swelling was impacting his breathing and the infection threatened to get into his brain, his treatment cost $5,000 to the public. And again, high dentists’ salaries cause this false economy.

    Not all countries pay their doctors so highly, but then they don’t have to. There are not many malpractice suits in Kerala or Cuba, and medical education is free for the doctor, and their salaries controlled and set by the government. And those countries also don’t have pharmaceutical companies profiteering – India doesn’t recognise patents on medicines, and Cuba gives theirs out free to their own people, selling them to foreigners for a profit.

    Lastly, the largest improvements in health and health-related quality of life come from very simple and cheap things. Having clean drinking water and soap saves millions of lives, especially those of infants. Eating a good range of fruits and vegetables adds a decade or so of life. Doing crosswords and having an hour or more of conversation a day staves off the onset of Alzheimer’s. And so on.

    Actual qualified medical care adds to all this, but in a relatively small way. As Sharon noted, we seem to be able to find $10,000 per pregnant woman for a Caesarean, but cannot find $50 per pregnant woman for nutrition advice, or $500 for some babysitting or subsidised prepared meals.

  15. Sharon says:

    Kyle, I agree that malpractice and education costs are the single largest thing driving medical salaries. When you come away from medical school with 200,000 in student loans (not exaggerating) of course you need high salaries. And of course, that means that while there’s no actual shortage of doctors, there’s a tremendous misallocation of doctors – lots of plastic surgeons, almost no gerontologists. Hmmm..which one pays better.

    This is actually an insanely easy problem to fix in any rational society (note, I do not claim to live in a rational society). Society serving education – agriculture, medical, educational through the graduate level could easily be made free. Malpractice could and should be capped – or handled through something like the national fund created to treat vaccine injuries.

    I’m not, however, sure that doctor salaries are really the primary driver – I don’t know about in your country but in the US, the doctor’s fees will generally only be a comparatively small part of the care costs – large chunks of it are due to inadequate ability to distinguish between valuable and useless care – for example, most Americans at the end of their lives don’t use hospice for a host of reasons, one of them being that in order to qualify for hospice, they must give up all other treatments and have a formal diagnosis of only months to live. Doctors are reluctant to give such diagnoses (because they don’t want to cause a death) and patients are reluctant to “give up” on things like chemo. This also could be fairly easily changed – and since almost 30% of all hospital stays involve people in the last six months of their lives (some of this is obviously unavoidable, but a lot of it isn’t), that would save a huge amount of energy – I have had several dying, very elderly relatives subjected to surgeries and other treatments that simply didn’t do anything except cost a lot of money and cause a lot of suffering.

    Birth is another place this would be easy to fix. I’ve written more on this, but I honestly could have gone much further with this, and perhaps will eventually.

    Sharon

  16. [...] An excerpt from Sharon Astyk’s book, Depletion and Abundance: If we were to ask “Where do we need energy the most?” we would get a very different answer. Perhaps the most bang for our fossil-fueled buck comes in health care. In fact, when anyone suggests moving to a much lower-energy society, the most disturbing and frightening thing for them to imagine losing is usually health care. When we talk about the changing economy, the question that most immediately jumps up is “What will we do about health insurance?” The shift here — from medical care to insurance — is a telling one, because right now medical care is so costly that almost no one can afford to pay for it outright. And yet, medical care in and of itself does not have to be as expensive as it is for us. The French, who arguably have the best medical system in the world, spend only half what we do. [...]

  17. Rosa says:

    Don’t forget the importance of environmental, worker safety, and land use legislation as part of public health.

    For instance; if we had banned lead in gasoline and paint fifty years earlier, that’s two generations of kids with much lower rates of lead poisoning. Right now we’re fighting asthma as a neighborhood problem – we need particulates out of our air, diesel engines cleaned up or off our streets, and housing upgraded to make roaches easier to eradicate (incidentally often the same housing stock that’s full of lead paint). Oh, and no more garbage burners, though I have a bad feeling we’re losing on that one right now.

    Worker safety laws can prevent tragic and expensive problems like mesothelioma and the hideous brain disease clump at a Minnesota meatpacking plant discovered last year that was caused by workers inhaling pig brain particles.

    Enforcing traffic laws in my neighborhood would reduce the trauma care needs by close to half, and effective gun laws would take care of another 20-30%.

    We have among the highest bike-commuter rates in the country despite having one of the least-bikeable climates, because of legislation giving cyclists equal road rights and investment in signage, lane planning, and offroad path development. That right there is part of the answer for diabetes, and we have groups working on the food side too – a neighborhood group spent years luring a grocery store into a neighborhood near me that only had bodegas and liquor stores, and the store is THRIVING because people wanted better food. Now there’s going to be a farmer’s market too, and a Native-organized group has been organizing food giveaways of healthy native foods (buffalo meat, wild rice, and various vegetables native and non-native) to elders and families with young children.

    Political action non supposedly non-health-related fronts is a huge part of preventitive medicine.

  18. Kerr says:

    “That is, often when we worry about the dangers of losing modern medicine and society, we see clearly the costs of not having easy access to high-technology, high-energy medical care, but don’t see, because we have assimilated into them, the high costs of the medicine and the society that makes it possible.”

    “You are right, Kerr, there’s a comma missing after “them” – good thing I’ve got another go ’round in the editing process still there. Clearer now?”

    Yes… But not until I cut and pasted it here, put the comma in, and and poised my fingers over the keyboard to type out why it still wasn’t clear. I wasn’t after looking for typos, I was just having a moment of partial syntax-blindness in one eye or something of that sort. Thanks for the clarification.

    This might be easier to read:
    “That is, often when we worry about the dangers of losing modern medicine and society, we see clearly the costs of not having easy access to high-technology, high-energy medical care—but we don’t see, because we have assimilated into them, the high costs of the medicine and the society that makes it possible.”

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