(
This paper was never published. Some 12 years old, still worth reading and give consideration. It is reproduced here to anyone's curiosity)
NORTH-AFRICAN IMMIGRANTS IN RURAL CENTRAL SPAIN
Health issues.
Xavier Allué
Department of Anthropology, Philosophy and Social Work
University of Tarragona “Rovira i Virgili”
Tarragona, Spain
Introduction
The overall picture of foreign economic migration into Spain has a variety of situations and settings. This variety is also reflected in the health related problems the migrants face. Even though the National Health System in Spain is supposed to be uniform, the differences result mostly from the different social and geographic settings. Most recent studies are centred in areas which concentrate large populations of migrants, mainly around the big cities like Madrid and Barcelona. The purpose of this paper is to present the situation in a rural area of central Spain and its peculiarities, differences and similarities, particularly from the professionals viewpoint.
The observational work was carried out during a brief period in the winter of 2004, particularly during a professional meeting of the Primary Health Care Society of Extremadura, the local autonomous region, held at Navalmoral de la Mata in January 2004.
History and present time
There is no way to consider the North-African migration into Spain away from history. No matter the years (centuries) passed, North-Africans for Spaniards are “moros”.
Historical construction o XVI century historic invention, the “Reconquista”, the eight centuries-long supposed struggle to oust the Arab, Muslim, rulers from the Iberian Peninsula, is a cultural reference constantly present in the collective imaginarium of the Spanish people. The “Reconquista” was capped up with the XV century expulsion of the “moriscos”, Muslim peasants and farmers that were part of the Spanish society, by Philip the Second.
Every Spaniard has the feeling that, somehow, and after so long a time and so much effort, they “got rid” of the “moros”, the moors, for good.
Historians, politicians and thinkers of a wide variety of schools of thought, have put the Reconquista under reconsideration and reclaim the Arab heritage as something essential to Spain. The wonderful architectonic monuments of La Alhambra or the Cordoba Mosque are the pride of any red-blooded Spaniard and thousands of cities and towns carry Arabic names all over the country, way up North, almost to the Pyrenees, later carried over the ocean by the Conquistadores to so far away places like Albuquerque in New Mexico or Guadalcanal in the South Seas. The Spanish language is constructed with many Arabic words, from A to Z, from “abalorio”, beadwork, to “zurrapa”, dregs, some 20% of Spanish words come from the Arabic.
Still, to claim some Arabic heritage in Spain has always had an undertone of exotism and left wing progressivism. A “proper” Spaniard, an “hidalgo” would claim “limpieza de sangre”, clean blood, not contaminated by moors’ or, God forbid, Jews’. Of course centuries have gone by and “hidalgos” no longer hold any sway in the Spanish society, but the deep feeling lingers on.
Differences will be considered between “Arabs”, the Cordoba caliphs, the Ummaya, rich, educated, powerful, and of Middle East origin, and the “moros”, North-African illiterate, semi-savage, dirty, rapists of women god-forsaken infidels, sarrazins, dog-moors.
This is reproduced today as oil-rich Saudi princes are welcomed as investors in the Costa del Sol, Arabs, whereas poor immigrants from North Africa may be considered jobs stealing scumbags in some poor Spanish districts.
The Civil War, started by Franco with the African Army and using Moroccan mercenaries as front line fighters, made a peculiar twist for winners and losers as the Republicans, atheistic, defended democracy and civilisation against the Francoist “Christian crusaders” dressed up in Moroccan tunics and donning the fez (Turkish) cap. Some historians, on the other hand, said the Spanish Civil War was the last Punic War. So there.
Twenty-five hundred years of struggle and confrontation, but also of living together, syncretism and miscegenation, the bridge between Europe and Africa, the Iberian Peninsula, is to be again the common land of Western Mediterranean peoples.
As Professor Seppilli put it once, the North Africans, the moors, the immigrants are not coming. They are coming back.
Setting
The geographical region of Campo Arañuelo is in the Northeast corner of the autonomous region of Extremadura, in the Cáceres province in Western Spain, some 180 km South West of Madrid. Navalmoral is the centre of the region, right on the National Highway VI, one of the main radial thoroughfares of the Spanish road system.
The population of the region is of some 55.000 inhabitants, and of those, 6626 are registered immigrants. The peculiarity is that the vast majority of the immigrants are located in just two towns, Navalmoral itself and Talayuela.
Navalmoral is the see of the Hospital Comarcal Campo Arañuelo a 120-bed community hospital built in the late eighties by the National Health System.
Ethnic data
The immigrants in the Navalmoral area belong to at least 32 different nationalities. However, almost 90% are Moroccan (Table I), most of them from a couple of specific towns in Eastern Morocco close to the Algerian border, Oudja and Taourirt.
Table 1. Foreign population in Talayuela, 2002
COUNTRY OF ORIGIN
|
NUMBER
|
|
Algiers
|
49
|
Brasil
|
5
|
Chekia
|
3
|
Colombia
|
31
|
Cuba
|
1
|
Dominican Republic
|
4
|
Equador
|
126
|
France
|
3
|
Italy
|
1
|
Jordan
|
1
|
Lithuania
|
6
|
Morocco
|
4401 (93%)
|
Mauritania
|
1
|
Netherlands
|
1
|
Poland
|
5
|
Portugal
|
31
|
Rumania
|
13
|
Senegal
|
31
|
Ukraina
|
2
|
TOTAL
|
4715
|
(Local Spanish population: 6880 )
Data from Alvarez C. Realidad de la inmigración en Extremadura, 2003.
Social and cultural data.
Language. Many Moroccans would speak Arab which is the Moroccan official language, used in schools and by the Administration. But many others speak Tamazight (Berber) or Chelja and dialects. Illiteracy is very common. Up to 55% of men and 80% of women are illiterate in Arab. Few can read Spanish although gradually they understand Spanish signs and posters.
Religion.
The vast majority are orthodox Muslims. There is a mosque ( an informant said a “quasi-mosque”) in Talayuela, located in a former tobacco leaves drying shed, a building quite run-down, rented to its owner by the Muslim community. Some four years ago an imam arrived in the area and settled down. Some time after he regrouped his family and now provides his services to the community on a full-time basis. He is also supported by the community. There is a fair attendance to the services, especially in the holy days. The Ramadan is generally followed by the vast majority of the settlers.
The use of head scarves, “chador” is very common amongst Moroccan women. However, most youngsters have done away with ethnic attire and dress as Europeans. Practically no school girls wear “chador” at school, by their own decision. There is no evidence of any conflict related to women’s ethnic wear.
The migration to the Campo Arañuelo area dates back to the early nineties, initially as seasonal harvest workers for the dark tobacco, that then stayed and got into the tobacco and asparagus planting and harvesting, both labour intensive crops.
The case of Talayuela
Talayuela was a sleepy little town in central Spain with a population slightly over 5000 inhabitants. The population was growing older as many young men and women migrated to the industrial belt of Madrid, just a couple of hours away by train or motorcar.
From the late eighties, Talayuela began to get some migrant workers from North Africa. The influx gradually grew with more newcomers and in the past 6-8 years with the regrouping of families, women and children. With the new century, the immigrant population equated and eventually surpassed in numbers the local population.
The higher birth rate of Moroccans meant a growing proportion of births to foreign-born mothers, up to 18% (83 of 440 deliveries) in the year2002. For all practical purposes, all the deliveries have taken place in the local hospital.
This settlement of foreigners in such a small community has evolved rather smoothly with very few incidents on the record, described in a national newspaper of large distribution as “the miracle of Talayuela”, as opposed to certain other concentrations of migrant workers in Spain such as Can Anglada, in the Catalan Vallés or Elejido, in Almeria, where racist incidents have taken place in the recent past.
Talayuela has a Local Health Centre with 4 Family Physicians and one Paediatrician, plus an assorted number of nursing personnel and one Social Worker.
The health problems detected
Imported problems
Parasitic infestations (scabies, lice, giardiasis, etc.)
Deficient growth development in children
Anaemias of multifactorial origin
Tuberculosis
Skin problems (dermatitis/dermatosis)
Chronic ear infections
Lack of vaccination
Health matters related to cultural peculiarities and social situation
The weight of religion: The Ramadan
Circumcision (tathir)
The use of henna skin paintings
The tea drinking
Illiteracy and poor education
Overcrowding
Meanwhile, the general health problems are no different from what is found in any poor and recently arrived migrant population, it is worth noting the problems the health personnel relates to cultural differences.
The large concentration of Muslim population and the settlement of families make the religious celebrations more of a routine. The health personnel feels that some of the traditions have reflourished a bit, over and above what the practices were in the land of origin.
The Ramadan observance poses a problem in certain persons more sensible to food intake: pregnant women, diabetics and children. Doctors have found it difficult to explain how Ramadan fasting can be circumvented without twisting the religious prescriptions.
The circumcisions are usually demanded as a service to the surgical units. No circumcisions are carried out by lay people.
The use of henna skin decorations is widespread even in new-born babies. Henna is a dye made of the dried crushed leaves of a plant: Lawsonia inermis, supposed to be completely harmless. The concern arises from the fact that some henna dyes may have heavy metal salts such as mercury, chrome, cadmium and cobalt, that may be incorporated into the body producing heavy metal poisoning and cutaneous allergic reactions. Also, some henna presentations are laced with PPD (paraphenylenodiamine) to shorten the impregnation time of the dye. PPD has been related to renal failure due to toxic glomerulonephritis.
Tea and herbal infusions are the most common drinks amongst Moroccans. Originally the purpose of boiling water had an anti-infectious reasoning in areas where drinking water was a constant health risk for gastrointestinal infectious diseases like typhoid fever, cholera, and other GI infections. The tea infusion carries a wealth of biologically active principles like flavonoids, vitamins and fluoride and carries a lot less caffeine than coffee. The unwanted effects of tea are related to the potential effect of iron binding, sequestering the available iron in the regular food intake, leading to iron deficiency anaemia. This affects mainly children and pregnant women.
Language and cultural barriers are considered insurmountable difficulties in health care. Illiteracy, almost universal amongst Moroccan women renders impossible written recommendations for prescriptions and dosage. History taking is a pain not just because the language distance but because the inability to understand the real meaning of the questions. Things like allergies or toxic habits are not interpreted as such and almost impossible to translate by the mediators.
On the whole, most migrants will address themselves to the Health Centre when they feel ill, but they would not report for follow-up visits of for check-ups if they do not feel sick. The idea of preventive medicine seems totally foreign to them.
As youngsters do learn more easily Spanish in school, they are used as interpreters commonly. This is very useful, with the noticeable exceptions of consultations related to gynaecological ailments in women, who would not confide their problems to a younger member of the family, particularly boys.
The informants
Most of the information was provided by Dr. Maged H. Abdulrazzak, a Lebanese paediatrician of Palestinian origin who settled in Villanueva de la Vera some 15 years ago to discover that his patients gradually changed from the Spanish local population to Arab speaking migrants, his own mother tongue.
Maria Antonia Martin, a Social Worker assigned to the Talayuela Health Centre provided an excellent insight of the migrant population behaviour. She also contacted and lead the interview with the members of the “Forum” (see below)
Maria Jesus Pascual, paediatrician, formerly at the Talayuela health Center, now working in Madrid.
Julian Ibañez, Family physician, collected information on vaccinations
Jose Luis Dominguez, male nurse, cared for children and provided child care norms and counselling to mothers.
The FORUM
In the 24th of January meeting, the afternoon session was dedicated to the view of the migrants. For that purpose, a number of migrants from the area were asked to form a panel of discussion and express their feelings and ideas about their experience as patients.
Members:
Abdallah. Moroccan, from the South East of Morocco, a very poor region. University graduate in English Philology. Out of work decided to emigrate into Spain. Worked in the fields for a while, now acts as cultural mediator.
Turia. Moroccan, wife of a Moroccan farming technical engineer. Came to Spain under the regrouping legislation. Homemaker. (A well dressed, good looking, Western style dressed, blonde dyed young woman in her thirties.
Ana Beatriz. Ecuadorian. Migrated into Spain six years ago to work in the fields. Regrouped her family (as many South American do: women migrate first, then recall their husbands and children) afterwards. Now she teaches clothes design and tailoring in Plasencia, a larger town, close to Campo Arellano.
Pape. Senegalese male, thirty-ish. Took two years of Medical School in Dakar, then quit when his mother died and had to take care of his younger brothers and sisters. Migrated into Spain via Amsterdam (didn't like Dutch weather) and works as ambulant vendor.
Houria. Translator. Moroccan, daughter of a former provincial governor in Morocco. Now living in Navalmoral, he is the president of a multicultural organisation that pays for her cooperation as a translator. She is not, remarks, a cultural mediator.
Pilar. Spanish Social Worker from Seville, married to a Senegalese man who works as a farmer, one son.
One way or another, all members of the Forum refer to the degree of tolerance found in Talayuela as something very appreciated and deemed extraordinary by most.
Turia referred here experience with the gynaecologist and considered positive and with no particular problems. Being of a better to do family, she had had contact with Western style gynaecological care back in Larache, where she was from.
(Ana Beatriz) The Ecuadorian professionals migrate to Spain and had to work as peasants, farmers, meanwhile they could not find a way to develop their careers and use their skills and potentials in their own corrupted and abusive society.
Pilar brought up the political side of migration. Commented on the Government responsibilities in providing a more sensible legal coverage and called for an end to the paper-less situation of many new immigrants, blaming the lack of understanding between the Spanish (European) governments and those of the countries of origin of the immigrants.
Integration
None of the Spanish informers would accept that there is an integration of immigrants. They talk about “convivial tolerance” or “living together but not mixed” (“Juntos pero no revueltos”). Although there are no situations of apartheid, by any stretch of the imagination, some would accept terms like “a dispersed ghetto”.
Many believe that it will take at least one generation when today’s schoolchildren grow up into the Spanish (European) culture and become “normal”, that the communities will integrate.
Some point out the lack of will to integrate as many immigrant women watch Arabic TV channels soap operas through satellite dish antennae (Algerian or Egyptian) and make no efforts to learn Spanish.
If one looks up Talayuela on the Internet, the most important site is the web page put up by ARJABOR (http://www.arjabor.com), an organisation that brings together “public and private wills, individual and collective to impulse the sustainable development of our towns and their people” as they claim on their home page. ARJABOR stands for Campo Arañuelo, La Jara and Los Ibores, the three major communities of the area, and the organisation is supported by the local tobacco growers.The web page gives quite a lot of information about History, Geography, Demography, Labor market, Healthcare, Social services and Economic and Trade data, completed with maps and graphs to illustrate the facts. In all this rather complete display of information, there is not a single word about immigration. None (!). This absence, this obliteration of a social reality says a lot about the “official/unofficial” feelings of the opinion leaders of the area.
On the other hand, the immigrants that could express their opinions consider themselves well accepted and willing to participate more and more in the social environment. As mentioned above, the participants in the Multicultural Forum publicly expressed their recognition and gratitude to the Campo Arañuelo society for their acceptance and reception, particularly in relation to health care.
(It must be said that no field work outside the limits of the meeting was carried out on individual immigrants).
The menace: a new farming machine used in the tobacco leaves harvesting, jokingly called by locals “Isabel, la Católica” after Queen Isabella who kicked out the moors from Spain in th XVth century. The machine will displace many workers from the now labour intensive tobacco harvesting.
PART TWO
Immigration is not a problem. It is just an event. Racism is a real problem. We all should work to prevent it to become an event.
Politicians
In the course of the meeting on January 25th there were two interventions by the Autonomous Government of Extremadura representatives. One was a high official of the department of Social Welfare and the other was the Director General of Health, the second in command in the Department of Health. Both addressed the issue of migration from a political point of view, praised the organisers of the meeting and offered their cooperation.
The discourse of the Director General of Health was a little more elaborated. It included the offering of a social category to the immigrants with words like “we are all in the same boat” meaning both the nation and the world. Also insisted that the immigrants were in need of social help and health care not only as citizens or taxpayers but as persons.
He called for coordination of efforts between the professionals and the administration, being the health professional in the front line in contact with the people. He understood that we are now in a new era in the conformation of the population of our country with the arrival of new people from abroad.
In this context, he came to consider that immigrants do not have welfare and social problems on one side and health problems in another. Rather those problems were not two processes but the same one.
He also asked for a continuation of the “Jornadas” in new editions, and demanded a summary of the conclusions of the meeting to be used as a guideline for further government policies.
Aside the fact that, nowadays, our politicians usually come to meetings with a well-prepared discourse and keeping in mind that politicians promises are very often empty words, the tone of the address and the way he put together social and health issues as a common and one matter, sounded nice and better structured than the general discourse one hears usually.
Worth to say is the fact that both politicians belonged to the Socialist party, the ruling party in Extremadura, on the whole interested in marking distances with the People’s Party (“Partido Popular”), the right-wing ruling party in the Spanish State, particularly in view of the upcoming elections in just couple of months. The People’s Party has changed twice in less than 15 months the General Immigration Law for Spain. The first time just to change the previous law, set up by the former ruling party, the Socialist, claiming it was too permissive with illegal immigrants, and the second to correct their own ruling as not working properly and turning illegal immigration into a criminal act.
However, the general sense of welcoming to the immigrants transpired all the addresses.
The view of doctors, nurses, and social workers.
Health care personnel find themselves confronted with the reality of immigration with the conscience that it means a problem that has been somehow imposed to them. Tha majority feel that they have not been prepared nor trained to take care of people from different cultures and with health problems that may be little known to them.
At the same time, many undertake their tasks with a sense of a mission, particularly when the number of foreign immigrants becomes a rather important part of their patients. They get involved in community activities, participate in Parents-and-Teachers meetings at the local school and cooperate closely with the social services.
The health personnel complaint that there is little recognition of the workload the immigrants represent, in part because it is a nonregistered population. This is despite the fact the immigrants are usually provided with health cards. As one put it: “...it is a phantom population, nowhere to be seen at any administrative level but that shows up in the clinic (for care)”.
In this particular area, the immigration is very recent altogether, just ten years. So most of the experiences are related to newcomers and a relatively short time after arrival. This is particularly so in the case of women and children, the vast majority having arrived in the past five years. Therefore, the predominant issues are related to the health problems carried over from the country of origin and the difficulties in communicating with the immigrants because of language and cultural barriers, as they have not acquired Spanish language abilities.
Within these parameters, it emerges fairly soon the difference between some immigrants and others depending on their origin in Morocco. The fact that so many come from the Oujda and Taourirt areas, a rather backward region close to the Algerian border, utterly abandoned by the Moroccan authorities, brings up the question of their previous exposure to Western medicine or medical. North-African immigrants from the Western part of Morocco and the large cities like Casablanca or Marrakesh and their surroundings are culturally closer and have had access to doctors and hospitals. The ones from the eastern border are rather primitive and vastly illiterate.
The first contact with the Spanish health system usually is to obtain a health card as a prerequisite for health care, but especially because with the health card they may demand an official health certificate, one of many documents needed to legalise their situation. Very often this will be the one and only contact with the health system, particularly for men. Women and children, as they come in the process of reuniting families also need to obtain a medical health certificate. This is used to engage these people in the health programs.
The professionals note that one major difference in the demand of health care is that the North-Africans are used to go to doctors only and when they feel sick, forfeiting any idea of preventive medicine. Furthermore, they will abandon any treatment once the symptoms have receded.
This attitude is widely criticised by doctors and nurses. The (relatively) young Family Physicians in Spain have been trained with a heavy emphasis in preventive medicine. Slogans such as “It’s more worth to prevent than to cure”, an old Spanish saying, are completed with an addendum: “and cheaper”. The officials doctrine calls for strong and very active programs on immunisations, early diagnosis of severe diseases like lung and colon cancer in men and breast and cervical malignancies in women, watch over for diabetes and hypertension, fight against tobacco use and the like. So much so that the very name of the health facilities “Centros de Salud”, Health centres, has been opposed to the “disease centres” meant for the hospitals Emergency Room services (See Uribe, 1996 and Allue, 1999). Therefore, they resent the immigrants attitude and consider it backward and primitive, when not utterly stupid.
Doctors, not so much nurses, and other allied personnel, resent that many immigrants show up for visits at the clinic without previous appointment. The system demands that any doctor while on duty in the clinic should take up to 10% of non-appointed visits (“spontaneous”). Over that, the patients may be referred to the Emergency Room. This may not mean much, as quite often the same doctor covers both the clinic and the Emergency service. What really upsets the professionals is that the “spontaneous” demand is for matter rather administrative, such as health certificates, vaccinations or getting prescriptions. Of course, this patients’ attitude is also relatively common amongst the local Spanish population, but the general sense is that the immigrants are “less disciplined”.
At the same time, doctors recognise that as the immigrants have been in contact with the health system for a longer time, gradually they become more and more orderly and demand and keep appointments.
On the whole, most professionals see the collective of immigrants as a problem due to the cultural distance. The difficulties encountered in the immigrants care, expressed in different points, it all boils down to cultural matters:
“...the features of the immigrants as a collective, educational, labour related and habits...”
“... the lack of knowledge (by the health professionals) of their culture and the best way to reach out to them...”
“... the absence of cultural mediators and social educators...”
“... the difficulties of the professionals for taking conscience of this population...”
“... the absence of protocols for the care of immigrants...”
“... the discoordination of the different administrations (local, community, state)...”
And in the six proposed possible strategies to confront the problems the word “culture” appears utmost in each and every one of them:
“To acquire a wider knowledge of the culture of the immigrant population...”
“Continuous education for professionals focussed in the integral view of the health-disease process in their cultural setting...”
“To include cultural mediators in the health team...”
“Common protocols adapted to the culture of the immigrants population...”
“Respect and take advantage of cultural concepts and habits of the immigrants...”
“To coordinate activities with the NGO’s, immigrants community associations, community and religious leaders,...” (Martin, 2004)
Immigrant children
The definition proposed for immigrant children is the one published by the American Academy of Paediatrics: an immigrant child is anyone born in another country now living here, whether legal or illegal, a refugee or a foreign adopted child.
The inclusion of internationally adopted children as “immigrants” relates to the fact that, as the “economic migrants”, adopted children usually come from Third World countries and share many of the health care deficiencies so common in those countries.
This comment is included here because the coincidence of the Navalmoral meeting and the presentation of a book on Chinese children adoption in Extremadura with the general assembly of ANDENI, an association for transnational adoption in Caceres, the provincial capital. The author of this text contributed with a paper on ethical matters in transnational adoption (Allué, 2004).
As mentioned above, the children of immigrant families are both born abroad and brought with their mothers in the regrouping process and born already in Spain. Of a total of 5012 born children in the Navalmoral area 1992 to 2002, 319 (6.3%) were born to non-Spanish mothers. Of those, 288 to Moroccan mothers. Since 1998 the annual number of newborns is maintained around 450 a year. However, the proportion of Spanish/Non-Spanish has changed from 94%/5.1% to 81%/18.8%. (Table II)
Table II. Births in the Campo Arañuelo Hospital
Year
|
Spanish mother
|
Moroccan mother
|
Other
|
Total
|
|
1998
|
443
|
23
|
6
|
459
|
1999
|
389
|
43
|
1
|
433
|
2000
|
429
|
52
|
1
|
482
|
2001
|
408
|
68
|
6
|
482
|
2002
|
351
|
83
|
4
|
440
|
This reproduces a common situation in Spain as a whole, since the country, now with one of the lowest birth rate in the world, is experimenting the influx of immigrants and an increase of their share of births.
Child care in the Talayuela Health Centre is extended to all the immigrant population. The problems the professionals encounter are the common health problems in children: upper respiratory tract infections, seasonal enterocolitis, and the like. But also and as mentioned above, some specific problems are identified as more frequent amongst immigrants, particularly newcomers: deficiency anaemias, parasitic infections (lice, scabies), chronic ear infections and primary tuberculosis.
The incomplete immunisations or the sheer lack of it is compounded with the difficulty in obtaining proper records of vaccinations given in Morocco. There is an added confusion on the BCG vaccination, supposed to be compulsory in Morocco, but not always given. This may be misleading when evaluating a positive PPD skin test.
Nutritional problems are detected in small children once they are weaned from breastfeeding.
CONCLUSION
The singular situation of North-African immigrants in the Campo Arañuelo region offers a specific picture of the reality of immigration in some rural areas in Spain.
The health problems found, show a mixture of Third World-First World collusion situations mostly related to the relatively recent immigration that has taken place in the area.
The health professionals express also a mixture of feelings and opinions as they resent the poor health background of the immigrant population and the difficulties inherent to the cultural distances and language differences, together with a sense of a mission in the care of this people.
Although there are no evident situations of exclusion or discrimination, more to the contrary, with an ample distribution of health cards and no administrative barriers for medical care, the gradual increase in health care demand due to the growing immigrant population and the limitations in resources available, may lead to difficulties in health care delivery in this particular area.
February, 2004
(Note: the author is indebted to Dr. JJ Morell who made possible this work and introduced the author to the Extremadura immigrants reality).
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