Part One: "It was very easy to see who was bearing the brunt of COVID-19."
The coronavirus pandemic’s impact on Black Americans and the health and access disparities that left Black Americans more vulnerable to coronavirus.
Gabriella Chiarenza is managing editor for Invested and Regional & Community Outreach and Steve Osemwenkhae is senior photography and video specialist for Invested and Corporate Communications, both at the Federal Reserve Bank of Boston.
Dr. Cassandra Pierre was at home, immersed in a remote conference, when she got the COVID call from Boston Medical Center on March 9th. Pierre—an infectious disease physician, Medical Director of public health programs, and acting Hospital Epidemiologist at BMC—and her colleagues had seen the novel coronavirus crisis looming toward Boston “like a far-off storm,” she told me. But lulled into a sense of security by the strength of the region’s medical community, and with so little then known about the new virus, they were unprepared for the reality of the pandemic that was about to make devastating landfall on the East Coast. The situation soon grew especially dire at BMC, even as many hospitals across Greater Boston faced the unexpectedly intense COVID-19 surge. BMC is a safety net hospital, one that cares for a medically underserved population and tends to a largely Black and brown community in one of Boston’s most economically disadvantaged areas—precisely the communities that would come to be particularly vulnerable to the worst COVID-19 outcomes.1
From the vantage point of her essential hospital, “it was very easy to see who was bearing the brunt of COVID-19,” Pierre said. “Even compared to our usual demographics—we care for disproportionately Black, Latinx, and other underserved patient populations in our hospital compared to other hospitals in Boston—we were now seeing that 80 to 85 percent of our patients were completely patients of color, which is a considerable shift.” Though the hospital immediately sprang into action designing response protocols, working to source needed personal protective equipment (PPE), and tending to a rapidly growing pool of coronavirus patients, it was obvious to the BMC staff that they were fighting an unpredictable, largely unknown virus with inadequate resources. “It was incredibly overwhelming,” Pierre told me. “We were not equipped with the same amount of PPE that other hospitals were. We didn’t have the same number of medical interventions like Remdesivir, or more accurately, we were not being included in the randomized controlled trials that were then being set up to evaluate those things. There was so much inequity that we were seeing.”
Such disparities in patient demographics and resource distribution are not unfamiliar to safety net hospitals,2 and Pierre has honed a particularly fortuitous combination of the skills and instincts needed to field a novel virus threat at a hospital like BMC. She specializes in untangling infectious mysteries with an eye to the health inequities that can worsen outbreaks among underserved communities. Her love for her work and deep understanding of the social, economic, and health disadvantages plaguing her patients are immediately clear in speaking with her. Coming from a Haitian family, Pierre said she is acutely aware of how interwoven race and medical disadvantage are in the United States. “Many infections and chronic diseases, due to systemic racism, were concentrated in people of color, the underserved—people who looked like me,” she said. “People of color had also borne the stigma of those infections. We may not have been initially at fault or the cause of the system that led to those diseases being concentrated in communities of color, but we were unfairly blamed for the perpetuation of those infections.” Now Pierre was seeing with COVID-193 what she has often seen in her work around HIV,4 diabetes,5 tuberculosis,6 and many other infections and diseases: the people affected were disproportionately Black and brown. In the United States, the death rate for Black people from COVID-19 was 2.4 times that for white people as of August.7 She was not surprised, but she was worried.
While safety net hospitals like BMC were being overrun with COVID-19 patients, Michael Curry saw that community health centers across the state were grappling with similar surges in COVID-19 infections among similar groups of patients. Curry is the Deputy CEO and General Counsel for the Massachusetts League of Community Health Centers, a primary care association representing 52 centers and over one million patients. Community health centers, or CHCs, are a product of the Civil Rights Movement and were developed to address the lack of preventive care available to communities of color. Inspired by South Africa’s health center model, medical and civil rights leaders established the first U.S. CHC in 1965 in Boston’s Dorchester neighborhood;8 from there, the model spread to the South and on to the rest of the United States. Unlike hospitals, which tend to see financially disadvantaged Black and brown patients largely in desperate situations in their emergency rooms, the CHC model centers on routine, comprehensive, preventative care for people who would otherwise not have primary care options available to them.9 Cultural competency is an especially important aspect of CHCs’ service to their neighborhoods, where residents may be fearful or distrusting of medical professionals due to traumatic past experiences or norms in their own cultures.10
Curry, who is also a past president of the Boston NAACP and serves on the NAACP Board of Directors, told me he and his siblings benefited greatly from the care they received at a Roxbury CHC as children. He pointed to the importance of the racial and ethnic understanding at the heart of the CHC model in getting residents in the door when they need care, and building the trust needed with patients so that they feel comfortable enough to come back. “We are the canaries in the coal mine,” Curry told me. “If you want to know what’s going on in communities of color, you need to come in and watch what’s going on in community health centers.”
CHCs also felt the strain of providing effective care in the midst of a pandemic.11 Curry said that CHCs saw a 50 to 70 percent loss of revenue from billing for routine and elective procedures, most of which were canceled or postponed for months during the initial pandemic lockdown in Massachusetts—a major financial shortfall just as CHCs were trying to address growing COVID-19 needs in their communities.12 CHCs faced similar problems as hospitals in finding and sufficiently stocking PPE for their providers.13 At the same time, Curry told me, public health officials were calling on CHCs to become testing and urgent care centers to respond to the pandemic, as hospitals were overrun and it became clear that COVID-19 was disproportionately affecting communities of color and essential workers.14 “We were being asked to do a lot with a little,” Curry said. “Some of our public health departments weren’t fully prepared for this pandemic and really turned to the local health centers to become the backbone for the response.”
The information these local providers gathered early on in the pandemic turned into important early warnings about who was being most heavily impacted in the U.S. by the novel coronavirus. But why were Black and brown communities so vulnerable to coronavirus to begin with?15 Curry shakes his head at this question. “We know this country is very much hinged to racism. It is why we get the inequities we have and see the deaths that we see. And shame on us—we should have known, and we should have acted on it. If we didn’t address the social determinants of health, the underlying health disparities, then when a pandemic hit we should have known that people of color would be disparately impacted.”
Social determinants of health16 are non-genetic factors that impact the quality and length of a person’s life; many of them are tied to where the person lives, and many are not entirely in that person’s control. They include the location and quality of housing, food security and quality, income stability and employment-based benefits, physical and environmental safety, and proximity to community supports, among others.17 In communities of color in the United States, and especially in Black communities, these social determinants of health have long been whittled away by racist systems.18 Redlining and rental discrimination have limited the location and quality of housing available to Black people.19 Food deserts,20 discrimination in hiring and workplace environments,21 and inadequate public transportation22 in Black neighborhoods have hindered Black Americans’ access to healthy food, stable jobs, and affordable health care. Pollutants in the air, water, and building materials in many majority-Black communities have poisoned those who live and work there.23 Disproportionate, ongoing mistreatment from law enforcement has left Black Americans in a chronic state of stress and anxiety, traumatized, brutalized, or worse.24 Many of these discriminatory conditions, systems, and structures contribute directly or indirectly to disease and premature death.25 Since the novel coronavirus takes its heaviest toll on those with preexisting health conditions—many of which are caused or exacerbated by deficiencies in the social determinants of health—Black Americans find themselves at the center of the coronavirus storm.
“The disproportionate impacts of COVID-19 on communities of color absolutely don’t surprise me. I think the surprise was that people were surprised,” Rev. Dr. Gloria White-Hammond told me. “These are longstanding disparities.” White-Hammond is co-pastor at Bethel A.M.E. Church in the Jamaica Plain neighborhood of Boston, where she and her husband Rev. Dr. Ray Hammond have led a largely Black congregation since 1988. She is also a retired physician who practiced pediatrics in a Boston CHC for almost 30 years. (Curry, Hammond, and White-Hammond serve on Boston’s COVID-19 Health Inequities Task Force.26) She noted that majority-Black neighborhoods in Roxbury, Dorchester, and Mattapan have the highest rates in Boston of many of the conditions, including asthma, heart disease, diabetes, and hypertension, that put people at greater risk for worse outcomes should they contract COVID-19.27
But the neighborhoods that make up the heart of Boston’s Black community have contended with higher rates of chronic disease and infection than neighboring communities for generations before this pandemic.28 White-Hammond explained that effective, community-oriented health care work in these neighborhoods goes beyond medicine to touch on many of the social determinants of health. She recalled one representative day in her pediatrics practice that involved calling a landlord to convince him to address a building’s rat and roach problem that was worsening one of her patients’ severe asthma; helping to arrange social services and mental health support for a child who she determined had been abused; and communicating in both English and Spanish with an immigrant family that lacked insurance and faced a number of other challenges to their health. To White-Hammond, advocating for the families she works with and teaching others how to advocate for themselves is a crucial part of protecting and healing the community. “It’s the twin work of not just holding people’s hands, but raising a fist,” she told me, “that does in fact speak power and advocate for power on behalf of individuals who are not feeling like they can speak for themselves.”
By early April, it was clear that Boston’s majority-Black communities would be among the most impacted by COVID-19 in several ways.29 Those dubbed essential workers in the spring during Boston’s pandemic lockdown period were largely Black and brown.30 Masks and other PPE were in short supply, and the public was asked not to wear them in the early weeks of the pandemic, in order to stretch the limited mask reserves for hospital medical staff. This rationing left many other essential workers—transportation operators, hospital cafeteria and grocery store workers, nursing and long-term care home staff, and janitorial workers among them—without protections that turned out to be vital to stemming the spread of the coronavirus.31 Many of these workers kept going to work not only because they were essential, but also because they relied on their often meager incomes to keep their own families afloat. “People were forced to wear [the same] masks or N95s for a week or a month at a time,” Pierre told me about her essential worker patients. “They had nothing. And so as a consequence, they tried as best as possible to figure out ways to protect themselves. I had some patients who just stopped coming to work, certainly at their own economic peril.”
It also became clear early on in the pandemic that COVID-19 death rates were significantly higher for older people, and many seniors were being intubated and dying without family members at their side to offer comfort, say goodbye, or share these patients’ care directives with doctors and nurses. White-Hammond told me that Black people are less likely than others to have advanced directives for end-of-life care in place, something that she has been working to change. Speaking with more than 200 of the Black families in her Bethel A.M.E. congregation about end-of-life preparations over the past five years, White-Hammond learned that a history of disparate treatment based on race lay behind these conversations as well. “They talked about not even necessarily being asked about what their wishes were, and when they wanted their wishes honored, not having those honored and respected; feeling like those kinds of life supports are not available to them, that they may be available to people who don’t look like them. And that in many ways has demonstrated that while death in America is a great equalizer, dying is not.” Knowing what she does about these disparities in end-of-life care and that relatives were not permitted to be in the hospital with coronavirus-infected patients even as they died, White-Hammond worried about Black seniors and their families.
Distrust, resentment, and skepticism around the mainstream health care system are not uncommon or unfounded in Black communities.32 The United States has a long and traumatic history of mistreating Black people in the name of medical research, from experimental procedures conducted on enslaved people without consent,33 to the Tuskegee experiments34 that refused treatment to Black men infected with syphilis to document how the disease progressed, and the forced sterilization of Black women.35 The longstanding lack of responsive, accessible medical care in communities of color has left space for damaging rumors and misinformation to fester. “I do find a lot of misinformation in communities of color because there’s a vacuum for medical and public health leadership from people that people of color can trust, or who look like them,” Pierre told me. “There is a perception that the hospital is not a safe place for people of color. People have been used to not being heard or seen by their doctors or their health care systems, not being taken seriously. People have historical concerns about being experimented upon or getting inappropriate or substandard care.”
It is worth noting here that just five percent of all physicians in the United States are Black.36 Culturally competent Black doctors like Pierre who understand their patients’ fears and mistrust of mainstream health care are left feeling powerless to help in some cases. They worry that the people they were treating before COVID-19, with whom they’ve built hard-won trust, are missing crucial care as the pandemic wears on.
Pierre had to rapidly establish and carry out pandemic response protocols as the acting hospital epidemiologist at BMC while also trying to continue care for existing vulnerable patients in her infectious disease practice through telehealth. I asked her what this new reality felt like, and Pierre sighed, visibly frustrated. “How does it feel taking COVID on, on top of the care that we were already doing for people who were already struggling with getting access, struggling with their out-of-control underlying conditions, struggling with the fact that they had to prioritize between attending a doctor’s visit and going to their jobs, and so many other things? It felt like I had to abandon my patients. That’s what it really felt like.”
Pierre, Curry, and White-Hammond dread the wreckage that health care providers and their patients will face as the COVID-19 storm continues to thrash the U.S., with so many chronic conditions left poorly managed during the pandemic in Black communities that have been left out in the cold for so long. “I am concerned that we might not take this opportunity to not just put a Band-Aid on it by addressing just the immediacy of the pandemic, and not solve for the underlying inequities,” Curry said. “We have to solve for the underlying issue, or we’ll be here again.”
- Centers for Disease Control and Prevention, “Health Equity Considerations and Racial and Ethnic Minority Groups,” CDC, July 24, 2020, https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/race-ethnicity.html. Robert S. Levine, Heather M. Johnson, Dennis G. Maki, and Charles H. Hennekens, “Racial Inequalities in Mortality from Coronavirus: The Tip of the Iceberg,” American Journal of Medicine, May 19, 2020, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7236709/. Boston Public Health Commission, “Coronavirus Disease 2019 (COVID-19): The Latest,” BPHC Blog Post, August 10, 2020, https://www.bphc.org/onlinenewsroom/Blog/Lists/Posts/Post.aspx?ID=1282.
- Liz Kowalczyk, “Color Line Persists, In Sickness As In Health,” Boston Globe, December 12, 2017, https://apps.bostonglobe.com/spotlight/boston-racism-image-reality/series/hospitals/.
- COVID Tracking Project and Boston University Center for Antiracist Research, https://covidtracking.com/race.
- Centers for Disease Control and Prevention, “HIV and African Americans,” CDC, https://www.cdc.gov/hiv/group/racialethnic/africanamericans/index.html.
- Centers for Disease Control and Prevention, “Addressing Health Disparities in Diabetes,” CDC, https://www.cdc.gov/diabetes/disparities.html.
- Centers for Disease Control and Prevention, “Reported Tuberculosis in the United States, 2015,” CDC, https://www.cdc.gov/tb/statistics/reports/2015/table2.htm.
- COVID Tracking Project and Boston University Center for Antiracist Research, https://covidtracking.com/race.
- Jessica Bartlett, “The nation’s first community health center celebrates 50 years in Boston,” Boston Business Journal, December 10, 2015, https://www.bizjournals.com/boston/blog/health-care/2015/12/the-nations-first-community-health-center.html. Massachusetts League of Community Health Centers, “History of Community Health Centers,” MLCHC, https://massleague.org/CHC/History.php.
- Elayne J. Heisler, “Federal Health Centers: An Overview,” Congressional Research Service, May 19, 2017, https://fas.org/sgp/crs/misc/R43937.pdf.
- See also: Bonnie Lefkowitz, Community Health Centers: A Movement and the People Who Made It Happen,New Brunswick, NJ: Rutgers University Press, 2007.
- Bradley Corallo and Jennifer Tolbert. “Impact of Coronavirus on Community Health Centers,” Kaiser Family Foundation, May 20, 2020, https://www.kff.org/coronavirus-covid-19/issue-brief/impact-of-coronavirus-on-community-health-centers/.
- Peter Shin, Jessica Sharac, Rebecca Morris, Sara Rosenbaum, and Feygele Jacobs, “As COVID-19 Surges, Health Centers Face Near-Term and Long-Term Funding Instability,” Geiger Gibson / RCHN Community Health Foundation Research Collaborative Data Note, August 3, 2020, https://www.rchnfoundation.org/wp-content/uploads/2020/08/As-COVID-19-Surges-Community-Health-Centers-Face-Near-Term-and-Long-Term-Funding-Instability-8.3.20-1.pdf.
- Dialynn Dwyer, “Community health centers grapple with financial strain, equipment shortages while battling COVID-19 in vulnerable communities,” Boston.com, April 21, 2020, https://www.boston.com/news/coronavirus/2020/04/21/massachusetts-community-health-centers-coronavirus. https://www.boston.com/news/coronavirus/2020/04/21/massachusetts-community-health-centers-coronavirus.
- Steph Solis, “Coronavirus testing expands to 12 community health centers in Massachusetts, governor says,” MassLive, April 22, 2020, https://www.masslive.com/coronavirus/2020/04/coronavirus-testing-expands-to-12-community-health-centers-in-massachusetts-governor-says.html. Sanjay Kishore and Margaret Hayden, “Community Health Centers and Covid-19—Time for Congress to Act,” New England Journal of Medicine, June 26, 2020, https://www.nejm.org/doi/full/10.1056/NEJMp2020576. Bradley Corallo and Jennifer Tolbert, “Impact of Coronavirus on Community Health Centers,” Kaiser Family Foundation, May 20, 2020, https://www.kff.org/coronavirus-covid-19/issue-brief/impact-of-coronavirus-on-community-health-centers/.
- Leana S. Wen and Nakisa B. Sadeghi, “Addressing Racial Health Disparities in the COVID-19 Pandemic: Immediate and Long-Term Policy Solutions,” Health Affairs, July 20, 2020, https://www.healthaffairs.org/do/10.1377/hblog20200716.620294/full/. Tonya Russell, “Racism in care leads to health disparities, doctors and other experts say as they push for change,” The Washington Post, July 11, 2020, https://www.washingtonpost.com/health/racism-in-care-leads-to-health-disparities-doctors-and-other-experts-say-as-they-push-for-change/2020/07/10/a1a1e40a-bb9e-11ea-80b9-40ece9a701dc_story.html.
- Paula Braveman and Laura Gottlieb, “The Social Determinants of Health: It’s Time to Consider the Causes of the Causes,” Public Health Reports, 2014 Jan-Feb, 129 (Suppl 2): 19-31, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3863696/. New England Journal of Medicine Catalyst, “Social Determinants of Health (SDOH),” NEJM Catalyst, December 1, 2017, https://catalyst.nejm.org/doi/full/10.1056/CAT.17.0312.
- Centers for Disease Control and Prevention, “What are social determinants of health?” CDC, https://www.cdc.gov/socialdeterminants/about.html.
- David R. Williams, Jourdyn A. Lawrence, and Brigette A. Davis, “Racism and Health: Evidence and Needed Research,” Annual Review of Public Health 2019, 40:105-25, https://www.annualreviews.org/doi/pdf/10.1146/annurev-publhealth-040218-043750.
- Richard Rothstein, The Color of Law: A Forgotten History of How Our Government Segregated America, New York: Liveright Publishing Corporation, 2017. Alanna McCargo and Sarah Strochak, “Mapping the black homeownership gap,” Urban Institute, February 26, 2018, https://www.urban.org/urban-wire/mapping-black-homeownership-gap. Bruce Mitchell and Juan Franco, “HOLC ‘Redlining’ Maps: The Persistent Structure of Segregation And Economic Inequality,” National Community Reinvestment Coalition, March 20, 2018, https://ncrc.org/holc/.
- Kelly M. Bower, Roland J. Thorpe, Jr., Charles Rhode, and Darrell J. Gaskin, “The Intersection of Neighborhood Racial Segregation, Poverty, and Urbanicity and its Impact on Food Store Availability in the United States,” Preventive Medicine, Volume 58, January 2014, 33-39, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3970577/.
- Lincoln Quillian, Devah Pager, Ole Hexel, and Arnfinn H. Midtboen, “Meta-analysis of field experiments shows no change in racial discrimination in hiring over time,” Proceedings of the National Academy of Sciences, October 10, 2017, 114 (41), https://www.pnas.org/content/114/41/10870.full.
- Andrew McFarland, Ari Ofsevit, Stacy Thompson, Lorraine Fryer, and Mary Buchanan, “64 Hours: Closing the Bus Equity Gap,” Livable Streets Alliance, September 2019, https://www.livablestreets.info/64_hours_report.
- Ihab Mikati, Adam F. Benson, Thomas J. Luben, Jason D. Sacks, and Jennifer Richmond-Bryant, “Disparities in Distribution of Particulate Matter Emission Sources by Race and Poverty Status,” American Journal of Public Health, April 2018, 108(4) 480-485, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5844406/. Harriet A. Washington, “How environmental racism is fueling the coronavirus pandemic,” Nature, May 19, 2020, 581, 241, https://www.nature.com/articles/d41586-020-01453-y. Oliver Milman, “Robert Bullard: ‘Environmental justice isn’t just slang, it’s real,’” The Guardian, December 20, 2018, https://www.theguardian.com/commentisfree/2018/dec/20/robert-bullard-interview-environmental-justice-civil-rights-movement.
- Lynne Peeples, “What the data say about police brutality and racial bias—and which reforms might work,” Nature, June 19, 2020, 583, 22-24, https://www.nature.com/articles/d41586-020-01846-z. Jacob Bor, Atheendar S. Venkataramani, David R. Williams, and Alexander C. Tsai. “Police killings and their spillover effects on the mental health of black Americans: a population-based, quasi-experimental study,” The Lancet, Vol 392, Iss 10144, 302-310, July 28, 2018, https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31130-9/fulltext.
- David R. Williams, “Why Discrimination Is a Health Issue,” Robert Wood Johnson Foundation, Culture of Health Blog post, October 24, 2017, https://www.rwjf.org/en/blog/2017/10/discrimination-is-a-health-issue.html.
- Boston Public Health Commission, “Health of Boston 2016-2017,” Research and Evaluation Office, 2017, see figures 8.7 (asthma), 8.38 (heart disease), 8.26 (diabetes), and 8.46 (hypertension) in particular, https://bphc.org/healthdata/health-of-boston-report/Documents/_HOB_16-17_FINAL_SINGLE%20PAGES-Revised%20Feb%202019.pdf. Centers for Disease Control and Prevention, “Coronavirus Disease 2019: People at Increased Risk—People with Certain Medical Conditions,” CDC, August 14, 2020, https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html#:~:text=Having%20other%20cardiovascular%20or%20cerebrovascular,severe%20illness%20from%20COVID-19.
- Kristen Jackson and Julia Del Muro, “COVID-19, Racism, and Health: Changing Predictable Outcomes,” Boston Medical Center HealthCity Newsletter, April 23, 2020, https://www.bmc.org/healthcity/population-health/coronavirus-worsen-disparities-distrust-black-community.
- City of Boston, “Racial data on Boston resident Covid-19 cases,” August 26, 2020, https://www.boston.gov/departments/mayors-office/racial-data-boston-resident-covid-19-cases.
- Sara Chaganti, Erin Michelle Graves, Amy Higgins, Marybeth J. Mattingly, Sarah Ann Savage, and Catherine Tonsberg, “The Effects of the Novel Coronavirus Pandemic on Service Workers in New England,” Federal Reserve Bank of Boston, Community Development Issue Briefs, March 31, 2020, https://www.bostonfed.org/publications/community-development-issue-briefs/2020/the-effects-of-the-novel-coronavirus-pandemic-on-service-workers-in-new-england.aspx.
- Irina Ivanova, “As states reopen, black workers are at greater risk for COVID-19,” CBS News, June 16, 2020, https://www.cbsnews.com/news/black-workers-lives-essential-frontline-jobs-risk-coronavirus-reopening/.
- Michele K. Evans, Lisa Rosenbaum, Debra Malina, Stephen Morissey, and Eric J. Rubin, “Diagnosing and Treating Systemic Racism,” New England Journal of Medicine, July 16, 2020, https://www.nejm.org/doi/full/10.1056/NEJMe2021693.
- Vanessa Northington Gamble, “Under the Shadow of Tuskegee: African Americans and Health Care,” American Journal of Public Health, November 1997, Vol. 87, No. 11, https://ajph.aphapublications.org/doi/pdf/10.2105/AJPH.87.11.1773.
- Vann R. Newkirk, “A Generation of Bad Blood,” The Atlantic, June 17, 2016, https://www.theatlantic.com/politics/archive/2016/06/tuskegee-study-medical-distrust-research/487439/.
- Equal Justice Initiative, “Racial Eugenics,” EJI, https://eji.org/news/history-racial-injustice-racial-eugenics/.
- Association of American Medical Colleges, “Diversity in Medicine: Facts and Figures 2019,” AAMC, Figure 18, https://www.aamc.org/data-reports/workforce/interactive-data/figure-18-percentage-all-active-physicians-race/ethnicity-2018.
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