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History, In the News, Stanford News

Remembering Kenyan statesman and Stanford medical school alumnus Njoroge Mungai

Remembering Kenyan statesman and Stanford medical school alumnus Njoroge Mungai

MungaiOn a visit to Kenya in 2005, I spent an extraordinary afternoon with Njoroge Mungai, MD, one of the country’s elder statesmen and a 1957 graduate of Stanford medical school. It was one of the most memorable experiences of that trip, so it was with bittersweet sentiment that I learned over the weekend that Mungai had passed on at the age of 88.

Mungai was one of the founders of modern Kenya and served the young East African country in many leadership capacities, including ministers of defense, foreign affairs, health and environment and natural resources. He helped establish the nation’s regional health care system, as well as its first medical school, which is based at the University of Nairobi.

I met Mungai on a trip to Kenya with my longtime friend and documentary photographer Karen Ande, in which we were interviewing families and children affected by AIDS. We had just spent several days with orphaned teens who were taking care of young siblings in a gritty slum neighborhood of Nairobi.

We then headed to the outskirts of the capital city to Mungai’s 45-acre estate, where he was growing roses for export. We were greeted in the expansive foyer by a stuffed lion as Mungai, a slim dapper man in a grey suit, arrived from a side door, his cane quietly tapping the floor.

We had expected perhaps an hour of his time for an interview for Stanford Medicine magazine, but it stretched well into the afternoon. After drinks on the patio, he invited us to a sumptuous buffet in a room peppered with photos of him with some of the world’s great leaders of the time.

With the air and caution of a diplomat, he told us stories of his life – from his humble beginnings as the son of a cook to his schooling in South Africa and the United States and his leadership in the revolution that led to the establishment of the Kenyan nation in 1963.

A cousin of the first Kenyan President Jomo Kenyatta, Mungai was particularly proud of his role in helping Kenya maintain a neutral stance while the world powers were creating chaos in neighboring countries in their eagerness to carve out their positions in Africa. He was also proud of his work in bringing the United Nations Environment Program to Kenya, the only country outside the West where the world organization has a presence.

We left him in the fading light of day with four dozen beautiful roses, a gift from a very gracious man.

Photo by Karen Ande

From August 11-25, Scope will be on a limited publishing schedule. During that time, you may also notice a delay in comment moderation. We’ll return to our regular schedule on August 25.

Medicine and Literature, Stanford News, Surgery

The operating room: long a woman’s domain

The operating room: long a woman’s domain

In my recent story for Stanford Medicine magazine on the transformational changes in surgery, I reported that “women were once personae non gratae in the operating room.” An alumna of the medical school, Judith Murphy, MD, took me to task for my choice of words, for as she points out, women have long been the backbone of the OR.

“In fact, for decades, women outnumbered men in the OR – circulating nurse, scrub nurse, overseeing nurse, etc.,” she wrote to me. “So it is not that there were no women in the OR, but there were no women surgeons. No Women Who Count, although everyone knows these nurses are essential to successful surgery.”

When she was a medical student at Stanford in the early 1970s, she says female students and faculty had to use bathrooms and lockers that were labeled “Nurses,” whereas the men’s room was labeled, “Doctors.”

“We all laughed about it, but it did reflect the unconscious assumptions that your language still perpetuates, all these years later and after so much progress,” she shared with me. “The women who came after us were a bit more empowered and did not think it was funny; they complained, and the doors were changed to Men and Women.”

Murphy, a practicing pediatrician in Palo Alto for decades, says she might not have made note of the issue were it not for a recent encounter with a male acquaintance who, on learning she was connected to Stanford Hospital, said, “I never knew you were a nurse.”

“When he said that, I thought, ‘Darn, I can’t believe this is still happening.’ I gave him my usual response: ‘I have great respect for nurses and could never have done as good a job without them, but in fact, I’m a doctor,’” said Murphy, who is now retired.

“The power of the cultural unconscious assumption remains strong, even here where we have come so far,” she wrote. “This has been happening to me occasionally for 40 years, less so lately. I had hoped it would become archaic.”

Murphy says her response may have been a bit testier than in the past. But she can be excused, for it is always good to be reminded of our unconscious biases about the role of women in health care, reflected both in our language and behavior.

Previously: Surgery: Up close and personal and Stanford Medicine magazine opens up the world of surgery

From August 11-25, Scope will be on a limited publishing schedule. During that time, you may also notice a delay in comment moderation. We’ll return to our regular schedule on August 25.

Global Health, Infectious Disease, Stanford News

Stanford global health chief launches campaign to help contain Ebola outbreak in Liberia

Stanford global health chief launches campaign to help contain Ebola outbreak in Liberia

A Medical Officer at Lacor hospital in Gulu, 360 kilometers (224 miles) north of the Ugandan capital, Kampala examines a child suspected of being infected with the Ebola virus Tuesday, Oct.17, 2000. Only days after it was announced that an outbreak of Ebola, the world's most feared virus, had struck in northern Uganda the death toll rose to 35 and according to health officials 38 other people have been affected by the virus. (AP Photo/Sayyid Azim)Michele Barry, MD, director of Stanford’s Center for Innovation in Global Health, has launched a fundraising campaign to help combat the Ebola outbreak in Liberia, which has claimed the life of a colleague who mentored residents in the Yale/Stanford Johnson & Johnson Scholars Program.

Samuel Brisbane, MD, was the first Liberian doctor to die in the outbreak, which the World Health Organization says is responsible for more than 700 deaths in West Africa and is by far the largest outbreak in the history of the disease. Brisbane was an internist who treated patients at the John F. Kennedy Memorial Hospital in the capital city of Monrovia, the country’s largest hospital. A second medical officer has become ill at the hospital, one of the sites for the scholars’ program, Barry told me.

Through the program, Brisbane mentored physicians from Stanford and other institutions who volunteer for six-week stints in resource-limited countries. He quarantined himself after showing signs of illness but died on July 26 after being transferred to a treatment center, Barry said.

Like HIV, the Ebola virus is spread through direct contact with blood or body fluids from an infected individual. Barry said Liberia is in desperate need of personal protective equipment for health care workers, such as masks, gowns and gloves, as well as trained personnel who can do contact tracing and isolation of infected individuals. The Ebola virus has a 21-day incubation period, during which time an infected individual can transmit the virus.

Barry joined an informal fundraising campaign with her colleagues on Tuesday to help Liberian health-care workers contain the spread of the disease, raising $11,000 in 48 hours. Today, she broadened the appeal in an e-mail sent to all Stanford medical school faculty.

Barry has had experience fighting Ebola in Uganda, where she said outbreaks have been limited by isolating patients in outdoor, tented hospitals and where physicians and nurses have had access to good protective gear. In the past, she said the disease typically has had “hot spots” that last a month and then subside.

But the latest epidemic, which has affected patients in Guinea, Sierra Leone and Nigeria, as well as Liberia, has followed a somewhat different path.

“I think we are doing a better job of taking care of patients and keeping them alive longer, so they become more viremic — meaning the virus has spread through their bloodstream — and more infectious,” she said. “And with globalization, there is more traffic across borders so spillover to other countries occurs.”

She said she does not see the disease as a major threat to the United States, where effective infection control methods are widespread.

“I think we need to be vigilant, but I don’t think there needs to be any true concern that this is going to spread to the United States,” she said. “There’s always a risk of a patient coming in unknown to the hospital, but we practice good universal precautions because we have the equipment and we’ve been trained to treat HIV.”

Donations to the health-care project can be made online here.

Photo, from 2000 outbreak in Uganda, by ASSOCIATED PRESS

Medicine and Literature, Patient Care, Stanford News, Surgery

Surgery: Up close and personal

Surgery: Up close and personal

gholami - smallTens of millions of patients undergo surgery every year in the United States, yet very few have the opportunity to be on the other side and observe a surgical procedure in action.

I had that rare privilege recently in the course of writing a story for Stanford Medicine magazine about surgery and how far the field has come in recent decades. The operating room, I discovered, is a world unto itself. It’s governed by a strict set of rules to help safeguard patients, but within those strictures, there is an elaborate kind of dance and much artistry in the way clinicians work together and finesse the tools to help heal their patients.

Sepideh Gholami, MD, a six-year surgery resident at Stanford who is featured in the story, said it was in part this sense of artistry – the movement, rhythm and pacing – that attracted her to the profession. And like many surgeons, she found it gratifying to be able to use her hands to fix a problem to quickly restore a patient’s well-being. She describes one of her early experiences, assisting in a procedure to remove a life-threatening tumor from a young man’s colon.

“I remember going to the family afterward, saying that we were able to get it all out, and seeing the glow in their faces,” she told me. She said it was reminiscent of the experience of her own mother, who had a tumor extracted from her breast: “This is how it happened for my mom, who is now disease-free,” she said.

In the story, Gholami talks about her rather unusual path from an early childhood in revolutionary Iran to becoming a surgeon in the United States, as well as the changes in the profession that have opened the way  to young women like her. The story also explores the remarkable innovations in technology that have made the patient experience today far less invasive and less painful. Those innovations, as well as new workplace rules that limit trainees’ hours, have dramatically changed the way young surgeons like Gholami are being trained to become the independent, skilled practitioners of the future.

Previously: Stanford Medicine magazine opens up the world of surgery
Photo of Gholami by Max Aguilera-Hellweg

Cancer, Genetics, Research, Stanford News

Stanford partnering with Google [x] and Duke to better understand the human body

Stanford partnering with Google [x] and Duke to better understand the human body

Most biomedical research is focused on disease and specific treatments for illness, rather than on understanding what it means to be healthy. Now researchers at Stanford, in collaboration with Duke University and Google [x], are planning a comprehensive initiative to understand the molecular markers that are key to health and the changes in those biomarkers that may lead to disease. The project was featured in a Wall Street Journal article today.

The study is at the very early stages, with researchers planning to enroll 175 healthy participants in a pilot trial later this year. The participants will undergo a physical exam and provide samples of blood, saliva and other body fluids that can be examined using new molecular testing tools, such as genome sequencing.  The pilot study will help the researchers design and conduct a much larger trial in the future.

“We continue as a global community to think about health primarily only after becoming ill,” Sanjiv Sam Gambhir, MD, PhD, professor and chair of radiology, told me. “To understand health and illness effectively, we have to have a better understanding of what ‘normal’ or ‘healthy’ really means at the biochemical level.”

“The study being planned will allow us to better understand the variation of many biomarkers in the normal population and what parameters are predictive of illness and may eventually change as a given individual transitions from a healthy to a diseased state. This will be a critical study that will likely help the field of health care for decades to come,” said Gambhir, who also directs the Canary Center at Stanford for Cancer Early Detection.

The researchers hope the work will provide insights on a variety of medical conditions, such as cancer and heart disease, and point to new methods for early detection of illness. Their studies will focus on the genetic basis of disease, as well as the complex interplay between genes and environment.

These kinds of studies haven’t been done before because of the cost and complexity of molecular measurement tools, the scientists say. However, the cost of some technologies, such as DNA sequencing, has been steadily declining, while some new tools and new ways of analyzing large quantities of data have just recently become available. So a first step in the study is to determine how best to use these technologies and determine what questions need to explored on a larger scale.

The work is sponsored by Google [x] and will be led by Andrew Conrad, PhD, a cell biologist and project manager at the company.

HIV/AIDS, In the News

Mourning the loss of AIDS researcher Joep Lange

Stanford researchers specializing in HIV/AIDS mourned the loss today of Dutch scientist Joep Lange, MD, PhD, a leading AIDS researcher who died in the Malaysian Airlines crash yesterday in Ukraine. Lange, a virologist, was particularly well-known for his work in helping expand access to antiretroviral therapy in developing countries. He was among dozens of people on the ill-fated flight who were heading to the 20th International AIDS Conference that opens Sunday in Melbourne, Australia.

“We are all in a state of shocked disbelief here in Melbourne at the tragic loss of one of the giants in the global fight against AIDS and HIV,” Andrew Zolopa, MD, professor of medicine at Stanford, told me in an e-mail from the conference site. “I have known Joep Lange for more than 25 years – he was a friend and a colleague.  Joep was one of the early leaders in our field to push for expanded treatment around the globe – and in particular treatment for Africa and Asia… The world has lost a major figure who did so much good in his quiet but determined manner.  I am shocked by this senseless act of violence. What a terrible tragedy.”

David Katzenstein, MD, also an HIV specialist at Stanford, learned of the death while in Zimbabwe, where he has a long-standing project on preventing transmission of HIV from mother to child. He said Lange, a friend and mentor, had been a “tireless advocate for better treatment for people living with HIV in resource-limited settings. He was universally respected and frequently honored as a real pioneer in early AIDS prevention and treatment.” In 2001, Lange founded the PharmAccess Foundation, a nonprofit organization based in Amsterdam, which aims to improve access to HIV therapy in developing countries. He continued to direct the group until his death.

Lange served as president of the International AIDS Society from 2002 to 2004 and had been a consultant to the World Health Organization, the federal Centers for Disease Control and Prevention and the National Institutes of Health. He led several important clinical trials in Europe, Asia and Africa and played a key role in many NIH-sponsored studies, said Katzenstein, a professor of medicine.

“He was a gentle, thoughtful and caring physician-scientist with a keen sense of humor and a quick and gentle wit. He was constantly absorbing, teaching and thinking about the human (and primate) condition and psychology,” Katzenstein told me. “He was much loved and will be sorely missed.”

Nutrition, Pediatrics, Public Health

Who’s hungry? You can’t tell by looking

child for hunger post2How can you tell if a child is hungry? Well, looks alone don’t tell the story.

That’s the message of a new photo exhibit on child hunger, which opened May 22 at San Francisco City Hall. The exhibit includes 20 photos of Bay Area children, who all appear to be healthy and well-fed. But half of them qualify as “food insecure,” meaning they and their families often go without enough to eat. In fact, one of four children in California lacks adequate food and may suffer the ache of hunger, what pediatrician Lucy Crain, MD, MPH, and her colleagues are calling a “silent epidemic.”

“I think people don’t want to focus on the prevalence of hunger and poverty. But we have to get it out in the open and acknowledge that it’s there. There shouldn’t be one child that goes to bed hungry for lack of food,” said Crain, who is an adjunct clinical professor of pediatrics at Stanford. Crain helped organize the exhibit, part of a larger campaign of the Child Health Advocacy Committee of the Northern California Chapter of the American Academy of Pediatrics to end childhood hunger.

The campaign was begun in response to the recent recession, when committee members all were reporting increased rates of hunger among their patients, said Lisa Chamberlain, MD, MPH, an assistant professor of pediatrics at Lucile Packard Children’s Hospital Stanford and founder of the advocacy group. Then in 2013, Congress threatened to eliminate the Supplemental Nutrition Assistance Program, which includes food stamps, on which millions of families depend. Congress did decrease the program benefits, with the result that more families and children are hungry and food banks are scrambling to keep up with demand, said Crain, who recently retired from her practice at Lucile Packard Children’s Hospital Stanford, where she treated children with disabilities.

child for hunger postAt one meeting, the pediatrician activists were struck by the fact that it is hard to tell which patients were hungry, noting, “You just can’t tell by looking – it’s all around us.” They decided to draw attention to the problem among legislators and the public at large and increase awareness among pediatricians and other health care professionals, who often fail to screen children for hunger issues. Children who lack adequate food, particularly those younger than age 3, may have developmental problems and are more likely to be in poor health as they grow up, studies show.

To illustrate the problem, the group enlisted the help of San Francisco documentary photographer Karen Ande, who has won awards for her work in photographing children in Africa (Karen happens to be a friend of mine who collaborated with me on a book on AIDS in Africa). She volunteered her time for the project, in which she shot photos of 20 children at a health fair and in neighborhoods in San Francisco. The project team screened the same children for hunger issues using the two most reliable questions from a survey developed by the U.S. Department of Agriculture. Half of the children were found to be food insecure.

“The real power of these photos is that you can’t tell by looking who screened positive for food insecurity and who did not,” said Crain, who is also a clinical professor emerita at UCSF.

The advocacy group is recommending to the American Academy of Pediatrics that its guidelines include screening for food insecurity as part of routine child health visits. If pediatricians know a family has inadequate food, they can refer parents to local resources, such as food banks and food pantries, or encourage them to apply for CalFresh, the state’s food stamp, supplemental nutrition program, Crain said.

As part of its campaign, the group also is preparing posters to be delivered to 2,000 Northern California pediatricians, as well as a BART display of the children’s photos. Collaborators in the project include the Food Security Task Force of the San Francisco Department of Public Health, the San Francisco Food Bank, WIC, CalFresh and the San Francisco Unified School District, all working to help achieve San Francisco Mayor Ed Lee’s goal of eliminating widespread hunger in the city by 2020.

Previously: Could a palm oil tax lower the death rate from cardiovascular disease in India?Lucile Packard joins forces with Ravenswood School District to feed families during the summer breakDoctors tackling child hunger during the summer and Annual federal statistics on children’s well-being released

Photos by Karen Ande

Global Health, Health Policy, Public Safety, Women's Health

Lobbying Congress on bill to stop violence against women

Lobbying Congress on bill to stop violence against women

capitol - smallWhen I walked into the U.S. Capitol building this week, it was with the weight of history – my own and my country’s. Years ago, I had walked these hallowed halls as a writer for a Congressional publication and had lived in a house just blocks away. But this time I was there for a very different purpose: I was going to try my hand at lobbying, plying Congress for a cause that had become dear to my heart.

I came to Washington, D.C. with nearly 150 volunteers and staff from the American Jewish World Service, an international development organization that promotes human rights and works to end poverty in the developing world. This year, one of the group’s legislative priorities is passage of the International Violence Against Women Act, now pending in Congress. In February, I had traveled to Uganda as a Global Justice Fellow with AJWS, learning first-hand why this bill is so crucial to the lives of women around the world. I met a gay woman whose life had become hell because of her gender identity; she’d been beaten, raped and robbed and was suffering the emotional trauma of being ostracized by family and community. I also met sex workers, many of them single mothers just trying to make a living, who had been subjected to unprovoked beatings and police brutality. And I met a transgender woman whose home had been burned to the ground and who had been terrorized by her community simply because of who she was. In fact, I would learn that one in three women around the world are beaten, abused or raped at some point in their lifetime – an appalling figure.

The bill would help combat this trend by using the full force of U.S. diplomacy, as well as existing U.S. foreign aid funding, to support legal, social, educational, economic and health initiatives to prevent violence, support victims and change attitudes about women and girls in society. When women become victims of violence, everyone suffers; gender-based violence can reduce a nation’s GDP by as much as 3 percent because women are so key to collective productivity.

“If you want to get a barometer on how a country will fare – its stability – just look at the way it treats its women,” Sen. Ben Cardin (D-Maryland) told our group as we prepared to head out to visit Members of Congress. “Women invest in children and family. Men invest in war.”

With the recent kidnapping of more than 250 Nigerian school girls, the need for the legislation has become all the more pressing. “This is the moment to strike,” Sen. Barbara Boxer (D-Calif.) said during a meeting with 20 members of our group. We met with Boxer in the sumptuous President’s Room in the U.S. Capitol, adorned with gilt, frescoes and historical portraits and the spot where Abraham Lincoln and Martin Luther King once stood. Boxer had just come from a vote on several new judges and was gracious enough to stop by to spend 20 minutes listening to our pitch and discussing strategy.

A strong women’s rights activist, she has been an ardent supporter of the bill from the start. With 300 nonprofit groups now clamoring for its passage, she said she felt it was time to introduce it into the Senate, which she did a week ago. It’s now critical, she said, to enlist additional Republican co-sponsors of the legislation, particularly among members of the Senate Foreign Relations Committee, to give it greater weight and bipartisan appeal. In the House, the bill already has 63 Democratic and 11 Republican co-sponsors, with more being sought.

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Global Health, HIV/AIDS, Research, Stanford News

Foreign aid for health extends life, saves children, Stanford study finds

Foreign aid for health extends life, saves children, Stanford study finds

Kenyan child pic - smallMany people are deeply skeptical of foreign aid, believing that these monies often wind up in the pockets of corrupt leaders or never make it down the chain of bureaucracy to the people who really need it. But a new Stanford analysis of both government and private aid programs shows that health aid has been extremely effective not only in extending the lives of people in developing countries but also saving the lives of children under age 5.

Lead researcher Eran Bendavid, MD, said foreign aid programs had their biggest impact between 2000 and 2010, when investments in health reached their peak. During that time, the U.S. government launched its hugely successful initiative, the President’s Emergency Plan for AIDS Relief (PEPFAR), while other private groups, such as the Gates Foundation, stepped up investments in health as well.

During that time, low-income countries receiving aid saw a dramatic decline – between 26 and 34 percent – in the number of children who died before their 5th birthday. With just a 4 percent increase in aid, or $1 billion, foreign aid could continue to have a major impact on child mortality, Bendavid said.

“If health aid continues to be as effective as it has been, we estimate there will be 364,800 fewer deaths in children under 5,” Bendavid said. “We are talking about $1 billion, which is a relatively small commitment for developed countries.”

He said many people may find the results surprising. “But for me, it fits with other evidence of the incredible success of public health promotion in developing countries,” he said. For instance, he did a study in 2012 which found that more than 740,000 lives were saved between 2004 and 2008 in nine countries as a result of the PEPFAR program. Other technologies, such as diphtheria, tetanus, measles and polio vaccines for children and insecticide-treated bed nets to prevent malaria, all have contributed to better health among adults and children in low-income countries.

He and colleague Jay Bhattacharya, MD, PhD, also found that aid programs had a lasting impact. The signs of aid’s impact on child mortality were measurable for three years after aid was distributed, while the link between aid and longer life expectancy was detectable five years after aid was made available, the researchers reported.

Previously: Stanford study: South Africa could save millions of lives through HIV prevention and PEPFAR has saved lives – and not just from HIV/AIDS, Stanford study finds
Photo by Karen Ande

Global Health, HIV/AIDS, Women's Health

Preventing domestic violence and HIV in Uganda

Preventing domestic violence and HIV in Uganda

Ugandan dancers - 560

The woman was terrified, as she had just come from the hospital, where she discovered she was HIV-positive. It wasn’t so much the virus she feared, as the reaction from her husband. If he were to find out, he would surely beat her and throw her out of the house.

As predicted, the husband arrived home and seeing his wife in distress, forced her to confess what she had learned. “Either I cut you in two pieces and throw you in the ditch or leave the house,” he yelled, his arm raised in threat.

Fortunately, the wife wasn’t harmed, for the drama was merely that – a work of street theatre designed to break the traditional patterns of domestic violence and HIV in Uganda. The drama is one of the creative strategies being used by the nonprofit Center for Domestic Violence Prevention in Kampala, Uganda to effectively reduce incidents of domestic violence by more than 50 percent in the communities it serves.

In the process, group also aims to reduce the incidence of HIV, which affects 7.2 percent of adults in the East African nation, according to the latest figures from the United Nations Joint Programme on HIV/AIDS.

The organization works by mobilizing local men and women and training them in various interventions, like the street drama, address pervasive problem of violence among intimate partners. According to its figures, 59 percent of women between the ages of 15 and 49 say they have experienced physical or sexual violence by a husband or partner at some point in their lives.

“We are talking about an epidemic,” said Tina Musuya, a social worker and a women’s rights activist who directs the organization.

I was fortunate to see the street theatre program in action during a recent trip to Uganda with the American Jewish World Service, an international development organization that works to end poverty and promote human rights in the developing world. Fifteen of us, all Global Justice Fellows with the organization, visited CEDOVIP’s offices in Kampala and then fanned out to see the group’s work in action in the streets of Kampala one sunny afternoon.

A crowd had already begun to materialize by the time we arrived in one of the city’s poor neighborhoods, where three drummers had lured people from their homes with a lively beat. Two female dancers in colorful red outfits (pictured above) then entertained the crowd, whose curiosity was heightened by the presence of us five white foreigners. By the time the drama began, more than 100 people had gathered in the dirt road – youngsters who tugged at our hands, older women who sat on wooden stools to watch and groups of men who stood on the sidelines, quietly assessing the unfolding drama.

The story begins when the woman returns from the hospital to cry on a neighbor’s shoulder. The husband then arrives and suspects something is up. He falls into a rage on learning the wife’s news, threatening to “break her bones” and ordering her to leave the house. But the wife says she has nowhere to go. Besides, she tells him, she acquired the virus from him.

A narrator, dressed in an orange shirt, periodically freezes the drama, soliciting suggestions from the crowd on what the couple should do. One observer tells the woman to call the police. Another urges bystanders to intervene to help save the situation.

“We have so many instances of violence in our neighborhood,” the narrator concludes, speaking in Luganda while our host translates. “See what happens in violent situations when the woman becomes HIV-positive. Be supportive. Support the victims, but also support the man. Change the behavior. Break the silence.”

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