Does poverty cause ACEs? Or do ACEs cause poverty?

 Street children, Jacob Riis photo, New York City, 1890

An article about a poverty simulation had me thinking about the belief that poverty causes ACEs. Dr. Vincent Felitti once said he thought ACEs cause poverty. Dave Ellis, a consultant and an ACEs master trainer in Minneapolis, said he thought poverty was a symptom of ACEs. 

 

The discussion about poverty usually focuses the spotlight on the individual. “Take a 19-year-old African-American single mother who dropped out of high school”….is often how people start the conversation. 

 

But the poverty simulator clearly shows that, once people live in poverty land, the systems that serve them collectively make a barrier — not a bridge — for them and their children to become economically healthy. 

 

The writer, simulating a 19-year-old single mom high school drop-out with a one-year-old child, was trying to find child care, housing and a job while living in a homeless shelter, then…

 

Upon returning to the shelter, I see a strongly worded notice from the state saying I needed to get to the family services agency immediately to re-certify my benefits, or risk losing them. So the next day I head there, Harvey, hungry and irritable, in tow, and find a long line. I must fill out a detailed form, and the counter closes just as I go to submit it. I’m told to come back the next day.

 

And that’s about when I realize I haven’t even budgeted time to shop for anything resembling healthy food for the family….I’m feeling a pit in my gut, the calling card of stress—increasingly anxious and irritable.

 

Summarizing, the author says: 

 

Bland's [Michelle Bland, manager of educational theatre at the Kaiser Foundation] first experience with the simulation was putting students through it who were studying nursing, criminal justice, or social services, to show them the day-to-day experiences of individuals living with low income.

 

He could also have said: “….to show them the disorganized, disjointed, and hope-sucking system we’ve created to serve poor people.” 

 

Economically poor adults tend to have high ACE scores. Traumatized as children, they were further traumatized by education, faith-based, healthcare, social service and juvenile justice systems that suspended, expelled, blamed, shamed, misdiagnosed, drugged, or further punished them to try to change their behavior. Hey! It didn’t....doesn’t...work. 

 

Our systems — whether they are populated by good-hearted people or not — corral a steady stream of children with high ACE scores into adult poverty (and/or healthcare and prisons). The systems that serve the adult poor continue the blame game. They tell the poor “It’s your fault!”, and make it as difficult as possible to climb out. 

 

So, do ACEs cause poverty? Or does poverty cause ACEs? Outside of natural disasters, systems exacerbate and cause poverty, which cause ACEs. Systems exacerbate and cause ACEs, which lead to poverty. We create those systems. As Louise Godbold, co-director of Echo Parenting & Education, says: Chicken or egg, no one’s getting out of the hen house the way it is now.  

 

(Besides changing our education, faith-based, healthcare, social service, and juvenile justice systems)…couldn’t we create a system for the economically poor like the one that Gilbert Gonzalez, the director of the Bexar County Mental Health Department, created for the mentally ill in San Antonio, TX? He brought together jails, hospitals, courts, police and mental health departments to create one integrated system that treats clients/patients with respect, that acknowledges their hard lives and the incredible strength it took to survive.

 

It regards them as valued customers and members of the community who deserve the services they need to become healthier. One good reason to do so is because our systems, in their collective ignorance — before we understood the consequences and biology of ACEs — didn’t provide those services when the adults, as children, (and their own parents) first cried out for help. 

 

ACEsConnection members, I really want to know what you think. On the right track? On the railroad spur heading for dead end? Or is there something creative like this happening in a community somewhere?

 

Please leave your comments below!

 

 

 

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I remember a quote of F. Scott Fitzgerald in Charles Hampden-Turner's Book: "Radical Man: The Process of Psycho-Social Development":..."The Children in Appalachia and Mississippi have been starving for centuries, but only recently have we chosen to see them."

The U.S is the only nation besides Somolia that refuses to ratify the UN convention on the rights of the child. I was a child slave in America. My parents told me so - I wanted to divorce them .... They could divorce each other. I survived by telling my self , my emancipation is near if they don't kill me first. I survived by telling myself at least I am not one of those skinny kids in Ethiopia dying of absolute starvation w/no hope of escape or the boy from Detroit sold as sex in exchange for crack who got AIDs. Kids are treated similarly even in the US and no one does anything because kids are property. I wrote this letter to my parents where I told them that I wanted a chip implant under the skin of every kids leaving the hospital that would automatically pick up child abuse so people like them could not continue. I still wish this were possible even if it is not possible but who protects the children? I don't know if ACEs made my parents poor... My grandpa had a hardware and my dad worked for him and sold combines, tractors and other farm equipment. They lost the business because no one was making anyone pay for the equipment and after grandma died there was definitely no one to collect.. She was a woman but would go around harassing people to pay. Less than 1 year after her death, they were out of business.  But if ACEs cause poverty- how did I leave it? Things are no where perfect here but I have far more than the nothing growing up (we had a broken down trailer, rats in it, little food except mystery meals, no indoor plumbing. Very unsanitary.  Now I have a car and can eat. Poverty at an extreme level where basic needs cannot be met is an adversity for kids and parents. At this level you get: dad punches mom, mom smacks kid, kid kicks dog, dog bites cat etc .... Or families at times resort to using children help get them money which may be more common in poorer countries but many kids are sold into the sex trade to help families deal w/poverty...... this is an adversity. It happens here too when parents are so burdened with the stress of not being able to survive they go down the slippery slope of selling their kids to survive.  It really doesn't matter if ACEs cause poverty (they do) or poverty causes ACEs (it does) and extreme poverty w/o loving parents is one of the most potent ACEs there is....TANF and food stamps bring one only to sbout 60 percent of federal poverty level but one needs about 200 percent to survive.... When people who want more tax breaks for themselves and successfully place blame on the millions of working poor or the 'free shit army' mothers w/young children ... They need to know about their corporate welfare and realize they are the fattest cats in the "free .....army".  Even middle class who complain about the same people as lazy etc should realize well maybe we should do away with unemployment benefits ... I have never used that and it sounds like free "shit" to me....

People are not seeing or are incapable of seeing or refuse to see the hypocrisy in their actions and deeds and wish to blame the poor but the safety nets for the poor are so thread bare that if you took them all away you may be able to buy a couple more special bombers or drones and kill more people w/war. But after you have your two bombers don't expect more from the poor .....they may have absolutely nothing in the way of the basics, they may die in mass of starvation but at least they could keep their dignity. (See Marian Edleman how to decrease child poverty by 60 percent).

Jim raised a very important point: "Children's Rights. Some time ago, I read an article by a Connecticut Jurist, who noted we (the U.S.A.) are the only "industrial democracy" on Earth, that does not include Children's Rights in our National Constitution. Not knowing the entire content of the Iroquois "constitution", but that they articulated Women's Rights to Assert, Debate, Vote, and Declare War (and care for returning "veterans"), almost 1,000 years before we (the USA) amended our constitution to avail Women the Right of Franchise, I'd be curious if they addressed Children's Rights in any form. When I looked at the World Health Organization's 2013 survey of the world's Healthiest Children (they used the ACE screening criteria in this 2013 assessment), the Netherlands was #1, followed by the Scandinavian nations and Iceland, and the U.S. was 25th, and Canada 26th, if my recall is correct. I believe some of our Canadian ACEsConnection members may be able to advise what if any reference to children's rights appear in the Canadian constitution. I thought I had seen an ACEs Connection Blog noting the (a committee of the) American Bar Association was collaborating with the American Psychological Association to address part of this issue. Some of the "Trauma-Informed Checklists for Family Court Justices" may be of use in developing some clarity on this issue. I may also try to get further particulars on this issue later.

Until we get honest about poverty, I fear we will continue the wasteful spending that Jim is speaking about that is happening at the federal AND states level.  If we believe that every life is important, we should advocate to protect and care for children after they are born as much as we advocate for life.  If we believe that families are important for healthy and vibrant children - kids who are "ready" for school and are successful, excited life-long learners - then we have to support them and make it easier for them to be parents to be present and available for their kids, to put good food on the table three times/day, have a roof over their heads and healthcare.  We should make sure that good quality childcare is available and affordable.  We should talk parents UP and not denigrate them, which only spills over to their kids causing more blame and shame.  We should champion every child's ability and right to succeed, to cultivate passion and make choices for themselves that takes them where they want to be.  We need to celebrate those who work with kids and pay them well for their talent, commitment and time.  When negative things are said about people in poverty, we should be able to counter them, to correct the message with facts immediately and demand retractions.  If we put children and families first, we would have more than enough money to do what needs to be done.  We all know that.  We are a nation of plenty.  Right now, we are squandering our plenty for the benefit of a few. Non-profits and churches and volunteers can only do so much .... government at all levels needs to be a willing partner at the table here and put money where our priorities and needs are.

Jane, I think the article that you posted in the Faith-based group says it all. We are becoming a society in which our attitude to social issues is... "whatever."  What is the bottomline to helping others find their self-worth, their value, and to have hope? Being connected to caring adult relationships that model trust, safety, connection, and hope. It is the same approach whether ACEs are the cause of poverty or poverty is the main cause of ACEs, people deserve to be valued and loved so that they can become the special individual they were meant to be.  We have the research and the blueprint to address this number one chronic health issue in our country, but we don't have the advocacy or fellow citizens screaming for justice.  My hope is that every one of us who is working on behalf to those who have been wounded by ACEs & poverty, that we become the voice, we demand that our most vulnerable get the support and services they need in order to lift up their heads and see their value. Our media is projecting a failed educational system in our country and implementing punitive policies to hold people accountable to an ideology rather than evidenced-based research. These political attacks on teachers, filters down to our children and they pay the ultimate price.  It does not matter what state I travel too, the stories are the same. We have too many people in pain, and our system only adds to the wound, we aren't doing anything to treat the wound. The critical piece of civil rights that is missing....is children's rights. Until we as a coalition of loud voices begin to demand justice, we remain a society that looks at those who need us most as...."whatever."  The members of this website are incredible resources and people of passion.  I believe it is time to step up and become one loud voice in collaboration and unity.  I appreciate the work that is shared daily on ace connections, and I appreciate the voice that is building across the country to advocate for the individuals we love unconditionally.  Approximately $9,200 a year to educate a child, $62,000 a year to house an inmate. The loud voice getting the attention is the $9,200 and the failure of education. I would say that $62,000 a year for housing inmates is a failure to follow what the research is telling us we need to do in order to make a difference in our country.  

When I served on the board of the NH Coalition for the Homeless (later Coalition To End Homelessness) we invited the 400 member state legislature and 24 member state senate to a "Welfare Simulation" exercise. One of the "impartial judges" was our state American Friends (Quaker) Service Committee director. A substantial number of the legislators showed up, some legislators complained that you couldn't survive without "cheating", but I have an appreciation for simulation exercises.

When we had a state Employment Security (unemployment) office in our city, they hosted a monthly "Wrap Around" meeting of representatives from a host of other local and state agencies to compare notes and Wrap Around appropriate services for clients from each agency, similar to what is noted in this poverty post going on in San Antonio, Texas.

Currently, our City Recreation Department hosts a weekly farmers market, and managed to get SNAP card terminals for the vendors to be able to accommodate Food Stamp recipients. It's increased sales for the farmers and vendors. During the cold season, a nearby church avails a large meeting room for the Farmer's market. 

There are a number of other positive community initiatives here, but I think we can find other factors which increase the stress and degradation that accompany Poverty. As one social psychologist noted, our individualistic culture doesn't ask "What" questions from an epidemiological perspective, only "Who" questions of the Heroic and Undesirable, and three primary institutions (Law, Medicine, & Religion) have their "criminals", "sick", and "sinners" and assorted Heroes. How do we view "What" causes poverty, what mitigates it with resilience building strategies, and what Alleviates it. My national service involved two "tours" in the War on Poverty, as a VISTA Volunteer. Can we look at the Alternative Economics strategy used in Anacostia/Washington, D.C. to start a Community Development Credit Union, and inviting Building Trades Unions to offer Apprenticeships to an area of high unemployment, deteriorated buildings, where the first renovated building became a day care center on the street level, employing a sizable percentage of neighborhood women (and a man or two), after all the formerly unemployed young men helped renovate the buildings, and rehabbed safe-affordable housing above it, then moved to the next adjacent building, which became a bakery, etc.,etc And In a rural area the C.D. Credit Union at the Navajo Nation might serve as one rural example. 15 years ago, at Dartmouth "Grand Rounds" continuing (medical) education, I listened to an Epidemiologist note that 52% of Detroit Metro Area Schoolchildren met the criteria for PTSD-witnessing shootings of classmates, being in proximity to domestic violence, high unemployment, etc.. Numerous other factors are noted in Susan Lawrence, M.D.'s book about ACEs:"Creating a Healing Society:The Impact of Human Emotional Pain and Trauma on Society and the World". Plenty more in the Community Resilience Cookbook.... (I should practice better self-care and not stay up past my bedtime!)

Jane/Shoshana, I just ran across a guidebook put out by SAMHSA that allows /guides measuring a trauma-informed setting (agency/community/etc), has great references in the footnote/bibliography on the last two pages, and it is on SAMHSA's bookstore page where it can be downloaded in adobe acrobat for FREE. I had downloaded it, and now can't search/find it, with this screen showing, roughly 19 pages. I'll try to locate its gov't. printing ID # and title. I'll get back to you about it later. I've used similar guides in the past, but I believe this guide is new this month.

Originally Posted by Jane Stevens:

That works.

On Facebook, a woman and I were having a convo, and came up with the idea for ACEs and resilience scores for community/systems experiences -- such as healthy food, access to safe & supportive schools, housing, safe neighborhoods, etc.

What do you think?   

The AAP today came out with a "whole food" idea.... It is really silly.... You cannot have whole food or healthy food if there is no way to afford to buy it... That is the essence of extreme poverty.... You cannot even purchase the basics..... No cloths, no food, no shelter. This exists in America too not just in a third world country.....

 

It is great to discuss these ideas but until children are seen for more (a resource to treasure vs an advertisement on a billboard for the hospital OB ward), they will continue to be left to fend off hunger with the cheapest food (if any at all) i.e. potato chips and Ramen Noodles from Aldies or Save A lot, they will continue to be left in neighborhoods where drive by shootings are a dime a dozen and kids grow up to either win the Heisman Trophy (akin to winning the lotto - which is the primary hope for the poorest among us) while on the Same Street in the Same Park they lose their leg to a stray bullet -- my example -- North Saginaw in Flint where there were bullet casings in the parking lot of an old clinic I worked in and down the street less than 500 yards, a park for kids to lose their leg or learn to be a Heisman Trophy Winner (Mark Ingram)....

 

It is the insanity that I saw in San Diego at the Marina Inn that is the root cause (as another member would say) of the problem...HUGE BOATS more than anyone could need(with most appearing empty at night having no one making these huge boats their primary residence) while down the street --- street teens have to sell their body sight unseen to eat and stay alive....

 

And if those teens are caught, they are the delinquent, the bad kid, the thing they knew they were since they were two...


These ideas are great but they are utopian. That doesn't mean that I don't think striving for utopia is naive.... But it will take a lot of work and for many people to see the world in a completely different light.....

 

The utopian world of safe and supportive schools, safe neighborhoods, and healthy foods among the many other things kids need to be healthy, successful and have a decent shot at reaching their full potential cannot be reached while we continue to accept such inequities...

 

So how do we begin to address what has concerned me for at least 40 years now? 

Poverty in itself doesn't have to be an ACE. I was speaking with a collegue who has one very significant ACE who is from Latin America and grew up in a dirt floor hut. However as this collegue was talking with me she let me know that the saving grace for her was the two loving parents she grew up with who she always knew were there for her. It is the extreme poverty that over stresses parents or extreme poverty w/ parents incapable of love that massively damages kids. The AAP even considers childhood poverty a priority issue and has the FACE poverty campaign. Donna does excellent work, in fact I think I will forward this question to her.

Thanks

The boyfriend that was an alcoholic i was just referring to just called me.... His parents paid for his education and gave him a large inheritance. As I am discussing this discussion with him of whether poverty is an ACE he just told me (He calls me rarely) that "it sounds like you should join the 'free-shit army'."   This is the type of discrimination and harassment that all of us who have come from massive poverty have to continue to face. I have paid far more in taxes than any welfare my parents received and it was a horrible experience...

Poverty is a terrible ACE that creates great shame, discrimination and abhorrence from others who simply do not understand the reality of this massive, chaining injustice.

Please do not take offense to my bluntness but this is something that is so important to me and should be to us all.

Today I spent the morning with public health nurses who have been incorporating the ACEs screening into their workflow with prenatal and new parents, many of whom are in recovery and/or have substantial chronic conditions themselves.  The sensitive way in which they approached this work - more than year "talking about doing this" and getting to their own comfort zone.  Using the screen in a sensitive, respectful and focused way such that it has improved relationships, increased patient confidence and communication,and greatly enhanced nurse understanding of the family challenges and the importance of their relationship.  We are moving together to create a "dialogue" based upon what they have learned 18+ months after implementation, as they now talk about moving from using the "paper" to relying upon the ongoing dialogue and maximizing the opportunity and "teachable moment" for both nurse and patient.  It was a grand morning and wonderful conversation.  

Originally Posted by Jane Stevens:

That works.

On Facebook, a woman and I were having a convo, and came up with the idea for ACEs and resilience scores for community/systems experiences -- such as healthy food, access to safe & supportive schools, housing, safe neighborhoods, etc.

What do you think?   

That could be a very interesting way to judge organizations. The biggest struggle (and what we are working with in our report) is what qualifications make a community/systems experience trauma-generating? Or on the positive side, what qualifications make a community/systems experience trauma-informed? The benchmarks we have looked at for trauma-informed policy are: 

  • supporting and resilience through the policy/program
  • training staff and management in Sanctuary or other trauma-informed models
  • considering the impact of past traumas when designing policies/programs
  • reducing triggering instances and unnecessary burdens on the population targeted in the policy/program

But measurement markers are tough to create for these.

And DHS offices in tow w/a fearful mother to apply for welfare benefits the humiliation that I see her go through as my bro, sis and I are in coats given to us way too big sleeves dirty from dragging on the ground... Transportation impossible.... No understanding by doctors or these systems.... So bad mother won't even bother to sign us up for free lunches so we go hungry but no matter ...I won't stand up in the  lunch line... Im glad she didn't sign us up... I'd rather be hungry and less effort needed to stay invisible...I am the master of invisibility. Sleep in a 20 below winter w/no heat. You are sleeping in a snow suit. Food ... Free government chess and what I call mystery meal ... Food from the bent can store.... Every one is doled out a dinner can.... No labels open it up and eat it... Definitely don't complain... More later
Originally Posted by Sue Mackey Andrews:

       
In Maine, we have been doing some poverty work in slight alignment with our ACEs/Resilience initiative, but not connected to one another.  We do believe that ACEs can and often does cause poverty, but we see so many families living in poverty whose ACEs are not bothering them, or perhaps haven't experienced any ACEs at all. Being poor isn't the issue, but I believe that what being poor does to people is the issue. The United Ways have a poverty simulation that is quite impressive.  We have done this in Maine and continue to roll out this opportunity for people to experience.  The stress of poverty is huge and significantly affects physical, psychological, mental health and well being, etc.  Babies in poverty experience changes in the developing brain, even in utero, as a result of poverty and its toxic stress.  We have designed social support and health care systems that have massive barriers for someone in poverty.  The impact of Maslov's Hierarchy can't be overstated.  If you are worried about where you and your baby will sleep that night, you aren't going to be thinking about getting the immunization that is due or being able to plan your day so that you can get to all of the places you need to go in a logical, plannedful sequence - poverty makes life more random and time is all too limited to get things done.

The association between ACEs and chronic conditions, social service and health care costs, is important to consider in this conversation too.  If we couple poverty (which is an ACE, no doubt) too tightly to causality of ACEs - in this particular political environment (state or nationally), we risk further victimizing and blaming people, claiming, for example, that poverty is a choice and "if you would just make better choices" .... you wouldn't be poor.  Doctors complain about "compliance" in healthcare - getting to appointments, following up with prescriptions, etc. and often don't comprehend that sometimes  "getting there" is well beyond the ability of the individual because there are so many other challenges in the way that day.  People living in toxic stress can't plan for tomorrow or next week because they are too consumed with getting through today.  Having to travel 3 hours to the DHS office for your eligibility determination visit (must be face to face) for TANF when you don't have a car means you will lose your benefits, for example.  Most of the reports that I hear are that the "systems" don't make it easy for people to access their supports and benefits.

Donna Beegle has been a tremendous coach for us in better understanding all the various permutations and implications of of poverty and in separating this work from our ACEs efforts.


This response is so very true and so easily not understood. I grew up it and I consider it and the severe sadistic emotional abuse I suffered to be my worse ACES. Growing up in extreme poverty results in socio-economic discrimination in rural areas where all are the same race and even after one has escaped poverty, it remains a core identy as much as shame. How did I get out of poverty to go to medical school? No choice stay w/an alcoholic boyfriend who strangles you and humiliates you because there is no other way to escape for a once homeless teen who basically has to continue to beg for others compassion. You are stuck in violent, sexually abusive relationships or become homeless. It took me several years to get to medical school. I couldn't go straight out like others ...I didn't have the money to take the MCAT or the means to have transportation to a testing site (300 miles closest site) and though I was valedictorian of my small undergrad school..... I still was poverty... This system is almost impossible to escape from and certainly not possible except by selling ones self metorically.. More later

In Maine, we have been doing some poverty work in slight alignment with our ACEs/Resilience initiative, but not connected to one another.  We do believe that ACEs can and often does cause poverty, but we see so many families living in poverty whose ACEs are not bothering them, or perhaps haven't experienced any ACEs at all. Being poor isn't the issue, but I believe that what being poor does to people is the issue. The United Ways have a poverty simulation that is quite impressive.  We have done this in Maine and continue to roll out this opportunity for people to experience.  The stress of poverty is huge and significantly affects physical, psychological, mental health and well being, etc.  Babies in poverty experience changes in the developing brain, even in utero, as a result of poverty and its toxic stress.  We have designed social support and health care systems that have massive barriers for someone in poverty.  The impact of Maslov's Hierarchy can't be overstated.  If you are worried about where you and your baby will sleep that night, you aren't going to be thinking about getting the immunization that is due or being able to plan your day so that you can get to all of the places you need to go in a logical, plannedful sequence - poverty makes life more random and time is all too limited to get things done.  

 

The association between ACEs and chronic conditions, social service and health care costs, is important to consider in this conversation too.  If we couple poverty (which is an ACE, no doubt) too tightly to causality of ACEs - in this particular political environment (state or nationally), we risk further victimizing and blaming people, claiming, for example, that poverty is a choice and "if you would just make better choices" .... you wouldn't be poor.  Doctors complain about "compliance" in healthcare - getting to appointments, following up with prescriptions, etc. and often don't comprehend that sometimes  "getting there" is well beyond the ability of the individual because there are so many other challenges in the way that day.  People living in toxic stress can't plan for tomorrow or next week because they are too consumed with getting through today.  Having to travel 3 hours to the DHS office for your eligibility determination visit (must be face to face) for TANF when you don't have a car means you will lose your benefits, for example.  Most of the reports that I hear are that the "systems" don't make it easy for people to access their supports and benefits.

 

Donna Beegle has been a tremendous coach for us in better understanding all the various permutations and implications of of poverty and in separating this work from our ACEs efforts.  

That works.

On Facebook, a woman and I were having a convo, and came up with the idea for ACEs and resilience scores for community/systems experiences -- such as healthy food, access to safe & supportive schools, housing, safe neighborhoods, etc.

What do you think?   

Very interesting article! Caitlin O'Brien and I have been working on a report at the Scattergood Foundation to look at what trauma-informed public policy means, specifically focusing on public assistance programs offered by the City of Philadelphia. We designed a conceptual model to lay out the different elements at play to show how poverty interacts with toxic stress, ACEs, health, and public policies. Feel free to check out the model (view below) and we will share our report with the ACEs community once it is finalized.



If you would like to speak with Caitlin and I on our report, please email us at cobrien@scattergoodfoundation.org and sakins@scattergoodfoundation.org.

I lived in Mali for a year, some 20 years ago. I spoke with a Peace Corps volunteer who told me that the highest cause of death in Mali was traffic accidents. Well, perhaps for Peace Corps volunteers in Mali, but for the actual people there, the highest cause of death is poverty. I have seen it happen, where the parents cannot afford 1 dollar worth of available medication to stop a tooth infection from getting out of hand and killing the girl.

That is what this conversation reminds me of. Poverty is ACE. It is a crime. It is the biggest crime against humanity there is. Nothing grates so much against human dignity as poverty. That is not to say that many, many poor people don't act with dignity. Don't hear me wrong here. Please. But the structural violence of poverty is just that, violence.

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