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Demeter and Tyler, 1995). All service providers and ... although in truth, conflict is part and parcel of any community (Brent,. 2004; Creed, 2004). What the more ...
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Religion, ethnicity, and community mental health: service provision and identity politics in an unplanned Egyptian community Elizabeth M. Coker

Abstract Successful community mental health programs depend on strong social networks and cooperation between resource providers, both of which are complex products of local culture and history. The results of an ethnographic study of an unplanned urban neighborhood in Cairo, Egypt emphasize the importance of the political, social and historical context to community service development. The informal nature of the community, characterized by migrants from different ethnic and religious groups and a relative lack of governmental services, produced a culture of service provision that indirectly serves to accentuate religious and ethnic tensions. The findings are relevant not only to the developing world, but also to community program development in large, multicultural urban centers anywhere.

Introduction Too often, community health initiatives in the developing world are impeded by a restrictive set of premises that ignore the complexities of the very term ‘community’ in an increasingly urban and mobile world. It is premature to speak of ‘needs assessment’, ‘service provision’ or ‘community empowerment’ without an understanding of the inner workings of a particular community at a particular historical juncture, nor can the functioning of a given community be adequately deduced from even the most in-depth ethnographic analyses of the larger culture. In Egypt, the features that characterize traditional communities, including intricate support networks, relative insularity and strong reliance on the extended family, may Community Development Journal Vol 43 No 1 January 2008 pp. 79–92

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be the same features that work against successful adaptation in a modern community created by migration, political change and financial necessity. Even when entire neighborhoods are relocated relatively intact, a significant period of adjustment is necessary before real integration and functioning social networks are once again established (Ghannam, 2002). Increasingly, the social fragmentation typical of urban environments elsewhere characterizes the modern Egyptian urban landscape. However, many areas in Egypt lack the basic social services that might substitute, at least partially, for comprehensive social integration and support. Large cities in the developing world are sites for untold numbers of emerging, unplanned areas consisting of diverse individuals and groups brought together by little other than the shared experience of migration (Obrist, Van Eeuwijk and Weiss, 2003). Thrown in with others with whom they have no common history or identity, there is little incentive to establish social networks beyond one’s limited circle of friends and family. The results of this social fragmentation can include typical symptoms of social breakdown and decay, including crime, drugs and violence, which seem to occur almost in a cultural vacuum. The apparent universality of these observed effects, however, is little more than skin deep. Social and mental health problems require social and political (and by extension, cultural) solutions (Kirmayer, Simpson and Cargo, 2003). There are currently no comprehensive community mental health programs in Egypt, and limited funding is available for mental health services in general. Mental health services are highly centralized in large-scale government hospitals, or consist of private clinics that are financially out of reach for the majority of the population. Added to this is the problem of very poor, informal communities that proliferate on the outskirts of Cairo and other cities and benefit from relatively few governmental services. Many western models of community mental health are based upon cultural assumptions that may be inappropriate in a low-income area in a developing country such as Egypt (Jacob, 2001). They too often assume that providing mental health services is no more complicated than building centers, training staff and providing funds, when in fact the real barriers are far more complex (Pelto and Pelto, 1997; Al-Issa, 2000; Azhar and Varma, 2000; Cant and Sharma, 2000; Coulter and Fitzpatrick, 2000; El-Islam, 2000; Kasper, 2000). Egypt, like any society, presents a unique socio-political situation that must be taken into account in the development of appropriate and sustainable mental health services. This paper will present the findings of an ethnographic study originally designed to help develop a model community mental health program in an unplanned, economically disadvantaged community in Cairo. During the course of the study, the dynamics of service provision in the area revealed

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a facet of intra-community relations that touched on deep issues of identity and belongingness. We found that non-governmental services are usually either religiously affiliated or target specific groups, i.e. Egyptians or Sudanese refugees. Even centers that strive to maintain a neutral stance may become unwillingly segregated as potential clientele begin to associate with one group or another. In sum, religious affiliation and religiously based services have historically played an extremely important role in this particular community, and many others like it in Egypt. However, as yet, there has been little or no critical examination of this topic, possibly explained by the different place of religion and religious institutions in social life in Egypt compared with the West, which produces most of the current research in this area. Several studies have criticized the relative neglect of religious subgroups in community research and development, reflecting the historical power differential between religion and service provision in the West (Kloos and Moore, 2000; Farnell, 2001; Smith, 2002). For the Egyptian general populace, however, religion and religious institutions are arguably as politically and socially powerful, or more so, than their governmental counterparts. Therefore, the question is not ‘how can we empower these religious groups to contribute positively to the objective of community development?’ but rather ‘what can the interplay of the (already quite powerful) religious entities teach us about community dynamics in Egypt and the possibility of promoting positive change and mutual cooperation?’

Methodology The setting The research, undertaken between December 2003 and June 2004, was conducted entirely in an informal neighborhood on the outskirts of Cairo, to be referred to here as ‘El Haganah’, an unplanned area populated by migrants from other parts of Egypt and more recently by Sudanese refugees and/or asylum-seekers attracted by the low cost of housing. Statistics compiled by the Centre d’Etudes et de Documentation Economique, Juridique, et Sociale (CEDEJ) in Cairo in 1996 estimated the total population in the area to be 35,161 (more recent statistics were not available at this time, and the numbers might well be much higher now). Many residents of El Haganah were without running water or electricity at the time this research was conducted, and unemployment/underemployment rates are much higher than in the rest of the country, according to unpublished official sources. Data collection The study utilized an ‘action research’ technique according to which research and intervention are interdependent and simultaneous (Pomeroy,

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Demeter and Tyler, 1995). All service providers and lay-respondents were classified according to ethnic and religious affiliation for a total of four groups: Egyptian Muslim, Egyptian Christian, Sudanese Muslim and Sudanese Christian. The data were collected by five interviewers who were trained in interviewing and data-collection techniques. Weekly meetings were held with all interviewers to assure consistency. Sixty-five interviews were conducted at twenty-three different services, including three churches, ten mosques, seven non-governmental organizations (NGOs), one private school, one private medical clinic and one Islamic relief organization. The information collected from each service provider included the following: types of services provided; affiliation (religious or other); personnel; population served; perceptions of perceived needs in the community; suggestions for improvement, and so on. Seventyfour interviews were conducted with a total of 117 community members in order to assess satisfaction with services and perceived need for psychosocial services, as well as general concerns and feelings about the community. The data were coded entirely by the principal researcher using a computerized data-analysis program (Ethnographw). The categories were derived from the data itself and honed through weekly discussions with the project staff. Among the fifteen or so major themes that arose were those related to service provision, community conflict and religious affiliation. It is this particular subset of the data that provided most of the basis for this paper. These categories were very common and surprisingly thematically consistent across and within the four groups, so much so that it soon became obvious that this was a major issue for this particular community.

Discussion El Haganah and the concept of community In spite of the widespread use of the word ‘community’ in the social science and development literature, the term itself evades precise definition. One common assumption equates community with locality, thus emphasizing an ‘organic’ or naturalized version of community (Brent, 2004). Still, others avoid this particular trap by focusing on the existence of multiple-nested subcommunities defined by identity and group roles rather than physical location (Brodsky and Marx, 2001). These definitional concerns highlight the importance of articulating exactly what we mean by ‘community’ in a neighborhood as historically and socially complex as El Haganah. It can be argued that the physical area of El Haganah does not denote a ‘community’ in the true sense, since most residents might prefer to identify themselves with other ‘imagined’ communities, including the Sudan, upper Egypt, a given village, or (more commonly) Islam or Christianity (Farnell, 2001).

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Recently, however, several authors have critiqued what Creed (2004) referred to as an over-reliance on the imaginative qualities of community, a tendency that leads to too much focus on the imagined, and not enough on the community. The main criticism is that the focus on the imaginary relies on notions of uniformity and cohesion; in other words, a highly idealized version of community that has little basis in lived realities, although in truth, conflict is part and parcel of any community (Brent, 2004; Creed, 2004). What the more flexible definitions of community have to offer is a way of finding community in the very conflicts that characterize El Haganah. It was obvious that the subjects in this study were aware both of sharing a physical and social space with others of different backgrounds and of being grouped with these others in the eyes of adjacent communities. It is these features, rather than a romantic notion of ‘unity and cooperation’, that define community for the purposes of this study.

Concepts of identity in El Haganah Although the notion of El Haganah as a community was defended in the preceding section, it is the dynamics of co-existing identity groups within the community that constitute the focus of this paper. El Haganah is inhabited primarily by four major groups: Egyptian Muslims, Egyptian Christians and Sudanese refugees, both Muslim and Christian. Most of the Egyptian Christians came, for financial reasons, from villages in the south of Egypt, whereas the Egyptian Muslims consisted of the original inhabitants of the area and more recent economic migrants from Cairo and around Egypt. The recent civil war in Sudan has resulted in an influx of mostly Christian refugees from the south of Sudan. Sudanese Muslims comprise both recent refugees of the war and longer term immigrants, some of whom have lived in Egypt for generations. It must be added as well that most southern Sudanese Christians have much darker skin than do the northern Sudanese or Egyptians, although this distinction is not absolute. Therefore, although Egyptian Muslims and Christians in the area distinguish themselves from one another mainly on religious grounds, identity for the Sudanese is much more problematic. Sudanese Muslims not only share the religion of the majority in Egypt, but often (if not always) are more culturally and even physically similar to Egyptians than are southerners. The southern Sudanese, for their part, face the triplewhammy of being in an unfamiliar culture and environment, Christian, and dark-skinned. Although Sudanese refugees self-identified according to both nationality and religion, as will be discussed in subsequent paragraphs, the politics of service provision tended to fragment groups along both axes.

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The following quote by a Sudanese Muslim man illustrates the shifting nature of identity for the Sudanese: The only two basic schools for Sudanese refugees in el Haganah are both Christian-affiliated, and I really appreciate their generosity of taking in some Muslim Children, but most of the Muslim children can’t join this schools and can’t even join Egyptian government schools too. Because the [Sudanese refugee] school only takes a limited number of the Muslims, most don’t have any chance of getting in.

This quote illustrates the dilemma shared by many Sudanese Muslims. The majority of services for refugees were run by Christian churches, and Muslims often either could not or did not feel comfortable accessing these services. At the same time, the Sudanese Muslims were clearly not tapped into the resources available through local mosques, and, as non-Egyptians, were not able to access the educational services available to Egyptians (although medical clinics do not discriminate in this way).

Service provision in the community The history of service-provision in El Haganah reflects a need-based, philanthropic impetus resulting in small-scale endeavors to address specific problems. The informal, ad hoc nature of the community coupled with a relative lack of government services in the area created a vacuum that was readily filled by organizations with more or less sectarian roots.1 Most (although not all) of the identified services in El Haganah were religious and/or charitable in nature and provided services such as medical clinics, literacy and sewing classes, food and money distribution and child care. The majority of the services catered to one sector of the population (i.e. Christians, Muslims or refugees) in terms of actual practice, if not original intent. However, apart from religious lessons that might be offered by a mosque or church, the services offered were fairly standard. Medical clinics in particular were staffed by trained physicians and stocked with medical equipment and pharmaceuticals according to available funds. In other words, a church-run clinic operates with the same practices as a mosque-run or governmental clinic, with the exception that it might be staffed by Christian physicians and other personnel, and vice versa. Medical practice in Egypt, long controlled by the State, is based on western models, and this is virtually never contested by religious 1 Although there was one government-run clinic in the area, few Egyptians frequented it and virtually no Sudanese. There seemed to be a general impression among the respondents that the government clinic was not as effective as the church- or mosque-run clinics, or, for those who could afford it, private doctors inside and outside the area. This phenomenon has been observed elsewhere in Egypt with regard to governmental versus religious medical clinics (Morsy, 1988).

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authorities. ‘Religious healing’ per se is a separate issue and not a regular part of the medical treatment provided by mosques or churches. There was very little reported interaction between the services identified, particularly between, but also within, the different sociodemographic categories. Service providers did few or no mutual referrals, nor did they tend to cooperate with one another to provide or improve their services. In fact, most service providers interviewed were more or less ignorant of the existence or scope of the other services in the area. Several of them lamented this fact and acknowledged that some of their work might very well be redundant, although there was general agreement that the depth of need was so great that it would be difficult to ever do too much in any one area. Regardless of religious or ethnic affiliation, one of the major complaints of the service providers was related to certain characteristics of the very population they were meant to serve. Prime on the list of complaints about the community in general was ‘ignorance’ ( gahl ). Ignorance in this context did not refer directly to illiteracy or lack of education (both of which were acknowledged problems that many of the programs were meant to address), but rather seemed to reflect a moral critique of the capacity of community members for mature, reflective action, or, as one person put it, a basic ‘lack of awareness’. Residents were seen as being short-sighted like children, unable to invest in the future at the expense of immediate gratification. For example, according to one mosque worker: People in the area need to be treated in a way that will set them straight or else otherwise they will ruin everything. Last Eid three mosques were wrecked when donations (of meat) were being given out because of the way people behaved. Some people [donors] used to come and give such loans [to start private enterprises] and some projects were started up such as kiosks for selling small items. Soon loan-receivers sold the kiosks and took the money.

From this statement (which was quite representative of the general tone among service providers when discussing community reactions to their charity), it is obvious that there is a somewhat adversarial relationship between the community and its benefactors. The service providers are usually better educated than the inhabitants of El Haganah, far wealthier, and as often as not from outside of the area. The implications for a community of an almost total reliance on services that are religiously based are two-fold: first, this type of service provision replicates existing social, religious and ethnic divisions in the community and thus causing them to become more entrenched and acting against community integration. The resulting disincentive to create anything

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resembling a functional Egyptian community means that culturally typical community and social networks are not established or maintained, resulting in an over-dependence on the aforementioned services regardless of their ability to objectively meet the needs of their recipients. This ‘vicious cycle’ is readily apparent in El Haganah, where service providers and community members alike complain bitterly about the inability of existing services to the meet the needs of the community, but remain powerless to explore alternatives. Following this, an over-reliance on charities, particularly sectarian ones, may actually impede community health by de-emphasizing individual and community empowerment. Although most of the service providers recognized the need to promote sustainable income generation rather than handouts, this was rarely, if ever, achieved. Instead, the predominant dynamic existing between provider and recipient was one of dependence, paternalism, and, not incidentally, mutual distrust that was remarkably consistent across the four identity categories. Although the service providers had a keen sense of the needs of the community, they also almost invariably conveyed a sense of hopelessness, or even outright disdain for their service recipients. The context of service provision: the community and its residents The particular sociodemographics of El Haganah make for social relations that are somewhat uncharacteristic of Egyptian communities on the whole, as many residents struggle to establish connections away from familiar extended family networks. There was a good deal of social isolation expressed by the respondents, which some attributed to not having people nearby who were of the same religion or from the same neighborhood of origin. Others stated that people in the area did not have time to visit anyone, and/or could not keep up with the financial obligations that sociality imposed. For example, an Egyptian Christian woman said that she did not go out to visit people because of the need to buy gifts on such occasions, which she did not have the means to do. Many others said that they tended to avoid others in the area because of the aggressiveness they could encounter in the streets. This was often true of refugees and people who were new to the area, but could extend to the longer term residents as well. Said one Egyptian Muslim woman: We [neighbors and acquaintances in the area] don’t hang out together. Everyone is on their own. I don’t let my kids in the street because of the bad words the other children say. We don’t want them to mix with them.

Although the general social problems and divisiveness described earlier characterized Christians, Muslims and refugees more or less equally, what these three groups also share is a deep and pervasive mistrust of

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the other. When it came to relations in the larger community, Sudanese refugees, particularly the Christians, complained more of problems because of their ethnic Sudanese identity than their religion. Their physical and cultural differences, they felt, singled them out for aggressive treatment by the majority Egyptians. Egyptian Christians often complained of similar aggressive treatment by Egyptian Muslims. Egyptian Muslims, the majority in the area and thus less likely to complain of overt aggression, nonetheless felt threatened by the (unsubstantiated) rumor that Christian service providers were attempting to convert Muslims, sometimes, for example, by having illiterate Muslims sign ‘papers’ in order to receive material aid, papers that they claimed attested to their conversion. Conversely, some Christians voiced similar fears about Muslim services. Religious and ethnic identity was such a salient issue in El Haganah compared with other communities in Egypt most likely because of factors related to the politics of identity that result from the unique history of the community. The migratory nature of the community and resultant lack of shared history between its members begin to explain this phenomenon, as well as the heightened distrust of the ‘other’ in this community compared with more established ones. Most Egyptian communities contain a mix of Christians and Muslims, and although there are certainly reports of tensions in some areas, in most cases, the relationships between these groups are quite cordial. In a long-standing Egyptian community, Christians and Muslims with roots in the community know each other in many different contexts and under many different guises, i.e. as a neighbor, shopkeeper, fellow student, co-worker, and so on, not just as a member of a religious group. In El Haganah, on the other hand, there is no shared history to fall back on, no long-term relationships between members of different religious groups, which would serve to mediate any inter-religious conflict or tension. The codes of conduct that regulate life in established Egyptian communities are missing here, and people are left with very few principles by which they identify the Self versus the Other. In this case, religion becomes the principle means of identification, and in El Haganah, the existing service institutions serve to accentuate religious identification at the expense of other forms. Regardless of group membership, ethnic and religious tensions seemed to revolve around issues of services. It is here that political nature of philanthropic service provision becomes most evident. As outlined previously, most of the existing health and social services in the area carry religious labels in one form or another (even many of the NGOs carry religious associations) and target Egyptians or Sudanese. Only a few NGOs were truly non-denominational, and even these clearly served one group more than another, usually because of a process of self-segregation by which

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individuals tended to prefer those places frequented by members of their own in-group. Therefore, the perception among community members was that services were divided into those that are ‘for us’ (in group) or ‘for them’ (out group), in spite of the assertion by most services that they are ‘for everybody’; a fact that serves to further divide the community along religious and/or ethnic lines. The segregation of available services meant that many community members were virtually unaware of services beyond those that catered to their particular ethnic group. In the case of health care, Christian residents tended to use the Church-run clinics, whereas Muslims were more likely to go to mosque clinics or private clinics. Many of the respondents, after listing their particular medical service, declared that there were ‘no other services in the area’, and few mentioned more than one or two clinics in spite of the range available. This is probably partly due to the fact that knowledge of available medical care is most likely spread through word-of-mouth in an area in which social interactions are highly restricted, and partly due to perceptions about religious exclusivity. One thing that most respondents shared regardless of religious or ethnic background was the fact that virtually no one was satisfied with the way things were. Most blamed the government for not providing needed services and the necessary police services to keep the area stable and keep out the criminal element. The crime and general social breakdown were a source of both personal and community stress and shame. Several respondents, particularly those who had been in the area the longest, expressed dismay that the media and outsiders in general believed that El Haganah was a place of crime and low morals, and that this reflected on them both directly and indirectly. An Egyptian Christian woman expressed this as follows:

If you go down to any other area in Cairo they will not employ you when they find out you live in el Haganah. Once you say the words ‘el Haganah’ they get a shocked and even a scared look on their face. They think the child will not be good because he is a product of the environment and his parents. People just think we are all the same.

What this demonstrates is that the lack of security comes not only from a lack of solid infrastructure, but also from a feeling of general vulnerability as a community. Residents are acutely aware of their marginal status as a community in the eyes of the government and police as well as the surrounding communities. Increased safety, therefore, cannot come without increased community solidarity as a whole (Nolan-Haley, 2002).

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Summary and conclusions The pilot study on which this paper is based was intended to aid the development of a model community mental health program that would incorporate existing services and involve active participation on the part of service providers, community leaders and lay-persons alike. We discovered, however, that accomplishing this will require, first and foremost, addressing deeply embedded dysfunctional forms of social identity and interaction that have come to characterize this community and color the nature of service provision in the area. A summary of the main findings relevant to this serves also to highlight some important theoretical implications. First of all, the community consists of three more or less insular groups, including Egyptian Muslims, Egyptian Christians and Sudanese refugees or asylum-seekers (Christian and Muslim). That these groups should be at odds with one another is arguably a function of the specific sociohistorical conditions of the immediate community in which they live; in other words, inter-group mistrust is part and parcel of the El Haganah experience, not of any deeper historical or cultural legacy. Rather, it is argued here that the identity conflicts that characterize the community are a result of what George Devereux called the ‘hyper-cathecting’ of one type of identity at the expense of others, a survival technique that takes place under situations of stress and fear (Devereux 1975). Residents of El Haganah are virtually all immigrants, forced to live a precarious existence apart from their usual forms of social networking, a condition that must be remedied before any community initiative can succeed (Hagan, 1998; Kirmayer, Simpson and Cargo, 2003). This leads directly to the second main finding, which is the existence of a pervasive sense of inferiority as a community vis-a-vis the larger Egyptian society and the resultant atmosphere of powerlessness among community members. Although residents would proudly proclaim their village of origin (various towns throughout Egypt, Cairo or Sudan), they could voice only shame at being seen as part of a community that they knew was viewed by outsiders as one of crime and other forms of immoral conduct. A general sense of hopelessness and shame regarding their own community, coupled with a weak sense of being part of a larger whole because of the insularity described previously, presents a formidable obstacle to mutual cooperation and involvement. Finally, the lack of social cohesiveness and incentive to create a mutually beneficial community leads to an over-reliance on service providers that may be ill-equipped to meet the needs of the community for a variety of reasons. The nature of charitable service provision in the area

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both reflects and reinforces social and religious divisions. These charities are most often religiously based and required to fulfill the mandates of wealthy donors who, although well meaning, know little about the community or its needs. The resultant association of social/medical service with religious affiliation creates tension and conflict (regardless of the intent of the service provider) as recipients find their religious beliefs inextricably linked with their material or health needs. In addition, many of the available services spend a significant part of their resources on immediate relief such as food, clothing and occasionally even cash. A ‘circle of disdain’ between service providers and their clients results, with community members complaining of the services available but unable to realize alternatives and service providers denigrating their beneficiaries, impacting the effectiveness of services while blocking the possibility of alternatives. This lack of common ground between service provider and client is not unique to El Haganah; however, it may be more salient there and possibly lead to more resistance on the part of the clientele because of certain factors unique to the area. The community lacks the basic social ties and shared history that characterize most Egyptian villages and communities (at least older ones). People cannot trust their neighbors because they do not know them and therefore do not have recourse to the kind of social support that leads to the development of common standards of conduct and the security necessary to work toward the future of the community. The two issues, weak or non-existent social networks and paternalistic or partisan service provision, are related in a circular fashion. A strong community will dictate the terms of the services it receives through the power of choice and censure. Participatory and unified service provision will help to bring these conditions about. The lesson here is that any community health promotion initiative must negotiate complex political and social factors and do so in a way that empowers all members of the community.

Acknowledgements This project was conducted in collaboration with the Association for Health, Environment and Development (AHED), Cairo, Egypt, and funded by the Social Research Center of the American University in Cairo, Egypt. We would like to thank the individuals who committed their time and effort to collecting data for this project, including Tamer Ismail el Maghreby, Hanaa-Dina Mostafa Helmy, Hala Wael Mahmoud, Suzanna Barnaba, Mariham Iskander Wahba and Nada Hamdan.

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Elizabeth M. Coker is an Assistant Professor, Department of Sociology, Anthropology, Psychology and Egyptology, the American University in Cairo, Egypt. Address for correspondence: Department of Sociology, Anthropology, Psychology and Egyptology, the American University in Cairo, 113 Sharia Kasr el Aini, P.O. Box 2511 11511 Cairo, Egypt; email: [email protected]

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