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GeoJournal (2009) 74:99–106 DOI 10.1007/s10708-009-9266-9

Social epidemiology as medical geography: Back to the future Tom Koch

Published online: 7 February 2009  Springer Science+Business Media B.V. 2009

Abstract There is something very traditional about Nancy Krieger’s decidedly modern work. She advances a social epidemiology that is multidisciplinary, advancing a ‘‘quantitative population science’’ that is also spatial in its approach and method of analysis. Many geographers see their work as affirming the potential of medical cartography and geography as disciplines critical to public health studies of disease incidence. This article argues that the history of epidemiology and public health are historically spatial and geographic, a link lost in the research of many twentieth century health researchers. A review of the history of medical geography, and of public health, insists upon the spatiality of disease studies as a critical groundwork not simply for contemporary disease studies but for the history of disease studies as they have slowly developed over for more than 200 years. Keywords Krieger, N  Medical geography  Sociology of science  Social epidemiology

T. Koch (&) Department of Geography (Medical), University of British Columbia, 1984 West Mall, Vancouver, BC V6T 1Z2, Canada e-mail: [email protected]; [email protected] URL: http://kochowrks.com

There is something very traditional about Nancy Krieger’s decidedly modern work in epidemiology and public health. There is, for example, her authorial focus on the social determinants of health (Krieger 1999; Krieger et al. 2005; Duzbansky et al. 2001), and especially income disparities, a subject that in the nineteenth century was the focus of critical work by, among others, writers like Edwin Chadwick (Chadwick 1843) John Snow (Snow 1855), and Charles Booth (Booth 1889). And, like those authors, Krieger has come to use mapping as a medium for the organization, analysis, and presentation of the data that argues the thesis that incidence of ill health is related to socioeconomic as well as geographic variables. In other words, she shares with that nineteenth century coterie the insistence that place matters (Krieger 2006a). Finally, in a thoroughly nineteenth century manner Krieger refuses to accept the disciplinary divisions that in the twentieth century have become too often adamantine barriers to ecological, multifactoral studies of the relationship between health and place, and the effect of social division on their correlation. This is a self-conscious decision on Krieger’s part. In a 2000 article she argued the necessity of a ‘‘critical reengagement’’ between, on the one hand, epidemiology and the public health agendas it supports, and on the other social science disciplines concerned with health: ‘‘sociology, anthropology, economics, political science, and psychology’’ (Krieger 2000) Surprisingly absent from that disciplinary list was

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geography, the oldest social science and one continuously engaged since the eighteenth century in the critical evaluation of environmental and social determinants of disease and health (Koch 2005). Krieger’s work has evidenced in recent years an increasing appreciation of spatiality and the importance of place as critical components in health studies, and of mapping as a means by which issues of disease and health can be assessed and considered. Thus, for example, in 2006 she wrote an article marking the centenary of U.S. census tracks as reportage areas for both socioeconomic data and data on the incidence of disease (Krieger 2006b). In this work she in part answers, albeit unknowingly, the criticism of geographer Peter Gould who, in his seminal work on the diffusion of HIV in the 1980s, disparaged epidemiological studies that focused upon temporality without equal attention to the spatiality of disease incidence and diffusion patterns (Gould et al. 1991; Gould 1993). This paper seeks neither to review the enormous body of Krieger’s work nor to claim it as geographic rather than epidemiological, sociological, or otherwise divisional. Rather, its goal is to assert the primacy of medical geography as an historical foundation on which epidemiology, public health, and other healthrelated disciplines developed. This fills a lamentable gap in Krieger’s history of disease studies and, with Krieger, insists upon a necessary unification of spatial and temporal studies of the social determinants of disease. That unification will come not, however, from multidisciplinary critiques, useful though they may be. Rather, it will advance through an enfolding of disciplinary histories and perspectives that together assert a more unified conception of historical and contemporary ideas of disease and health. In its emphasis on medical geographic traditions, and a cartographic methodology for their expression, this paper seeks to advance Krieger’s reengagement of epidemiology and public health with medical cartography and geography as primary rather than secondary venues of disease and health research. It seeks to demonstrate that the mapping of spatial relationships has been from the start a means by which disease incidence was first located and then considered within an ecological context that seeks to quantify both disease and the environmental conditions that inhibit or promote its presence (or absence) in this or that population.

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Medical geography For Krieger, public health is a quantitative population science in which cartographic and medical-geographic contributions are at best ancillary. ‘‘Preconditional to the emergence of quantitative population sciences,’’ Krieger writes, ‘‘are the fundamental beliefs that intimate relations exist between mathematics and material reality, that counting and categorizing are the currency of durable knowledge, and that the empirical study of variegated humanity—chock full of irreducibly unique individuals—can uncover universal truths’’ (Krieger 2000, p. 155). To this tripartite list might be added a fourth, spatialization. ‘‘Counting and categorizing’’ may be the currency of durable knowledge but they presuppose a means by which that data can be first located and then analyzed as a class and in relation to other attributes in a spatial framework. This is and has been the domain of ‘‘medical geography’’ and represents its most significant contribution to the history of disease studies and public health. The history of public health investigation is, at heart, as much cartographic and geographical as it is numerical and statistical. Since the late eighteenth century issues of disease and its determinants have been first collected and then analytically considered in the map. The data of health studies has been grounded in geographic reportage areas created in maps for bureaucracies responsible for the health of specific populations. Nor are maps simply a means of constructing data catchments for statistical health studies. In the nineteenth century health mapping and health statistics developed conjointly as bureaucrats and researchers struggled with a series of emerging epidemic diseases that threatened industrialization and the trade on which it was based. A brief review of what medical geography is, how it began, and its importance to studies of disease and health is, perhaps, in order. Among the earliest known uses of the term ‘‘medical geography’’ to describe the spatial distribution of disease is found in Leonhard Ludwig Finke’s Versuch einer allegemeinen medicinish-praktischen Geographie … Published in 1792, Fink’s ‘‘Notes on General Practical Medical Geography’’ was an early attempt to describe a broad topography of disease in which a taxonomy of observed conditions, and pharmacologies relevant to their treatment, were joined textually and cartographically, the latter in a map Finke is said to have drawn but

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did not publish (Koch 2005, pp. 24–26), This very early work argued a relation between diseases and potential treatments as outcomes of local environmental factors affecting specific populations. In addition, it argued the presence of local plants as a potential source of healing, a proto-ecological perspective joining disease and its treatment at a specific scale. Eighteenth century socioeconomic transformations including, in a partial list—early industrialization, increasing trade, emigration and immigration, etc.— promoted the diffusion of previously localized conditions as well as the development of previously unknown, increasingly epidemic diseases. This accelerated what is sometimes called ‘‘The Columbus Exchange,’’ a microbial transfer that began with the first European settlements in North America (Crosby 1972), Notable in this eighteenth century history was the diffusion of yellow fever from sub-tropical colonial regions like the Caribbean and Siam to climatically temperate cites, especially in the United States. The spread of the disease was seen by many as a direct threat to the trade that supported both colonial cities and European trading nations like England. As Noah Webster put it, rhetorically if succinctly: ‘‘Why should cities be erected, if they are only to be the tombs of men?’’ (Webster 1796). Attempts to understand yellow fever, its nature and the means of its diffusion, demanded localized studies of epidemic incidence where potential determinants—atmospheric, geographic, and social— could be assessed in relation to patterns of disease incidence. The mapping of a New York City yellow fever outbreak by Valentine Seaman in 1798 is the best-known example (Seaman 1798). In it Seaman used copperplate maps to argue a relation between odiferous waste sites and disease incidence in an attempt to prove a miasmatic theory of disease incidence (Koch 2005, Shannon 1981). The mapping permitted the aggregation of individual yellow fever cases in disease clusters as well as the mapping of clusters of odiferous waste sites some believed were causally related to the incidence of disease. Resulting areas of disease, on the one hand, and possible environmental determents on the other, revealed an apparently causal relation between the two: yellow fever was most intense on streets proximate to odiferous waste sites. For Seaman this appeared to prove a causal link between disease and a local airborne environmental contaminant.

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Mapping was a means not only of data collection and organization but also of analysis and argument, the map was a medium in which a theory of airborne disease was tested in an outbreak. The study was numerical but not statistical, using visually identifiable ‘‘clusters’’ but included no detailed analysis of them. At that time mechanisms for the collection of population and health-related data required for more detailed statistical analysis (for example, local population counts) were typically unavailable not only in New York City but in England and Europe as well.

‘‘La me´thode numerique’’ As Krieger tells the history of statistical health sciences, it was in the early eighteenth century that French mathematicians began to employ a statistical methodology applicable to health and social problems (Krieger 2000). ‘‘La science sociale’’ depended on a bureaucracy capable of collecting adequate population-related data that could be used to consider health-related and social problems. This in turn required the division of the nation into political jurisdictions within which health and population data could be adequately collected. This bureaucratic revolution, one in which health and population data became a function of officialdom, in turn employed mapping as a means of creating divisional jurisdictions defining reportage areas and districts within which local demographic and health-related data could be collected and then considered. The result was that an increasingly rich resource of spatially located population data would be available for researchers Collected at national, regional, and local scales, that data (longevity, income, housing density, etc.) was joined with data on disease incidence, and geographical attributes (altitude, rainfall, etc.) for those interested in studying disease incidence in relation to socioeconomic and physical geographic variables. This wealth of spatially grounded data provided an opportunity for the advancement not only of statistical analytics, principally simple mortality ratios, but cartographic analysis as well. The result, embodied in work by among others, Andre´-Michel Guerry in his seminal Essai sur la Statistique Morale de la France, was transforming (Friendly 2007). This early nineteenth century health science was typically cartographic and numerical at once. As the

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population database grew in complexity, the transformation of incidence tables and general statistics into maps was a way in which large amounts of data on everything from drunkenness to prostitution could be effectively first collected, analyzed and then reported in government documents and in professional books or journals. This ‘‘medicostatistical mapping’’ investigated various medical phenomena, including the location of surgical operations at Paris Hospitals, the incidence of fractures, and even the potential causes of hernias in military recruits in France (Jarcho 1974). The French approach quickly spread to other countries. In England, for example, it was championed by, among others, William Farr. A student apothecary in Paris in the 1820s, in the 1830s Farr became a proponent of statistical analytics generally and their importance to medicine specifically. In 1839 he was appointed to the then newly created General Registrar Office where he was engaged almost immediately in preparations for Britain’s first modern census, executed in 1841. That census was in part the conclusion of a decades long process of jurisdictional reformation in which the map of bureaucratic England was reconstructed to promote district and sub-district reportage areas for health-related and socioeconomic data. It was in these reportage areas that data on health events—for example, cholera—would be collected and tested in the context of other demographic data.

Maps of disease and health The conjunction of mapping, population data, and health statistics encouraged a series of new analytics. The subjects addressed were both disease specific and locationally grounded. For example, Chadwick used data from the 1841 census to argue an inverse relationship between income and the incidence of cholera and respiratory diseases (Chadwick 1843). In his map of Leeds, Chadwick created a city surface in which areas of greater and lesser wealth were imposed upon a map of the city. To this he added different colored dots symbolizing the incidence of reported cholera and respiratory diseases generally. The greater concentration of these dots in areas of relative poverty argued their centrality as reservoirs of ill health that might affect the broader community. Secondly, Chadwick’s tables and mapping insisted on a causal relationship between disease incidence

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and the environments in which disease incidence was especially intense. The work was at once cartographic and statistical. Chadwick aggregated his data across the surface of the city, creating a kind of socioeconomic ‘‘density map’’ within which disease (cholera and respiratory disease) could be seen to cluster. With these data Chadwick created areas of ‘‘good’’ (lower mortality) and ‘‘bad’’ (higher mortality) streets whose location could be correlated to income and other socioeconomic variables. Others were quick to employ similar techniques in arguments on the effect of abysmal sanitary conditions on population health generally, and the incidence of cholera specifically. In 1848, for example, an assistant of Chadwick’s, Hector Gavin, published his ‘‘Sanitary Ramblings’’ that while based on his work with Chadwick also included maps and a more general argument on the relationship between income and disease in, for example, Bethnal Green (Gavin 1848; Gilbert 2004). Augustus Petermann (1848) and then William Grainger (1850) constructed density maps of cholera and its assumed relationship to South London geographies in 1848 and 1850, respectively. Both created for their maps statistical surfaces in which disease incidence reported in individual registration districts was smoothed in a manner permitting causal arguments, for example in Grainger’s case, an apparent inverse relationship between cholera and altitude above sea level. This thesis was then advanced in 1852 in William Farr’s 400-page treatise on cholera and its potential environmental determinants (Farr 1852). Farr’s wellmapped argument employed mortality statistics and algebraic expressions to describe disease-environment relations based upon multiple tables of finely detailed data argued at once cartographically and graphically, on the one hand, and numerically or statistically on the other hand. The result was a cartographically and statistically robust study in which graphic and numerical methodologies were conjoined in a multifactoral argument on disease incidence, diffusion, and promotion.

Krieger redoux It is in this tradition of mapped statistics, and mapping as a means of making a statistical argument about the relationship between disease incidence and social or physical environmental attributes, that

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Krieger’s contemporary work is located. First, mapped statistical studies of disease are not exclusively, or even primarily, the provenance of a single academic or professional discipline. Instead nineteenth century disease studies were the provenance of a broad community of bureaucrats, medical professionals and skilled amateurs. Disciplinary boundaries in the academy were no impediment to the broad focus upon health and disease studies that were broadly rather than narrowly constructed. The result was the multiplicity of authorial perspectives Krieger today promotes. In its focus on geographical and social factors promoting disease the medical geographic approach was from the start profoundly ecological in its attempt to describe multifactoral environments that promoted ill health in general and diseases like cholera or yellow fever specifically. Disease was in the air, as Seaman believed, the neighborhoods of poverty, as Chadwick argued, and in the drinking water that John Snow famously insisted was the source of cholera (Snow 1855). This ecological, or at least multifactoral perspective, as Krieger has noted, ebbed and flowed over the last 150 years and is again resurgent. At every turning, however, its construction of necessity argues a place-based and therefore intensely geographic perspective. In this history and in Krieger’s work mapping is, explicitly or implicitly, a means of first defining and then locating environmental niches that promote disease while transposing tables of incidence into statistical conclusions that can be simultaneously located in the map. Importantly, it was in the mapped tradition of nineteenth century disease studies that the issue of income inequality engaged today by Krieger was first systematically argued (Eyler 2000). To embody inequality as an engine for ill health typically required (and requires) mapping. It is in the map that the health reportage areas are constructed, in the map that social and physical data are inscribed. It is in the map that the relative incidence of disease in different jurisdictions, each with specific attributes, is often best argued. It is for this reason that Krieger’s Public Health Disparities Geocoding Project is so important Krieger 2006a). With its tutorial website and in her classes on the transformation of census data to maps of specific health and social criteria Krieger returned to the mapped environment a perspective that from the start has been not simply graphic but also statistical.

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The maps of this history were not simple graphic representations of tables of data analyzed statistically. Rather, they were the instantiation of arguments that were numerical and then statistical, as well as cartographic. From the maps of Valentine Seaman to those in the 1999 U.S. Atlas of Cancer (Devesa et al. 1999) cartographic arguments cannot be separated from the numerical and statistical arguments made on the basis of spatially located data. Maps report mortality of populations in reportage catchments constructed in maps. Disease maps located a host of potentially critical variables— atmospheric, demographic, climatic, geologic, economic and social, for a start—to permit the analysis of their role in encouraging or inhibiting the progress of this or that disease. Graphically and statistically, different techniques may be used to construct an argument at the fine scale of the neighborhood street or at the level of nations. Again, the issue is cartographic and statistical, epidemiological and geographic at once. It is the issue of scale.

Public health, the American turn While an ecological, multifactoral perspective on disease incidence and promotions remained a critical element of medical geography—for example the work of Jacques May (May 1961, 1956)—it was less emphasized in post-World War II courses in epidemiology and public health. There the emphasis typically was on aspatial, especially temporal analysis of disease incidence and cycles. In the immediate post-war period it was left to medical geographers like May, who was also a physician, to insist upon an ecological and spatial perspectives in the consideration of disease incidence and diffusion. And it was first and foremost geographers who mapped patterns of disease diffusion in a manner that was also statistically rigorous. Here for example there is Hunter and Young’s 1971 work on influenza and Gould’s critical studies of HIV (Gould 1993). More generally, the relation between cartography and statistics in the study of disease ecologies was seen in the work of Peter Haggett and Andy Cliff who critically advanced the teaching of disease as a spatialtemporal phenomenon (Cliff and Haggett 1988, 2003). In U.S. public health studies, on the other hand, mapping played a diminishing role from the end of World War II through the 1980s. One reason for this

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may have been the lack of comprehensive and reliable demographic data for the nation at large. As Krieger notes, the U.S. census tract as a scale of national data collection is barely a century old (Krieger 2006b). And through much of the twentieth century, bodies of public data were suspect or unreliable. For example, for many years the official United States statistical abstract warned readers that reliability of data was uncertain, in part because of the extreme mobility of U.S. citizens (Hansen 1946). Even more problematic was the general failure to collect data on rural and non-white citizens. Data available to health researchers thus had both an urban, and perhaps more importantly, a racial bias. The first U.S. cancer atlas published in the 1970s, for example, reported cancer incidence at the county level, but only for Caucasian citizens. A later atlas of non-white citizens was less complete in the data it mapped at a coarser scale. This problem was not rectified, in cancer studies, until the 1990s. In another related research area with resonance for Krieger’s contemporary writing, 1960s geographers were active in attempting to ground issues of social justice and social inequalities in an analysis that was at once statistically rigorous and yet grounded in the spatial arena of the map. Famously, there was the work by Detroit geographer Bill Bunge whose Detroit Expedition project attempted to use mapping at a community level to advance the idea of inequalities and injustices as seen by local residents. In a more academic vein there was the ‘‘welfare approach’’ of those, like David M. Smith (1977), who cartographically and statistically argued first the reality of massive socioeconomic inequalities at a range of scales—local, national, international—and then the deleterious effects of the inequalities their statistical mapping brought forth. It is this tradition that Krieger unknowingly evokes in her own place-based work on multifactoral disease, income inequality, and the importance of socioeconomic place in the generation of ill health. This is not to suggest that Krieger is a geographer or that geographers with an interest in health are epidemiologists. Differences in focus and methodologies exist and persist. Rather it is to insist that the work of social epidemiologists like Krieger is grounded in a history that is geographic, and of which they (and many geographers) are unaware. One reason for this is the division between allied

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disciplines that Krieger herself decries. Each discipline tells its own history as if it were unique, ignoring the work of others similarly engaged in the subject of public health. Another reason may be the withdrawal in recent decades of many geographers from an empirical and positive approach to a range of social problems. The contributions of geographers like Gould, May, and Haggett do not fit easily into the esoteric, post-modernist debates of contemporary geographers with little interest in pursuing concrete studies. Nor is this an argument that suggests that medical geography is not embedded in contemporary social theory. She has written, for example, that ‘‘self-styled objective empirical quantitative science’’ is simply one ‘‘mode of knowing’’ and that the epistemologic and ontologic assumptions of this are largely shaped by social and political context (Krieger 2002). In this she is, however, less a follower of the historian Foucault than of the nineteenth century researchers— from Edmund Guerry in France to Edwin Chadwick and later Charles Booth in England—who used public health data in their analysis of the social determinants of disease and health. In recent years this tendency to the theoretical and general rather than the concrete and specific has begun to be redressed. The reemergence of epidemic disease as a subject of critical social attention has drawn researchers to the field of disease studies. From Legionnaire’s Disease through AIDS to West Nile Virus a new interest in disease is reflected, in part, by the growing attention paid to disease studies, and the effect of place on them, by a new generation of medical geographers. Among specialists from other fields, the study of these emerging epidemic diseases has demanded mapping of outbreaks and epidemics. This has been facilitated by the emerging digital technologies whose diffusion has affected the course of many areas of study.

New technologies Over the last 20 years the desktop computer, with enabling software, has democratized the performance of complex and time-consuming calculations whose computation formerly required specialized training. Confidence levels, mortality ratios, risk ratios— indeed the range of calculations that formerly were

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the principal domain of experts with access to mainframe computers—have become accessible to the average graduate student. At the same time, new desktop and laptop mapping programs have democratized the mapping medium, opening to all the instantiation of disease-related arguments that were formerly restricted to specially trained cartographers. As critically, the migration of official datasets of both socioeconomic data and of disease incidence from a print to a digital format has advanced the potential for multidisciplinary analysis in a manner that can only be termed revolutionary. It is not simply that spatially embedded census and other socioeconomic data are now increasingly accessible in digital form. Availability means little without the ability to analyze that data cartographically and statistically. The digitization of data is part of equation including the general availability of the mapping and statistical software capable of its analysis. To see the effect of these two factors one need only consider that West Nile Virus was continually mapped in a public manner—with databases of incidence available to all—at US government websites from 2000 onward (CDC 2008). Thus the fields of medical geography and of epidemiology, joined historically but then divided by the necessity of specialized training and equipment, can again be joined in Krieger’s ‘‘critical reengagement’’. A medical geographer may confidently attempt the creation of risk ratios based on disease incidence in specific socioeconomic catchments. An epidemiologist may employ mapping as a tool without spending hours learning the arcane niceties of different projection systems. Disciplinary divides do exist. Few geographers have even elementary training in epidemiology. Few epidemiologists are steeped in geographic theory. Not all researchers are equally adept with cartographic or statistical arguments. There remain areas of specialization galore, each demanding specific and sometimes quite specialized expertise. But this has always been the case. Seaman did not make the copperplates that became his maps. Chadwick, Farr, and John Snow did not draw the maps that were critical to their studies. No one person compiles a national report on this or that condition, at least not without months or years of labor by teams of investigators.

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No one person does it all. Health studies have always been cooperative and multi-disciplinary, engaging teams of local researchers gathering data that is assessed by researchers whose biological, cartographic, and statistical arguments are the result of multiple labors. This is obvious in Krieger’s contemporary work. In an interview with the author in 2008 she explained that her work teams involve both mapmakers and statisticians who from the start are involved in data collection, analysis, and presentation. Issues of data reliability are discussed, problems of resolution assessed, issues of scale considered and the resulting analysis employs both cartographic and statistical solutions. The necessity not only of an interdisciplinary approach but also of a team approach to research is thus argued as an historical necessity here, and in Krieger’s work, as a modern necessity. This journal’s issue in appreciation of Krieger does not honor the social epidemiologist as an honorary geographer. Rather, it recognizes the cooperative engagement of the challenge disease has always made to researchers from a range of disciplines. To be understood disease outbreaks must be seen as spatial realities embedded in specific geographies. To be understood, those outbreaks are of necessity conceptualized as numerical or statistical as well as clinical phenomenon. In this, the epidemiology at the heart of public health, medical cartography and the geographic perspective supporting it has always been a player, recognized or not. Krieger’s work brings that history to the fore, teaching geographers as much as it teaches epidemiologists. References Booth, C. (1889). Life and labour of the people in London (Vol. 1). East London. London and Edinburgh: Williams and Nargate. CDC. (2008). Centers for Disease Control West Nile Virus Home Page. Retrieved May 31, 2008, from http://www. cdc.gov/ncidod/dvbid/westnile/. Chadwick, E. (1843). Report on the sanitary condition of the labouring population of Great Britain; a supplementary report on the results of a special inquiry into the practice of interment in towns made at the request of Her Majesty’s principal Secretary of State for the Home Department. London: Clowes. Cliff, A. D., & Haggett, P. (1988). Atlas of disease distributions: Analytic approaches to epidemiological data. London: Blackwell.

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