Black Midwives: A Labor of Love and Change

Black Midwives: A Labor of Love and Change

A midwife–especially a Black midwife–can tilt the balance between life and death for African American infants and their mothers. Regardless of income and education level, childbirth for Black women is more dangerous than it is for White women. Even Serena Williams had a dangerous close call during her pregnancy, after doctors failed to heed her request for a CT scan and blood thinner medicine. Despite her history of blot clots, it was posited that “Williams’ pain medication must be making her confused.”

The Centers for Disease Control reports that African American mothers die at three to four times the rate of White women, and the mortality rate of Black infants is higher than that of any other ethnic group in the US. Why? As AmericanProgress.org states in a 2019 policy blueprint, “Racism is part and parcel of being black in the United States, and it compromises the health of African American women and their infants… Put simply, structural racism compromises health.” According to Dr David Williams, a pioneer in measuring the effects of racism on health, “We now know that discrimination is linked to higher blood pressure, to high levels of inflammation, to low infant birth weight…”

Enter the Midwife

One action that promises to change these dire statistics is expansion of the midwifery movement, especially within the African American community. Angela Doyinsola Aina, interim director of the Black Mamas Matter Alliance (BMMA) recently told an American Public Health Association (APHA) conference, “We have to go beyond just talking about giving people, especially low-income people, access to care…. We also need to ask whether that care is high quality and culturally relevant.”

Where do Black midwives come into the picture? ProPublica notes in a report on how increasing the role of midwifery in the US could reduce maternal complications and mother/infant mortality rates, “Many… [US] states characterized by poor health outcomes and hostility to midwives also have large black populations, raising the possibility that greater use of midwives could reduce racial disparities in maternity care.” And Lamaze.org suggests, “When Black families are cared for by Black health professionals, like midwives, they are better heard, seen, respected, understood, and get their needs met, which relates directly to health outcomes.”

One of the women at the forefront of the Black Midwives movement is Jennie Joseph, founder of the Birth Place in Winter Garden, FL. Joseph’s work as a provider of perinatal services to underserved and uninsured women of color has already brought about positive change in the CDC numbers. Trained in the UK, where half of all babies are delivered by midwives, Jennie Joseph arrived in the US to find that in the most affluent country in the world, owing to concerted opposition from doctors and hospitals, midwives attend only 10% of all births. She also found that the US has a much higher incidence of maternal and infant mortality rates—particularly among minorities and the disenfranchised—than in countries such as Canada, Sweden, and the UK, where midwives attend the majority of births.

Joseph’s “open access” clinic at the Birth Place provides pre-natal and post-partum care for women regardless of their ability to pay and focuses on minority and underserved women in the area. As Miriam Zoila Perez marveled in the New York Times, the Birth Place manages to beat the dire maternity figures for women of color: “When you look into her statistics, you find something quite rare: Almost all of her patients give birth to healthy, full-term babies… maybe not surprising until you learn that the majority of them are low-income African-Americans, Haitians and Latinas….”

Expanding the Midwives’ Movement

Another pioneering Black midwife is Shafia Monroe, who has long been one of the major forces behind the Black midwives’ movement. Founder of the International Center for Traditional Childbearing (which was re-formed in 2018 as the National Association to Advance Black Birth) and winner of a Lifetime Achievement Award from the Human Rights in Childbirth Foundation, Monroe started working with mothers and infants as a nurse’s aide in the postpartum ward at Boston City Hospital at the age of 17. It was in 1991, when she encountered difficulties in finding a midwife of color for her own pregnancy, that Monroe founded her influential International Center for Traditional Childbearing. Under the auspices of the ICTC, she became a pioneering figure in the cause of Black midwifery. Monroe has worked tirelessly to reduce mortalities linked to pregnancy and to increase the number of Black midwives and doulas. To women who are interested in becoming midwives, Moore urges, “Join an organization! There’s MANA (Midwives Alliance of North America), ICTC, ACNM (American College of Nurse Midwives); there’s so many organizations. Look into organizations that are familiar with black reproductive issues, and our history.”

As the co-director of Black Mamas Matter Alliance (BMMA), Elizabeth Dawes Gay, says, “If even one more person just says they want to take up the cause, they want to become a doula, they want to become a midwife, they want to start an organization—to me that’s a success.”

Coronavirus: How to Address Your Patients’ Concerns

Coronavirus: How to Address Your Patients’ Concerns

The world is watching the developments related to this new coronavirus, officially designated 2019 Novel Coronavirus or 2019-nCoV, As a nurse, you may be wondering what to tell your patients about this life-threatening virus. 

Coronaviruses are so named due to their particular shape, which is similar to a crown. They are very common; many are responsible for the upper respiratory infections from which we often suffer and treat their symptoms with rest and over the counter medications. But occasionally coronaviruses become much more serious, as in the cases of Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS)

To help you educate and prepare your patients, we’ve provided some basic information and tips to help them avoid panic and stay as healthy as possible.

By the Numbers

As of this writing, there have been 31,472 confirmed cases of 2019-nCoV, according to the real-time status map from Johns Hopkins University’s Center for Systems Science and Engineering. The majority of cases have been in mainland China and surrounding Asian countries. There have been 638 deaths thus far, all of which were outside the United States. In North America, there are twelve cases confirmed in the US, five in Canada, and none in Mexico at this time. No deaths have occurred in North America.

Who is Most Susceptible?

You should be concerned about any patient who has recently traveled to China and is symptomatic. You should also be concerned about any patient who has been exposed to a lab-confirmed 2019-nCoV within fourteen days of the onset of symptoms. For any patients presenting with a fever and cough, you should obtain a detailed travel history.

As with most viruses and illnesses, the most medically fragile are those who are most at risk. The Journal of the American Medical Association (JAMA) reports the median age of patients is 49 to 56 years, with rare cases in children.

Do Face Masks Help?

There have been many news reports of Asian retailers of medical face masks being out of stock, as people rush to purchase them for protection. Unfortunately, these masks give a false sense of protection against the disease for healthy persons, as coronavirus is not airborne, and they do not prevent the wearer from putting their hands behind the mask to touch their face. The CDC is not currently recommending the use of facemasks for the prevention of coronavirus. However, they can be beneficial for infected persons to prevent them from coughing or sneezing into their hands and thus more readily spreading the disease.

The best prevention tactics are the very same as the CDC recommendations for the common cold, says Neha Pathak, MD:

  1. Wash your hands thoroughly and regularly throughout the day.
  2. Avoid touching your eyes, nose, and mouth with unwashed hands.
  3. Avoid contact with people who are sick.

What to Look For

Symptoms of coronavirus can appear in as few as two days or as many as fourteen after exposure to the virus, according to the CDC. Some of the most common symptoms are fever, cough, and shortness of breath. People who suspect that they may have been exposed should contact their doctor immediately.

Treatment for coronavirus is the same as for a cold- namely supportive care – rest, fluids, and over the counter medicine for sore throat and fever. But if the symptoms worsen, those individuals should contact their physician.

What About a Vaccine?

There are multiple efforts underway to create a vaccine for 2019-nCoV, however, there are none expected to be ready for deployment until approximately April of 2020. One of the potential vaccines is the previous labors to develop a vaccine for the coronavirus SARS, which was shelved before reaching clinical trials. The vaccine was shelved when SARS was defeated by improved hygiene efforts. 

The second potential vaccine is under development in Boston, an mRNA vaccine that is showing promise. The earliest trials with people show a good immune response, but the vaccine has not yet been tested in an outbreak. There are reportedly other vaccine candidates being developed as well.

For daily updates on the worldwide developments of 2019-nCoV, in addition to the real-time map from Johns Hopkins, you can follow WHO’s daily situation reports or the CDC’s Situation Summary.

Improving Kids’ Hand Hygiene Skills: A Global Campaign

Improving Kids’ Hand Hygiene Skills: A Global Campaign

Healthcare providers all over the globe are fighting the good fight, working to inculcate healthy hand hygiene habits among youngsters.

In Ottawa, Canada, schoolchildren aged 6 through 9 are following the World Health Organization’s (WHO) six-step hand-washing routine while singing kid-approved lyrics to the tune of “Frere Jacques”:

“Scrub your palms, between the fingers

Wash the back (one hand), wash the back (other hand)

Twirl the tips (one hand) around (other hand)

Scrub them upside down

Thumb attack (one thumb)! Thumb attack (other thumb)!”

To test the effectiveness of the didactic sing-and-wash routine, researchers applied fluorescent marks to the kids’ hands prior to hand-washing and checked for the reduction of the markings afterwards.

In southern India, researchers from the University of Glasgow in Scotland and Amrita Vishwa Vidyapeetham University have been conducting their own experiments in improving kids’ hand hygiene. At a government primary school in Kerala, 45 Indian students ages 5-10 were trained in hand-washing skills while guided by an anthropomorphic hand-shaped attendant named Pepe.

Mounted on a wall beside the school’s hand-washing stations, Pepe consists of a basic robotic arm assembly with a plastic hand and a videotronic “mouth” through which he “speaks” to students as they wash. As kids clean their hands, Pepe refers them to an illustrated poster depicting an eight-step hygienic hand-washing routine, and “follows” their progress with his moveable eyes. Pepe has taught students to wash their hands before meals and after using the toilet, and overall has improved their hand-washing skills by 40%, according to the researchers.

In addition to the marked improvement in the children’s hand hygiene habits, Pepe was a hit. Over 90% of the students said they would like to see Pepe again after their summer holiday, and “over seven in 10 of them thought Pepe was alive, largely due to its ability to talk.”

Other projects focus on the spreading of germs to emphasize the importance of proper hand hygiene. During a height-of-flu season lesson at Angie Grant Elementary in Benton, Arkansas, a school nurse, Ronda Wagner, collaborated with second-grade school teacher Anna Lawrence to depict the ease with which germs can be transferred. They coated a soft football with a special powder, which students then tossed among themselves in the room. Afterwards, viewing themselves under ultraviolet light, the kids could see that the powder had spread—not only to their hands—but also to their faces and arms.

The Centers for Disease Control (CDC) presents compelling reasons to encourage training in hand hygiene at an early age. According to the CDC, hand-washing education can:

  • Reduce the number of people who get sick with diarrhea by 23-40%
  • Reduce diarrheal illness in people with weakened immune systems by 58%
  • Reduce respiratory illnesses, like colds, in the general population by 16-21%
  • Reduce absenteeism due to gastrointestinal illness in schoolchildren by 29-57%

And if plain statistics on hand hygiene are too dry for youngsters with dirty hands, you can always refer them to the revolting findings of the (figuratively) viral “Bread” science project of behavioral Specialist Jaralee Annice Metcalf in Idaho.

Anti-Vax Groups Attack Pediatrician for Pro-Vaccine Post

Anti-Vax Groups Attack Pediatrician for Pro-Vaccine Post

“Dead Docs Don’t Lie”

When Nicole Baldwin, MD, made a playful TikTok touting the benefits of vaccination, she wasn’t expecting to fight an endless social media battle that destroyed her online ratings — and even led to a threat against her life.

In her TikTok, Baldwin, a pediatrician in suburban Cincinnati, listed a handful of diseases that vaccines prevent to the pop song “Cupid Shuffle,” ending on the note that vaccines don’t cause autism.

It wasn’t an instant hit when she posted it on Saturday, Jan. 11, but by Sunday it had 50,000 views so Baldwin decided to share it on Twitter.

“That’s when everything exploded,” she told MedPage Today.

Members of the “anti-vax” community discovered it and launched a “global, coordinated attack,” posting negative comments across Baldwin’s social media pages including her Facebook and Twitter.

They also went for the jugular: knowing that a physician’s online presence is critical, they barraged her online review sites, including Yelp and Google Reviews, with one-star reviews to sabotage her practice.

Some even called her practice, Northeast Cincinnati Pediatric Associates, and harassed the staff. One woman — whom Baldwin described as “very angry” — threatened to “come and shut down our practice,” prompting Baldwin to call the police.

But most intimidating was a post from an anti-vax Facebook group that said, “dead doctors don’t lie.”

“Shots Heard Round the World:” A Pro-Vax Sheriff in Town?

“Ultimately what the anti-vax community wants is to scare us into silence,” she told MedPage Today.

Baldwin first tried to stem the tide on her own by deleting comments and reporting abuses. Then she enlisted the help of a friend, and then her husband, until it became too much to manage — which was when she called in Shots Heard Round the World, a network of vaccination advocates who describe themselves as a “rapid-response digital cavalry.”

Founder Todd Wolynn, MD, a pediatrician in Pittsburgh, knows what it’s like to be on the receiving end of a global social media attack from anti-vaxxers. In 2017, his practice Kids Plus Pediatrics posted a video promoting HPV vaccination that triggered a massive blast from the anti-vaccine crowd.

Some 800 different accounts posted more than 10,000 negative anti-vax comments to the practice’s Facebook page, Wolynn said. Associates of Shots Heard who had infiltrated some of the anti-vax Facebook groups sent him screen shots of commenters who were celebrating their efforts of posting bad online reviews for the practice.

The 6-day onslaught against Kids Plus Pediatrics resulted in an academic publication that was widely picked up by the press, including the Los Angeles Times and the Washington Post.

Baldwin had learned about Shots Heard through a talk Wolynn gave in Ohio and had signed up to be part of that team. Little did she know she’d be the one needing the help.

“One doctor has no time to handle all of this,” Wolynn told MedPage Today. “We have a vetted rapid-response network that can come to your aid.”

He said anyone can send an email to the Shots Heard alert box, and once it’s vetted, the request for online help is distributed through an email blast to their network of vaccine advocates — other doctors, nurses, paramedics, parents, and others who promote vaccination science.

Baldwin said that since she allowed Shots Heard to take over her Facebook account, they’ve been posting positive comments and blocking commenters from her page; a total of 5,000 anti-vax accounts have been banned as of Monday night, she said.

“Docs Need to Know That There’s Help Out There”

Shots Heard is also helping to get the fake online reviews taken down, which is never easy, particularly with Google, Wolynn said. But ongoing media coverage likely pressed the tech giant into taking down the reviews, Baldwin said.

Yelp, which has a process for removing fake reviews, took most of them down and posted a box on the page noting that the practice has been in the news recently. Some fake reviews could still be seen on the page on Monday night.

“They’ve been amazing,” Baldwin said of Shots Heard. “Doctors need to know that there’s help out there if we’re attacked. We don’t need to give in to these bullies.”

While there’s been debate in the medical community over the utility of TikTok for sharing messages about medicine and health, Baldwin said she won’t be quitting anytime soon, and that it’s an effective way to reach the young people who are her patients.

That includes aspiring physicians, she said: “I’m getting messages from young people who say they want to go to medical school, asking about classes.” She adds, “It’s also showing that doctors are human and can have fun.”

by Kristina Fiore, Director of Enterprise & Investigative Reporting, MedPage Today

Originally published in MedPage Today

Border Flu Shot Protest: 4 Docs arrested

Border Flu Shot Protest: 4 Docs arrested

Four physicians and two others protesting their inability to vaccinate migrant detainees at the U.S. Customs and Border Protection (CBP) headquarters here were arrested last Tuesday for failing to comply with federal orders to disperse.

They were held for about an hour, according to some of those who were arrested.

The two groups of protesters — about 60 people in total — had gathered in two driveways leading to CBP headquarters for about an hour when one of the groups received a warning from federal officials that if they stayed in the driveway, they would be arrested, said Marie DeLuca, MD, an emergency room physician from New York who was one of those arrested. Some of the members had blocked the driveway by laying down across the road while others chanted, “No more death.”

“We stayed peacefully in the driveway entrances of their building and said that if they weren’t going to let us in to vaccinate against the flu, we were going to remain. They didn’t let us. Instead they chose to arrest members in one of the two groups,” DeLuca said.

She said her hands were secured behind her back with zip ties by officials from the Department of Homeland Security (DHS) as she and the other protesters were led into a conference room and told to wait. After about an hour following the protest, they were issued tickets with a court date for “failure to comply with the lawful direction of federal police officers or other authorized individuals,” and then released, she said.

A San Diego Union-Tribune reporter posted a video of some of those doctors being arrested.

At about 2 p.m. Tuesday, DHS’s press secretary tweeted a picture of the protesters and said, “Of course Border Patrol isn’t going to let a random group of radical political activists show up and start injecting people with drugs.”

Sen. Elizabeth Warren (D-Mass.) also tweeted a link to a video of the protesters, saying that “Children are dying in CBP custody due to the flu. Refusing to administer flu vaccines is neglectful and cruel.”

Other doctors arrested, who were part of the group Doctors For Camp Closure, included Mario Mendoza, MD, a former anesthesiologist who now lives in New York City and runs the organization Lifeundocumented.org; Hannah Janeway, MD, an emergency room physician in Los Angeles who helps run the Refugee Health Alliance; and Mathieu De Schutter, a pediatric hospitalist from San Luis Obispo, California. The non-physicians arrested were Rebecca Wollner of Jewish Action San Diego and Matthew Hom, a graduate student from Cerritos, California, who works with the group Never Again Action.

On Monday, the physicians began their three-day vigil and protest of federal immunization policies at the gate of the detention center in San Ysidro at about 11:30 a.m. They stayed until about 4:30 p.m. with no response despite repeated requests. Tuesday’s action took place nearby at the Chula Vista CBP headquarters.

DeLuca said the doctors and their supporters planned to return Wednesday to try one more time to administer the 120 influenza vaccines they brought with them for the detainees. They say it’s important for public health, not just to protect these detainees, but also everyone else they come in contact with.

Members of the groups chanted slogans and carried banners and signs calling on federal officials to let them administer the vaccinations to those inside. The vaccines were purchased with financial donations.

Originally published in MedPage Today.

The Problem of Pain: Prescribing Opioids to Addicted Populations

The Problem of Pain: Prescribing Opioids to Addicted Populations

Between 2006 and 2012, more than 32 million prescription pain pills circulated through Berkshire County, Massachusetts, a rural area of about 130,000 people.

Patients recovering from opioid addiction are seen at the local emergency department every day, according to Martha Roberts, a critical care Nurse Practitioner (NP) and Georgetown University School of Nursing & Health Studies alumna. Roberts works in Berkshire’s emergency department, which sees 50,000 patients per year — more than a third of the county’s population.

“It’s challenging,” she said. “It’s also an opportunity to help those patients in a way that may improve their outcomes.”

Patients in addiction recovery aren’t exempt from the need for pain relief in the case of acute injuries, surgical operations, or chronic pain. Providers like Roberts are tasked with finding and offering alternatives to opioids.

How can clinicians balance the weight of ethical responsibility with a patient’s need for immediate relief?

Opioid Dependence and Addiction in the United States

About 21% to 29% of individuals who are prescribed opioids misuse them, and 8% to 12% of them develop an addiction, according to the National Institutes of Health. Though only a small percentage of patients are likely to develop an addiction, there is still a chance of dependence, which is characterized by a physical reliance on the medication that, if unaddressed, can lead to addiction.

Even if the patient is not demonstrating symptoms of addiction, providers look for specific signs of dependence, according to Dr. Jill Ogg-Gress, assistant Family Nurse Practitioner (FNP) program director at Georgetown University.

“Opiate medications have side effects of dependence,” said Ogg-Gress, who works as a board-certified emergency NP in several Iowa and Nebraska emergency rooms. “If a provider recognizes that a patient is experiencing dependence, or if a patient demonstrates behaviors of dependence, it should be recommended to the patient they should talk to their primary care provider or the prescriber of the opioids.”

Signs of opioid dependence
  • Taking painkillers more frequently than prescribed
  • Taking higher doses than prescribed
  • Seeking a euphoric effect to counter physical pain
  • Experiencing excessive sleepiness or irritability

Taking these signs into account, providers can evaluate patients’ needs on an individual level to assess the magnitude of pain. If the patient is likely to develop a dependence, the providers may need to help them find an alternative treatment plan that is effective and sustainable.

Ruling out opioids altogether isn’t a realistic approach, Roberts said.

“There are still some painful injuries that will benefit from short-term opioid use,” she said.

Her key to implementing an effective treatment plan is working with the patient to assess their needs and openness to non-opioid pain medication.

Commonly Used Alternatives to Opioids

Opioids are a class of drugs that can be prescribed for pain relief but are highly addictive and illegal for consumption when not prescribed by a health care provider.

Individuals recovering from drug addiction might encounter injuries or surgical operations that require management of immediate acute pain or chronic pain in the long term. Providers can evaluate a patient’s needs when creating a treatment plan to manage that pain.

Pharmacological alternatives to opioids

Analgesics: Some of the most common painkillers can be obtained over the counter in small doses or prescribed in high doses by a health care provider. Roberts and Ogg-Gress agreed that these are the most common alternatives to opioid prescriptions.

Acetaminophen can be used for pain relief and fever reduction, but it does not reduce inflammation. It’s one of the most common pain relievers among Americans, used by roughly 23% of adults each week.

Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen can treat acute pain and inflammation. A 2018 report found that NSAIDs make up 5% to 10% of all medications prescribed each year.

Gabapentinoids: This class of drugs includes gabapentin and pregabalin and has been historically used for seizure prevention. It is available by prescription to address pain but only in circumstances set by the Food and Drug Administration. While these painkillers can be an alternative to opioids, Roberts said they are not her intervention of choice because studies show there are other, more effective alternatives.

When medication isn’t appropriate or preferable, many non-pharmacological options exist to relieve pain and suffering.

“There are a lot of other nonpharmacological therapies that are available, if people are willing to try it,” Ogg-Gress said. “Providers need to educate patients regarding these pain therapies instead of the common thought of, ‘Here, take a pill, swallow it, and you’ll feel better.'”

Non-pharmacological alternatives to opioids
  • Localized numbing
  • Ice
  • Massage
  • Exercise
  • Physical therapy
  • Acupuncture
  • Relaxation

Supporting Patients in Recovery

Every patient deserves time and attention to explain their case and their needs to a provider who is listening thoughtfully. Providers treating addicted populations must keep a constant eye out for identifying drug seeking behaviors, without stereotyping or wrongly assuming a patient’s motives. A 2016 report published by the National Institutes of Health described several types of drug-seeking behaviors:

Common Drug-Seeking Behaviors
Requests and complaints
  • Describing a need for a controlled substance
  • Asking for specific opioids by brand name
  • Requesting to have a dose increased
  • Citing multiple allergies to alternative pain therapies
Inappropriate self-medicating
  • Taking more doses than recommended by the provider
  • Hoarding a controlled substance
  • Using a medication despite not being in pain
  • Injecting an oral formula instead of consuming orally
Inappropriate use of general practice
  • Visiting multiple providers for controlled substances
  • Calling clinics when providers who prescribe controlled substances are on call
  • Frequent unscheduled visits, especially for early refills
  • Consistently disruptive behavior
Patterns of resistance
  • Hesitancy to consider alternative pain treatments
  • Declining to sign controlled substances agreement
  • Resisting diagnostic workup or consultation
  • Being more interested in the medication than solving the medical problem
Illegal activity
  • Obtaining controlled drugs from family members or illicit sources
  • Using aliases or forging prescriptions
  • Pattern of lost or stolen prescriptions

Clinicians who have identified these behaviors can use electronic medical records and crossover notes from other providers to see how many times a patient has sought medication for the same problem.

“People are here for assistance, but they’re not taking personal responsibility,” Roberts said. Engaging with patients to help them understand treatment plans can build a sense of agency over their own care.

Roberts said providers can help patients identify ways to care for themselves before writing a prescription for opioids. She recommended a gradual approach to trying different types of treatment:

A Step-Wise Approach for Pain Management

  1. Get to know the patient
  2. Use analgesics to address pain symptoms
  3. Use non-pharmacological treatments as intervention for side effects
  4. Encourage patient to stop smoking and drinking alcohol
  5. Eliminate foods that irritate the stomach or digestive system
  6. Reflect on previous steps: Did you really exhaust everything?
  7. Consider opioids as a last resort, and only enough to support immediate pain relief

Nurse Practitioners who work with a multidisciplinary team are uniquely positioned to provide holistic care. Clinicians serving communities with large addicted populations have to be familiar with law enforcement, social work organizations and, in the case of making a referral outside the clinic or emergency department, recovery programs and child protective services.

Roberts also acknowledged that providers working in communities fraught with addiction are at a high risk for fatigue. “If you have three back pain patients in a row, you’re going to be pretty burned out within two hours of working your shift, so you really, truly have to look at each case individually,” she said.

Taking time to self-reflect on personal motivations for treating patients can help remind providers of why caring for others is important to them.

“It’s hard to walk in and do a good job if you’re upset about the work you’re doing,” Roberts said. “Make sure you can do this without letting your own bias get in the way.”

Please note that this article is for informational purposes only. Individuals should consult their health care professionals before following any of the information provided.

Citation for this content: [email protected], the online DNP program from the School of Nursing & Health Studies

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