‘Reshaping global health’ – a radical proposal for global health?

What is it with shapes and global development? Seems a week doesn’t go by without someone proposing a new one. I wish I worked in sustainable development – they get food-inspired shapes like doughnuts. In public health you just get triangles. At least you used to. Now we have a proposal to consider from three well-known global health scholars: Mark Dybul, Peter Piot and Julio Frenk. They want to re-shape global health. They think it’s a radical proposal. Here’s what I think.

2000-2010: The decade of global health

“The opening ten years of the 21st century arguably were the decade of global health”

Arguably. Everything is arguable. We can describe health as ‘global’ to the extent that an ill-health-causing phenomenon affects us all (not necessarily equally) irrespective of where we are on the planet. So, climate change, for example, or sovereignty, or capitalism are global health problems. Because global health is not defined by how much money donor countries decide to give to certain health problems, a decade receiving more money for (some) health is no more ‘global’ than a decade (before or after) receiving less money.

Paris principles – paternalistic, moi?

From paternalism to shared responsibility and mutual accountability

“The rapid expansion in global health was part of a broader conceptual movement that created core principles for the use of resources in a new era in development”.

Let’s be clear: the ‘core principles’ – shared responsibility, mutual accountability, country ownership – are an extension of paternalism not a shift away from it. That’s not all that surprising: donors don’t like to just give their money away (a reality that has done for the Global Fund). Later on in their article, Dybul, Piot and Frenk worry that the recipients of donor money aren’t spending enough of it on health. Tell me if this isn’t paternalistic:

“It is essential that all countries contribute financial resources to the health of their own people. The very low levels of national financing for public health in certain countries, including emerging economies, are not acceptable. And nothing is more likely to halt interest in global health than recent data that some governments have treated increased international resources for health as an opportunity to redirect their own funding to other areas”.

I won’t go into the data and debate around this issue – you can read it here, here, and here. My general point is that the principles exalted by the authors (shared responsibility, mutual accountability, country ownership) perform a specific function: namely, to obscure the self-interest of the donors that devised them. You can imagine, if you wish, that relations between rich and poor are defined by such principles, but you’re fooling yourself if you do.

Jeez, Wilson, lighten up! You’re spoiling the mood.

Let’s take a closer look at one of these principles: shared responsibility. According to the authors: “key to shared responsibility is leadership and strategic direction”. Is it? No, it isn’t. First and foremost, responsibility is individual responsibility, which can evolve into collective responsibility. It is fundamentally not about leadership. But also key to responsibility is doing what you say you’re going to do. It builds trust. If there’s trust, then there’s more chance you’ll actually do what you said you were going to do – something leaders are extremely bad at doing (see here, or here for example).  

But don’t worry, Dybul, Piot and Frenk have a plan for getting countries to spend the money they are given on the things that donors want them to spend it on. They call it “transition planning for financial responsibility” – yes, I know, gripping. The authors think it’s the real deal.

“It is difficult to conceive of a more effective way to create shared responsibility and mutual accountability that would transform health care”.

Not that difficult actually.

First, we shouldn’t start from the assumption that we have sufficient knowledge, experience, insight, or wisdom to design and implement a framework for global health without, apparently, any consultation from anyone else, particularly not from those recipients of our largesse. Has anyone actually asked the authors if they could re-shape global health for us? Here’s a radical idea: ask developing countries to come up with their own framework for what they want the world to look like.

Ha-Joon Chang also does his own laundry

Second, recall that the last half-millennium of European intervention has been premised not on a sense of shared responsibility but on the principle of kicking away the ladder – enriching ourselves and then preventing others from enjoying the opportunities for wealth creation that we have enjoyed. Recall also that ‘shared responsibility’ – lets just call it responsibility – is a cross-cutting theme. This means that we have a responsibility to join the dots between what we give to other countries to support their health systems and what we take away again with development strategies such as agricultural subsidies or debt servicing.  

And third, don’t start from the premise that countries receiving development assistance don’t know how best to spend the money they receive. There are lots of reasons why money for health isn’t spent on heath, one of which is that recipient governments know all too well how unpredictable donor funding can be, and they are (sensibly) insuring themselves against a fall.

A rational global health strategy?

With global health leaders having demonstrated no rational, joined-up, thinking about global health throughout the so-called golden years, our esteemed trio now think it’s time to get rational. One of the great mysteries of public health is how so much policy is influenced by so little evidence. Ideas, it seems, are simply plucked out of a hat, announced to the world, and then left to stagger into a ditch somewhere. When sensible people call on their governments to get rational – on drug policy, for example – they are sacked.

The problem with rationality is that it is always trumped by political ideology. So, for example, if a government wanted to privatise its country’s health service it would, regardless of the evidence showing that that would not be in the best interests – or health – of its electorate. Furthermore, as Ted Schrecker put it recently, rationalism neglects “the power of actors standing to gain from the continuation of business as usual”. 

Nevertheless, rationality is what the authors want to bring to global health policy. The past irrationality stemmed from a “focus on specific diseases” (like HIV/AIDS) that “has imposed and exposed fault lines in delivering services in places where many suffer from multiple health issues at the same time”. Yes, ok, we’ve heard this vertical-horizontal debate before. I would just note that PEPFAR, which Dybul led for quite a few years, had its part to play in promoting a vertical, single-issue health agenda. But let’s not dwell on that. What the authors now propose is an “integrated approach focused on the health of a person and community”. Great, sounds good to me. So, how do we get there?

The sound of one idea clapping: a Bretton Woods agreement for global health

“It is time for a Bretton Woods-style agreement to guide a new international health strategy and rationalize its structure”.

In the mosh pit of global health policy only certain ideas survive. Academics spend a happy time trying to understand which ones prevail. There are currently a lot of ideas swirling around, jostling for purchase in time to influence the RioPlus20 agenda. Hopefully, we’ll learn the lessons of the MDGs and not have another set of development goals. Dybul, Piot and Frenk have a ‘big’ idea – a Bretton Woods agreement for global health.

There isn’t much detail in the article about what a Bretton-Woods agreement for global health would entail. It would, however, be led by the G20 “with the active engagement and leadership of the emerging economies and other middle- and low-income countries”. The aim of this agreement would be “to rationalize the institutional structure of global health”. If we weren’t being charitable, we might point out that the G20 is not an obvious choice to lead the rationalization process. Devi Sridhar has blogged here about some of the problems facing a G20-led approach to global health, highlighting weak representation, low capacity and lack of political will as problems that the group would have to overcome. 

Actively engaging “emerging economies” is also a strategy built on quick sand, not least because the rate of those economies’ growth is rapidly slowing down. And yet the authors see this politically disparate group of countries as essential for sustainable financing:

“To achieve sustainable financing, the direct and deep engagement of emerging economies and other middle- and low-income countries is essential”.

Dybul, Piot and Frenk need to step out of the health silo for a minute and take a look around them. To achieve sustainable financing, banks need to be regulated and transparent in their investments. Governments need to re-introduce the Glass-Steagall Act immediately as one way of separating casino and savings banks. That goes to the surface of the matter, if not the heart. To go to the heart of the matter requires a fundamental rethink of socio-economic relations. We have an opportunity to do that now, to look honestly at how the original role of the Bretton Woods institutions evolved from reconstructing European economies during the the 1940s-60s to deconstructing ex-colonial economies during the 1970s-90s in the name of neoliberal economics –  immiserating millions in the process . I think Pinky’s perspective is spot on here.

The Pinky Show: Banked into submission: the globalizationists guide to developing poverty

“As we approach the post-MDG era, now is the time for a new framework to establish an accelerated trajectory to achieve a healthy world.”

Dybul, Piot and Frenk have a new framework for us, the basic principles of which are: focusing on the health of persons, but also communities (yes, I know, you may be wondering ‘you mean, we haven’t been focusing on these groups?)’; health as a public good; and human rights. These principles aren’t developed further. Shame. Here’s an interesting question to think about in relation to health as a public good: who provides it? The Bretton Woods financial institutions – the World Bank and the IMF? Read Rick Rowden’s book on the IMF to find out why that is extremely unlikely. Unfortunately, it is precisely these institutions that the authors have in mind as principal financiers of their re-shaped globe.

The new principal financiers of global health

They give us two options: create something new or reform the World Bank and/or the Global Fund. The authors are open to ideas for the ‘something new’ category, but the bottom line is that donors don’t trust country-level pooled-funding anymore and might be more attracted to a globally-pooled fund. In fact, one gets the sense that the ‘something new’ category isn’t really an option on the table. Later on, for example, we hear a call for ”a certain degree of healthy pluralism and competition…that keeps principal financiers and multilateral and bilateral partners in the game”. So, nothing new, in fact.

To reiterate, what we really need are “innovation and competition”. And I bet you can guess where that’s going to lead us? Not surprisingly, the authors are keen to emphasise the importance of the private sector – hardly the champions of innovation or competition, as the pharmaceutical industry’s opposition to generic drug manufacture makes clear. And they’d like to see the private sect..sorry, I mean “greater engagement of nonhealth stakeholders” to “maximize [the]  key convening authority” of the World health organisation.

“The key role of the private sector is finally being recognized as an important element of global health and development. The private sector could play a particularly useful role in rationalizing the structure of global health”.

Unfortunately, there is not further elaboration on this, but perhaps they were thinking of the sugar industry’s strategy for health (the subject of an excellent piece of journalism here), or the alcohol industry’s concern for our livers, or the soft-drinks manufacturers’ interest in our teeth, or burger MNCs’ concern about our waistline, or private healthcare providers’ interests in our wallets? The private sector has NO useful role in structuring global health, but it is doing it nonetheless – to our collective detriment.

You’re ideas are unrealistic, my ideas are big

The authors end with some puzzling mixed-messages: “The era of advocates demanding unachievable new commitments, and organizations and leaders acquiescing with the full knowledge that they are unreachable, must end”. But not, presumably, until you’ve read and acted upon the ideas presented in the authors’ paper? “Repeatedly setting unachievable targets and failing to meet them shatters a sense of accountability and perpetuates commitments that no one intends to keep. But that does not mean big ideas should not be pursued”. Because, if it did, then I guess there would be no reason for us to take your ‘big ideas’ seriously, would there?

A Bretton Woods agreement for global health?

So, what do we have? The authors say they are presenting “a radical vision”. As a rule of thumb, if you have to describe your idea as radical it probably isn’t. But take time to look at the detail. Maybe you will see something good here. All I can see are further retrenchment of paternalistic development principles, the same global health financiers financing global health (albeit now with more control over what and how that money is spent), and a greater role for the private sector in global governance.

We simply don’t have time for this ‘big idea’. 

Andrew Harmer




11 thoughts on “‘Reshaping global health’ – a radical proposal for global health?

  1. On the question of which institutions can be trusted with provision of public goods, and why I don’t think the Bretton Woods financial institutions are the right ones for the job, I can’t resist sharing this factoid from a recent paper on ethics and climate change by Jerome Singh:

    “Alarmingly, an estimated 6,000 and 10,700 annual deaths just from cardio-pulmonary diseases and cancer can be attributed to the 88 coal-fired power plants and companies that received public international financing, including from the World Bank. Further, more than US$37billion in direct funding and over US$100 billion in indirect financial support for new coal-fired generation has been provided by multilateral development banks and export credit agencies since 1994, compared to the $6.36 billion mobilized by the United Nations Global Environment Facility for climate change mitigation over the same period”.

    Why Human Health and Health Ethics Must Be Central to Climate Change Deliberations, PLOS, 2012

  2. Thanks Andrew for the comments.

    I also felt a bit uncomfortable when I read the article by Dybul et al. last week. By the way, I notice that you criticize the scholars for trying to give public health explanations for the “rational” behavior of donors. Maybe we shouldn’t shy away from calling a cat a cat. Aid business is part of the bigger global business picture in which the outcomes that we, global health experts, pretend to be ‘measuring’ have very little to do with outcomes expected by the fat cats on the giving end. This
    cartoon (‘Pompe Afrique’)
    summarizes it neatly, in my opinion.

  3. Andrew –

    A thoughtful critique, though it seems a little one-sided. If your point is that the authors are nothing more than the henchmen of well-heeled neocolonial interests, I don’t agree. On the contrary, I think they are deeply committed to doing good and we probably ought to be working with them. Moreover, the attributes you suggest are part of a plan to maintain the social order – shared responsibility, mutual accountability, country ownership – don’t seem all that bad to me. In fact, I think they can be quite good when implemented properly. I’m not saying they can’t be twisted for evil purposes, but I also don’t think they should be removed from the global health / development toolbox.

    That’s not to say I completely disagree with you. I think you are right to be skeptical. My favorite line: “Ideas, it seems, are simply plucked out of a hat, announced to the world, and then left to stagger into a ditch somewhere.” This is really quite good and unfortunately all too true. And I think it perhaps most accurately gets at the potential weakness of the authors suggestions. Bottom line, I’m not sure their proposal is going to get us to a better place but I think the attempt to move us forward is rather laudable.


  4. Dear Andrew,

    So what if we try to be ‘fraternalistic’ about global health, for a change, not ‘paternalistic’? What if we acknowledge that the health of ALL ordinary people, in ALL countries of the world, will increasingly depend on cooperation between states and between people beyond state borders? What if we acknowledge that most public health improvements have been the result of public spending – for water, sanitation, and healthcare – not private spending, and that all public spending is now at risk because of what Thomas Friedman called the Golden Straitjacket (competing for investments and high skilled workers, states are forced to decrease taxation)? What if we throw sympathy, empathy and compassion for ‘poor people in poor countries’ overboard, and acknowledge that it is about us, about ALL of us ordinary people in ALL countries of the world?

    It is not an easy exercise, because sitting in Belgium or England or Italy, we do care about children dying in Burundi or Mozambique, and we cannot easily pretend that we don’t. But we must, to shake off the suspicion of ‘paternalism’: we are looking at our brothers and sisters, ordinary people like we are, and we are trying to find solutions for problems that are common to all of us. Sure, for now problems in Burundi and Mozambique are far worse, but this is only a matter of time: look at what’s going on in Greece right now; it is coming to Belgium and England and Italy too.

    Would we come up with solutions that are fundamentally different from what Mark Dybul, Julio Frenk, and Peter Piot propose? (http://www.hoover.org/publications/policy-review/article/118116) I don’t think so.
    * We would propose global health to focus on people, not on diseases. That’s what Dybul, Frenk and Piot do.
    * We would emphasize the importance of public health efforts, as opposed to private and privately financed efforts. That’s what Dybul, Frenk, and Piot do.
    * We would refer to international human rights law, as tools to help clarify the relationship between duties of states towards inhabitants and duties of the international community towards states needing assistance. International human rights law is not a perfect tool for global governance, but it beats ‘realism’ or ‘anarchy’. And referring to international human rights law is what Dybul, Frenk, and Piot do.
    * We would emphasize the role of the WHO. That’s what…
    * We would propose the possibility of international taxation, in addition to national taxation.
    * And we would call for a BIG cnference, to fine-tune all of this. Now, Andrew, you know that I’m not a big IMF and World Bank fan. When I visit Bretton Woods, I feel like visiting Berlin, where the colonization and exploitation of most of Africa by a handful of European states was r’regulated’. So I would never propose to hold a meeting about global social protection – because that is what is at stake – at Bretton Woods. For symbolical reasons, I would propose to have the conference at the opposite side of the globe, that is in Adelaide, Australia. But is that a sufficient reason to trash the entire proposal? I don’t think so.

    Andrew, I think you’re trashing this proposal because of your preconceived assumptions about Dybul’s, Frenk’s and Piot’s intentions. If only you would try to see their proposal as one with fraternalistic (not paternalistic) intentions, you may see its true value. And frankly, I think you’re wrong about your assumptions, and awfully self-righteous about thinking that your intentions are any better.

    Take care,


  5. David, Nathan, Gorik, thanks for your replies. It makes a change to have real people leave comments. Usually, I just get computer-generated spam. Just to reply to some of your points:

    Yes, this is a one-sided response to the authors’ paper (which is also one-sided). I make no apologies for that. In fact, the main reason why I do the blog is so that I can write what I think without having to qualify every statement with ‘on the other hand’.

    I’m not interested in who the authors are: I know of them, of course, but don’t know them. The planetary gravity they command when it comes to influencing policy is undeniable – Piot has a moon orbiting his office at LSHTM. So when they write, people listen – and maybe even act. Ideas like theirs have the power to distract and divert energy, resources and time. I don’t think their ideas or arguments stack up but care enough to say why.

    Nathan, I’ve never met a ‘henchman of well-heeled neocolonial interests’ but would be interested to read their job description – must have own black cape? I do, however, like Chomsky’s seminal essay on the responsibility of intellectuals, where he argues that: “Intellectuals are in a position to expose the lies of governments, to analyze actions according to their causes and motives and often hidden intentions”. Anyone interested in global health should start with this.

    I think that concepts like ‘shared responsibility’, ‘mutual accountability’, or ‘country ownership’ are meaningful to the extent that they are upheld. You can trot them out over and over again, but if – when it matters – governments just turn their backs on them and act unilaterally, then where’s the meaning? Look at Germany’s recent – unilateral – decision to suspend funding to the Global Fund. There was zero discussion of their intentions to do this with their other so-called ‘partners’. Kazatchkine, like everyone else, woke up one morning to read about the decision in the newspapers.

    These concepts have moral value to the extent that they evolve mutually, freely and democratically. Country ownership? On the one hand, there are examples where governments have acted against the advice of the Bretton Woods institutions (Malaysia, for example, during the 90s) to protect their national economies, and this could be described as a government taking back ownership of its economic policy. On the other, countries like Jamaica have almost completely lost control of their national economy to multinational corporations. In this sense in what way could ‘country ownership’ be taken seriously? A ‘rational’ international health policy would reflect these experiences, not ignore them.

    Gorik, I commented on paternalism because Dybul introduced it in his paper, and because later on he appeared (to me at least) to be paternalistic in suggesting that countries didn’t know how best to spend their aid money (see the text in red – I may be misinterpreting this part of their paper). I don’t disagree that fraternalism sounds better than paternalism, but how is that different from saying that we should just all learn to love one another? Anyway, it makes no sense to attribute these characteristics to states, or governments.

    You ask: “Would we come up with solutions that are fundamentally different from what Mark Dybul, Julio Frenk, and Peter Piot propose?” Well, solutions to what? Obviously, the aim should be to improve people’s health not just diseases. This is indisputable! Odd to be told it by people who have spent a good portion of their lives working on single diseases (however important this is), but I suppose we can all be wise after the event.

    Yes, emphasize the importance of public health. But what, then, do you make of suggestions in the article towards greater flexibility for private sector financing? I’m guessing you may have something to say about the authors’ general assertion: “The key role of the private sector is finally being recognized as an important element of global health and development” – including a greater role for this sector in the WHO. On the WHO, emphasizing that it must have a key role doesn’t help – financing does. It needs more money from its members. Will principal financiers provide the short-fall?

    I agree with the authors when they say: “Silos in health not only make little sense to local providers, they make little sense to policymakers”. But the same must be true for ‘global’ health too. In which case it would make more sense to have principal financiers for something cross-sectoral, like sustainable development, rather than just for global health – something like a global fund for sustainable development? This is not what the authors are proposing. We agree that neither the World Bank nor the IMF would be appropriate guardians of global social protection, but one of these institutions is suggested as a key contender for the throne of principal financier.

    Gorik, it seems to me that you have selectively chosen the bland bits of the paper that most people would agree with – public health, WHO, human rights, people – and glossed over the bits which I assumed you’d be more interested in, and which interest me: a greater role for the private sector and the World Bank, rationality and policy, the possibility for global social protection under this new proposal.

    To reiterate, it’s the ideas and arguments presented in the paper that interest me – and which should interest anyone working in ‘global’ anything. Sure, I have some preconceived ideas about how the world works – as does everyone. I don’t know what the authors’ intentions were in writing this paper – how does anyone know that? But it’s papers like these that set agendas, and the authors will know that. So if we are going to reshape global health, I’d like it to be an inclusive process, based on need guided by those most in need. But, yes, well-heeled, white men can contribute too.

  6. Dear Andrew,

    While I do agree with Noam Chomsky about one of the responsibilities of intellectuals – i.e. unmasking the hidden intentions of government policies – I don’t think that this applies to Mark Dybul, Julio Frenk, and Peter Piot. As far as I know, they do not or no longer represent governments. I certainly would not refer to Germany’s attitude towards the Global Fund to build a case about the intentions of Dybul, Frenk and Piot.

    Perhaps we should use the ‘freedom of the blogs’ to build our own best case scenario for global health, instead of deconstructing others’ attempts. True, there are no moons orbiting our offices and we are not invited to write for Policy Review, but that does not mean we have no space to develop our own thinking.

    So let me kick off. You asked me about the possibility of global social protection under this proposal (by Dybul, Frenk and Piot), but allow me to save that for last.

    Why global social protection? Because, as Gunnar Myrdal wrote, “the play of the forces in the market normally tends to increase, rather than to decrease, the inequalities between regions”. (Rich Lands and Poor, 1957, p. 26.) The winners of market competition invest their gains in additional competitive advantages and become even richer, while the others become poorer. And Myrdal predicted that the same effect would happen between countries, under economic globalization.

    Ironically, the Bretton Woods institutions were intended to simultaneously create conditions to correct and control market forces – to establish re-distribution of income for social protection, a.k.a. ‘the welfare state’ – at the national level, and conditions to unleash uncorrected and uncontrolled market forces at the international level. What Myrdal predicted became reality: on average, inequality between countries increased, during the second half of the 20th century, that is.

    Myrdal himself did not believe in global corrective measures or global social protection. First of all, “because we have hardly more than the faintest beginnings of something like an international authority which could perform for the world as a whole the tasks of the national state in an individual country.” And second, because “there does not exist for mankind as a whole that psychological basis upon which such a policy could be founded: the basis of human solidarity.” (Rich Lands and Poor, 1957, p. 63-64.)

    What Myrdal did not predict, however, was how easily capital, savings, and there owners, would detach themselves from their national roots. My grandparents’ savings – f they had any – would not have gone any further than the bank at the center of the village, from where the director would invest them in a local or national enterprise. Transnational investment hardly existed. My own savings travel around the world without me knowing where they are. And that undermines the authority of the national state: to attract national and transnational investment, states now have to obey market forces. As a result, social protection is under attack; even the governments of the wealthiest countries are now considering the welfare state as ‘unaffordable’. Inequality between countries has started to decrease in the 21st century, while inequality within countries (between people) is fast growing – that is in all countries, rich and poor.

    In my opinion, there’s nothing unaffordable about substantial taxation and social protection, but high levels of taxation and social protection are difficult to uphold nationally, within the context of a global competitive economy. Either markets have to be locked up within national borders again, or social protection has to be globalized – or a combination of both, of course.

    Global social protection will not replace national social protection; global social protection will build on national social protection, or be the footstall of national social protection – depending on the direction you look at it. But it will require negotiations on minimum levels of national taxation and social protection. These negotiations will be tough: governments of poorer countries will want to keep taxation levels low in order to obtain a bigger share of global markets; they may object against international efforts to control market forces, after richer countries promoted these same forces during decades (as long as they were winning). At the same time governments of poorer countries may consider it useful to accept and promote international standards: the Government of Kenya cannot increase taxation levels if the Governments of Uganda and Tanzania don’t.

    The point I’m trying to make is that there won’t be a lot of space for paternalism in negotiations about global social protection. It will be ‘hard talk’, between peers. Countries foregoing economic growth for the sake of a global social protection regime will demand compensations – and rightfully so – as they will demand compensations for foregoing economic growth for the sake of reducing greenhouse gas emissions. (So when I argue for or predict ‘fraternalism’ rather than ‘paternalism’ in global health, it is very different from “saying that we should just all learn to love one another”, as you phrased it, Andrew. It really has nothing to do with ‘flower power’. It is about understanding that the ‘donor versus recipient’ mythology is obsolete. It is grounded in the understanding that if we don’t find ways to globalize social protection, if we don’t find ways to correct market forces at the global level, most of us are in deep trouble.)

    Now, I’m not sure Dybul, Frenk and Piot agree with my analysis. When they write “Partnership, not abdication”, they may have something very different in mind. Frankly, I don’t know. And frankly, I don’t care. Because we cannot deny that the first decade of the 21st century has been the decade of global health, we cannot deny it has been promising, and we cannot deny it has left many promises unfulfilled.

    So, unlike you, I’m willing to make time for the big idea of Dybul, Frenk, and Piot. Frankly, I think my own big idea is much smarter (tongue in cheek, as they say), and I suspect that your big idea is better than theirs too, but not as good as mine. Unfortunately, no moons orbiting our offices… Shall we give them a chance? After all, the former heads of UNAIDS and PEPFAR writing that “focus on the health of a person requires ever-expanding integration” is not a small thing. Ignoring that would make us the Statler and Waldorf of global health.

    Take care,


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