FEDERAL TRUST RELATIONSHIP
To sufficiently examine and ultimately address health disparities affecting Native Americans, it is essential to understand the unique historical and legal context of Native American communities in the United States. Native American tribes have a legal relationship with the federal government that can be traced back to the 18th century, which has shaped the conditions that impact the health of this population. According to a report transmitted by the U.S. Commission on Civil Rights (2004), the special relationship between the federal government and Native Americans, referred to as a “trust” relationship, requires the government to protect tribal lands, assets, resources, treaty rights, and health care, in addition to other responsibilities (United States Commission on Civil Rights, 2004). The original basis for the federal–tribe relationship is rooted in Article I, Section 8 of the U.S. Constitution, which grants Congress the power “to regulate commerce . . . with the Indian tribes.”1
While there is no single legal source of the federal government’s trust obligation to Native American tribes, there is an extensive history of treaties, laws, and judicial decisions that collectively form the legal basis of this obligation. The American Indian Policy Review Commission Report commissioned by Congress (1977) cites treaties in which the United States acquired land in exchange for its commitment to protect the people and
1 U.S. CONST. art. I, § 8, cl. 3.
property of tribes from encroachment by U.S. citizens (American Indian Policy Review Commission, 1977). Among the most noteworthy court cases is Cherokee Nation v. Georgia,2 in which the Supreme Court concluded that the relationship of states to Indian nations is analogous to “that of a ward to his guardian.” The following year, in Worcester v. Georgia, the Supreme Court held that Indian tribes are guaranteed protection against interference from the states, as they are domestic sovereigns of the United States.3 These two cases established that only the federal government has jurisdiction over Indian nations and that, as a trustee, the federal government must ensure that states do not interfere with tribes’ self-governance or intrude on their land (U.S. Commission on Civil Rights, 2004). The aforementioned cases and legislation, in addition to other policies and treaties, have shaped the unique “trust” relationship between Native American tribes and the federal government.
Role of Policies Over Time
It is important to highlight the role of assimilation policies that began in the late 1800s because these policies have had sustained effects on Native American communities and, ultimately, their health conditions. As the United States expanded westward, Native Americans were forced to move to reservations, and the federal government made efforts to assimilate Native Americans into mainstream society. As tribes resettled, they continued to suffer from the infectious diseases that plagued the population during the prior decades of warfare. Assimilation policies took on many forms, including the General Allotment Act of 1887,4 legislation that abolished the group title of a tribe to land and replaced it with individual plots. In addition, the Bureau of Indian Affairs implemented a boarding school system, which prohibited traditional Native American practices, including religion, medicine, language, and other traditional cultural expressions (e.g., dress, hairstyle, etc.) (Shelton, 2004). This boarding school system, coupled with the prohibition of traditional health care activities, exacerbated the already dismal health and living conditions of Native American communities at the time. The results included rampant infectious diseases, poor sanitation, malnutrition, poverty, overcrowding and inadequate ventilation in homes, poor education practices, and isolation. The harsh conditions that Native Americans had to endure on reservations were extensively documented in The Meriam Report, a study
2Cherokee Nation v. Georgia, 30 U.S. (5 Pet.) 17 (1831).
3Worcester v. Georgia, 31 U.S. (6 Pet.) 515, 557 (1832).
4 The General Allotment Act of 1887, Ch. 119, 24 Stat. 388-91 (1887) (also known as the “Dawes Act”).
commissioned to assess the status of tribes across the country at the time (Meriam, 1928).
After the assimilation era, there was a series of policies and legislation that formed the periods of Native American policy known as reorganization and, subsequently, termination. In his report on the legal and historical roots of health care for Native Americans, Shelton detailed the chronology and impact of these policies, including the Indian Reorganization Act of 1934 (IRA).5 The IRA was designed to stimulate economic development and self-determination, while also promoting the adoption of modern business-like practices for governing tribes (Shelton, 2004). This positive shift in power was short-lived, as it was followed by termination policies in the 1950s, which had enduring effects on Native American communities regarding mental health, identity, and social and family networks (Walls and Whitbeck, 2012). Congress passed legislation discontinuing the special federal–tribe “trust” relationship with 109 tribes and bands (Shelton, 2004). The termination policies resulted in the removal of tribes’ federal recognition, the elimination of their reservations, and the forced relocation of Native Americans from their tribal lands to major urban areas.
Following the termination-era policies, the federal government made the official transition to tribal self-determination and passed laws to restore tribal sovereignty. In 1975 Congress recognized the importance of tribal decision making in tribal affairs and the significance of the nation-to-nation relationship between the United States and tribes through the passage of the Indian Self-Determination and Education Assistance Act (ISDEAA).6 The ISDEAA directs the Secretary of the U.S. Department of Interior and the Secretary of the U.S. Department of Health and Human Services to enter self-determination contracts or compacts with tribal organizations, upon the request of any Native American tribe (Bauman and Floyd, 1999). Subsequent amendments to the ISDEAA strengthened the federal policies supporting tribal self-determination and self-governance.
Health Care Services
Unlike other racial and ethnic minority groups in the United States, Native Americans have legal rights to federal health care services. Federal responsibility for Native American health care was codified in the Snyder
5 Ch. 576, 48 Stat. 984 (codified as amended at 25 U.S.C. §§ 461, 462, 463, 464, 465, 466–470, 471–473, 474, 475, 476–478, 479) (1934).
6 The Indian Self-Determination and Education Assistance Act of 1975, Public Law 93-638.
Act of 19217 and the Indian Health Care Improvement Act8 (IHCIA) of 1976, which together form the legislative authority for the federal agency known today as the Indian Health Service (IHS) (U.S. Commission on Civil Rights, 2004). The Snyder Act authorized funding for health care services to federally recognized tribes, and the IHCIA defined the structure for the delivery of health services and authorized the construction and maintenance of health care and sanitation facilities on reservations (U.S. Commission on Civil Rights, 2004). Although these pieces of legislation marked significant progress, the Snyder Act has been criticized for its use of broad and vague language, which does not facilitate long-term planning or provide resources based on need. This is considered to have influenced the piecemeal approach that has shaped the funding and distribution of health care resources for Native Americans (IOM, 2003).
The IHS is the federal agency responsible for fulfilling the trust obligation to provide health services to Native Americans. When the federal responsibility for health care services was transferred from the U.S. Department of the Interior to the U.S. Department of Health, Education, and Welfare in 1955, the IHS was established under the Public Health Service. This transfer resulted in the doubling of appropriations for the IHS. Currently, the IHS operates within the U.S. Department of Health and Human Services. IHS is only required to provide federal health care services to federally recognized tribes. Individual eligibility for services is determined by a number of criteria, including, but not limited to, the requirement that the individual is of Native American descent, is regarded as a tribal member, has some legal evidence of tribal enrollment or certificate of origin, and resides on or near a federal reservation (IOM, 2003). The IHS consists of a network of hospitals, clinics, field stations, and other programs that collectively serve approximately 2.2 million Native Americans (IHS, 2015). The IHS system is divided into three major branches: the federally operated direct health care services, tribally operated health care services, and urban Native American health care services and resource centers. For those who are eligible, health care services can be received at any IHS facility; however, there are complex rules that restrict the delivery of contract medical care that is not available in IHS facilities (Jim et al., 2014).
Since the passage and amendments of the ISDEAA, there has been an increasing trend toward tribal self-governance with respect to all domains of life, including health care. As a result, tribes have the option to receive direct services from the IHS, to assume responsibility for health care with
7 The Snyder Act of 1921, Ch. 115, 42 Stat. 208 (1921) (codified as amended at 25 U.S.C. § 13 ).
8 The Indian Health Care Improvement Act of 1976, Public Law 94-437. The IHCIA was permanently reauthorized in 2010 as part of the Patient Protection and Affordable Care Act.
the option to contract with IHS, or to fund the establishment of their own programs or supplementation of ISDEAA programs (IHS, 2016). The option of self-governance allows tribes to tailor health care services to the needs of their communities. The IHS operates from the understanding that tribal leaders are in the best position to assess and address the needs of their communities. More than half of the IHS appropriation is currently administered by tribes, through self-determination contracts or self-governance compacts (IHS, 2015).
There are a number of barriers that preclude the IHS from reaching its full potential of providing quality, efficient health care services to its target population to reduce disparities (U.S. Commission on Civil Rights, 2004). The persistent lack of adequate funding is often cited as a barrier to reducing the pervasive health disparities that affect Native Americans (Sequist et al., 2011; Warne and Frizzell, 2014). Every year, Congress appropriates funds to IHS to fulfill the trust responsibility to provide health care services. According to the National Congress of American Indians, in 2014 the IHS per capita expenditures for patient health services were only $3,107, compared to $8,097 per person for health care spending nationally, and when examining medical spending only, IHS per capita was approximately $1,904 (National Congress of American Indians, 2016).
A physician survey conducted in 2007 explored barriers to quality improvement within the IHS. The findings revealed that access to high-quality specialists within geographic proximity, nonemergency hospital admission, high-quality imaging services, and high-quality outpatient mental health services were high-priority barriers for physicians (Sequist et al., 2011). Furthermore, a majority of the physicians felt that a lack of IHS funding to support provision of care through subspecialists was a crucial barrier to quality improvement (Sequist et al., 2011).
SOCIAL DETERMINANTS OF HEALTH
As is the case with all other populations, Native Americans’ opportunities to achieve optimal health are affected by the social determinants of health in their communities, which in turn have been shaped by social and political processes, both historical and contemporary. A keen understanding of the root causes and determinants of health will help inform the most effective and just solutions to address health inequities among Native Americans.
Income and Wealth
Native Americans are one of the most economically impoverished populations in the United States. The median household income for this
group is $37,227, as compared with $53,657 in the nation as a whole (U.S. Census Bureau, 2015). Given that income is a strong predictor of health outcomes and life expectancy (Chetty et al., 2016; Woolf et al., 2015), this disparity in income has severe consequences for the health and well-being of Native Americans. This particular population also has a higher proportion of people living in poverty than the rest of the country, with 28.3 percent of Native Americans living in poverty, compared with 15.5 percent of the total population (U.S. Census Bureau, 2015). Income and poverty are inextricably tied to employment opportunities, of which there are too few for Native Americans. Native Americans have the highest unemployment rate (9.9 percent in 2015) of any racial or ethnic group in the United States (U.S. Bureau of Labor Statistics, 2016).
In terms of recent trends in economic well-being, it is important to recognize the lasting effects of the economic recession of 2008. Native Americans saw declines in employment and income that were similar to other racial and ethnic groups; however, this population on average was in a more vulnerable financial condition than other groups at the beginning of the period. The unemployment rate for Native Americans spiked from 11 percent in 2008 to 18 percent in 2010 (Pettit et al., 2014). In that same time period, Native Americans also experienced almost double the percentage increase in the poverty rate as other racial and ethnic groups did, with the largest increase observed in the West (Pettit et al., 2014). By 2013 the overall Native American unemployment rate had dropped to 11.3 percent, but rates were still high in the Midwest (16.9 percent), Northern Plains (15 percent), and Southwest (15 percent) regions of the country (Austin, 2013).
Education is a significant determinant of health for Native Americans, as the U.S. educational system has historically been a source of discrimination and, in many cases, trauma for this population. One of the most overt examples of this is the implementation of the boarding school system, which was designed with the purpose of eliminating students’ tribal identity and facilitating assimilation into mainstream American culture (Executive Office of the President, 2014; Shelton, 2004). Today, educational progress for Native Americans is far behind that of other racial and ethnic groups. A report from the National Center for Education Statistics reveals that Native Americans have the highest high school dropout rate in the country, which was at 14.6 percent in 2012, compared with a low of 3.3 percent among Asians/Pacific Islanders (Stark and Noel, 2015). In addition, Native Americans had the lowest high school completion rate in 2012, which was at 79.0 percent compared with a high of 94.9 percent
among Asians/Pacific Islanders (Stark and Noel, 2015). This disparity has serious implications for health inequities among Native Americans because the evidence demonstrates that there is a strong link between high school completion and health (Cutler and Lleras-Muney, 2006).
Since the civil rights movement in the 1960s, there has been an emergence of grassroots educational institutions that seek to support tribal identity, address academic deficiencies, and resolve the lack of quality education experiences and sense of displacement among tribal students (Crazy Bull, 2015). Research suggests that culturally relevant education increases the likelihood that a young Native American stays in school. Currently, approximately 20,000 students attend tribal colleges and universities full time in the United States (Crazy Bull, 2015).
Housing conditions for Native Americans are a major consideration for health disparities, on and off of reservations. Housing affordability is a community-level factor that affects Native Americans’ access to shelter. According to a recent U.S. Department of Housing and Urban Development report, from 2006 to 2010 roughly 4 out of 10 Native American households had excessive cost burdens, paying more than 30 percent of their income on housing (Pettit et al., 2014). This was comparable to households among other racial and ethnic groups; however, Native American households were more likely to be severely cost-burdened (i.e., paying more than 50 percent of their income on housing) than households of other racial and ethnic groups (Pettit et al., 2014). While home ownership rates in tribal areas were relatively high (67 percent) in 2010, the overall homeownership rate for Native Americans lagged behind that of other racial and ethnic groups, at 54 percent and 65 percent, respectively (Pettit et al., 2014).
Safe and healthy housing is a determinant of health to which many Native Americans do not have access. For example, the U.S. Environmental Protection Agency reports that as of 2011, there were more than 120,000 tribal homes lacking access to basic water sanitation (EPA, 2012), and the IHS reports that almost 1 in 10 Native American homes are without safe and reliable water (Indian Health Service, 2011). It should also be noted that there are certain Native American communities that are particularly affected by the lack of quality housing (i.e., not having complete plumbing and kitchen facilities) in the Alaska, Arizona, and New Mexico regions (Pettit et al., 2014). Those living in extreme climate conditions, such as Alaska, are especially vulnerable to potential damages to their poor-quality housing caused by extreme weather.
Overcrowding in homes is an issue for Native Americans that research suggests is linked to the onset or exacerbation of many health problems. These health issues include respiratory conditions, the transmission of infectious diseases, child well-being (i.e., academic achievement, behavior problems, physical health), depression, and sleep deprivation (Angel and Bittschi, 2014; Solari and Mare, 2012; Webster, 2015). From 2006 to 2010, Native American households were much more likely to be overcrowded than all households in general, with 8.1 percent of Native American households being overcrowded and about one-third of these being severely overcrowded (Pettit et al., 2014). The highest incidence of overcrowding in Native American homes was in larger tribal areas, where 11 percent of households were overcrowded, compared with 3.1 percent of all U.S. households (Pettit et al., 2014). When examining overcrowding and its effects, it is important to recognize the cultural values and customs that shape household traditions in Native American communities.
Living in Urban and Rural Places
Whether Native Americans live in urban or rural areas has implications for the types of barriers and health disparities they face. The 2010 U.S. Census reported that 71 percent of Native Americans live in urban areas (UIHI, 2013). Racial misclassification is more of an issue for collecting mortality data on Native Americans in urban areas than those in rural areas because there is less awareness of Native American status off of reservations (Jacobs-Wingo et al., 2016). This population reportedly has less access to hospitals, health clinics, or contract health services that are managed by the IHS and tribal health programs, but they may have greater access to other health care resources that reduce mortality (HHS, 2016; Jacobs-Wingo et al., 2016). This group of Native Americans must also face the lasting effects of the termination policies from the 1950s, which lead to the coerced migration of many individuals and, in some cases, the breakdown of familial ties and social structures. Although the leading causes of death are similar between urban and rural Native Americans, death rates are generally higher among rural Native Americans (Jacobs-Wingo et al., 2016). Furthermore, rural residence has been associated with later cancer stage diagnosis, inadequate cancer treatment, and increased cancer mortality (Campbell et al., 2001; Monroe et al., 1992; Singh and Siahpush, 2014).
Similar to the case for other racial and ethnic minority groups, Native Americans experience systematic differences in exposure to violence and
interactions with the criminal justice system as compared to whites. The findings from the 2010 National Intimate Partner and Sexual Violence survey showed that relative to white women, Native American women are 1.2 times more likely to have experienced violence in their lifetime and that relative to white men, Native American men are 1.3 times more likely to have experienced violence in their lifetime (Rosay, 2016). In particular, violence against Native American women is being addressed as a major public health and public safety issue (Crossland et al., 2013). In terms of the criminal justice system, Native Americans are arrested at 1.5 times the rate that whites are, with a larger disparity for specific violent and public order offenses (Hartney and Vuong, 2009). Furthermore, Native Americans are incarcerated and on parole at twice the rate that whites are (Hartney and Vuong, 2009). Research suggests that, when convicted, Native Americans are often sentenced more harshly than white, African-American, and Hispanic offenders (Franklin, 2013).
Native American youth, specifically, are at an elevated risk for delinquency and incarceration. The risk factors for delinquency can be directly linked to the social determinants of health. For example, Native American youth are more likely to live in poverty, drop out of school, and be exposed to violence than youth in the general population (Rolnick, 2016). A 2014 report from the University of Wisconsin Population Health Institute on the Wisconsin juvenile justice system revealed that Native American youth were twice as likely to be arrested and almost twice as likely to be detained following arrest as white youth, with little change from 2006–2012 (Lecoanet et al., 2014). This disparity was found to be much higher in certain counties in Milwaukee (Rolnick, 2016). The Indian Law and Order Commission reports that the federal and state juvenile justice systems incarcerate Native American youth and remove them from their families, reducing opportunities for positive contact with their communities and often contributing to trauma in this population (Rolnick, 2016).
American Indian Policy Review Commission. 1977. American Indian Policy Review Commission final report, submitted to Congress May 17, 1977. Washington, DC: Congress of the United States.
Angel, S., and B. Bittschi. 2014. Housing and health. Mannheim, Germany: Centre for European Economic Research.
Austin, A. 2013. High unemployment means Native Americans are still waiting for an economic recovery. Washington, DC: Economic Policy Institute.
Bauman, D., and J. Floyd. 1999. Indian tribal health systems governance and development: Issues and approaches. Menlo Park, CA: Kaiser Family Foundation.
Campbell, N. C., A. M. Elliott, L. Sharp, L. D. Ritchie, J. Cassidy, and J. Little. 2001. Rural and urban differences in stage at diagnosis of colorectal and lung cancers. British Journal of Cancer 84(7):910–914.
Chetty, R., M. Stepner, S. Abraham, S. Lin, B. Scuderi, N. Turner, A. Bergeron, and D. Cutler. 2016. The association between income and life expectancy in the United States, 2001–2014. JAMA 315(16):1750–1766.
Crazy Bull, C. 2015. Helping native youth succeed with culturally responsive education. The Aspen Journal of Ideas, July/August. http://aspen.us/journal/editions/julyaugust-2015/helping-native-youth-succeed-culturally-responsive-education (accessed November 5, 2016).
Crossland, C., J. Palmer, and A. Brooks. 2013. NIJ’s program of research on violence against American Indian and Alaska native women. Violence Against Women 19(6):771–790.
Cutler, D. M., and A. Lleras-Muney. 2006. Education and health: Evaluating theories and evidence. National Bureau of Economic Research working paper no. 12352. http://www.nber.org/papers/w12352 (accessed November 5, 2016).
EPA (U.S. Environmental Protection Agency). 2012. The Clean Water Indian Set Aside Grant Program. https://www.epa.gov/sites/production/files/2015-01/documents/epa-cwisa-report-final-2012-11-29-12_508cmpl.pdf (accessed October 24, 2016).
Executive Office of the President. 2014. 2014 native youth report. Washington, DC.
Franklin, T. W. 2013. Sentencing Native Americans in U.S. federal courts: An examination of disparity. Justice Quarterly 30(2):310–339.
Hartney, C., and L. Vuong. 2009. Created equal: Racial and ethnic disparities in the U.S. criminal justice system. Oakland, CA: National Council on Crime and Delinquency.
HHS (U.S. Department of Health and Human Services). 2016. Profile: American Indian/Alaska native. http://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=62 (accessed August 25, 2016.
IHS (Indian Health Service). 2011. Public Law 86-121 annual report for 2011. Rockville, MD: U.S. Department of Health and Human Services.
IHS. 2015. IHS year 2015 profile. https://www.ihs.gov/newsroom/factsheets/ihsyear2015profile (accessed October 24, 2016).
IHS. 2016. IHS year 2016 profile. https://www.ihs.gov/newsroom/index.cfm/factsheets/ihsprofile (accessed November 5, 2016).
IOM (Institute of Medicine). 2003. Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: The National Academies Press.
Jacobs-Wingo, J. L., D. K. Espey, A. V. Groom, L. E. Phillips, D. S. Haverkamp, and S. L. Stanley. 2016. Causes and disparities in death rates among urban American Indian and Alaska native populations, 1999–2009. American Journal of Public Health 106(5):906–914.
Jim, M. A., E. Arias, D. S. Seneca, M. J. Hoopes, C. C. Jim, N. J. Johnson, and C. L. Wiggins. 2014. Racial misclassification of American Indians and Alaska natives by Indian Health Service contract health service delivery area. American Journal of Public Health 104(Suppl 3):S295–S302.
Lecoanet, R., D. Kuo, S. Lindsley, and S. Seibold. 2014. Disproportionate minority contact in Wisconsin’s juvenile justice system. Madison, WI: University of Wisconsin Population Health Institute.
Meriam, L. 1928. Meriam report: The problem of Indian administration. Washington, DC: The Institute for Government Research.
Monroe, A. C., T. C. Ricketts, and L. A. Savitz. 1992. Cancer in rural versus urban populations: A review. Journal of Rural Health 8(3):212–220.
National Congress of American Indians. 2016. Fiscal year 2017 Indian country budget request: Upholding the promises, respecting tribal governance: For the good of the people. Washington, DC: National Congress of American Indians.
Pettit, K. L. S., G. T. Kingsley, J. Biess, K. Bertumen, N. Pindus, C. Narducci, and A. Budde. 2014. Continuity and change: Demographic, socioeconomic, and housing conditions of American Indians and Alaska natives. Washington, DC: U.S. Department of Housing and Urban Development.
Rolnick, A. C. 2016. Locked up: Fear, racism, prison economics, and the incarceration of native youth. American Indian Culture and Research Journal 40(1):55–92.
Rosay, A. B. 2016. Violence against American Indian and Alaska native women and men: 2010 findings from the National Intimate Partner and Sexual Violence Survey. Washington, DC: National Institute of Justice.
Sequist, T. D., T. Cullen, K. Bernard, S. Shaykevich, E. J. Orav, and J. Z. Ayanian. 2011. Trends in quality of care and barriers to improvement in the Indian Health Service. Journal of General and Internal Medicine 26(5):480–486.
Shelton, B. L. 2004. The legal and historical roots of health care for American Indians and Alaska natives in the United States. Menlo Park, CA: The Henry J. Kaiser Family Foundation.
Singh, G. K., and M. Siahpush. 2014. Widening rural–urban disparities in life expectancy, U.S., 1969–2009. American Journal of Preventive Medicine 46(2):e19–e29.
Solari, C. D., and R. D. Mare. 2012. Housing crowding effects on children’s wellbeing. Social Science Research 41(2):464–476.
Stark, P., and A. M. Noel. 2015. Trends in high school dropout and completion rates in the United States: 1972–2012 (NCES 2015-015). Washington, DC: National Center for Education Statistics.
UIHI (Urban Indian Health Institute). 2013. U.S. Census marks increase in urban American Indians and Alaska natives. http://www.uihi.org/wp-content/uploads/2013/09/Broadcast_Census-Number_FINAL_v2.pdf (accessed October 24, 2016).
U.S. Bureau of Labor Statistics. 2016. Labor force characteristics by race and ethnicity, 2015. Report 1062. Washington, DC: U.S. Bureau of Labor Statistics.
U.S. Census Bureau. 2015. FFF: American Indian and Alaska Native Heritage Month: November 2015. http://www.census.gov/newsroom/facts-for-features/2015/cb15-ff22.html (accessed October 24, 2016,).
U.S. Commission on Civil Rights. 2004. Broken promises: Evaluating the Native American health care system. Washington, DC: U.S. Commission on Civil Rights.
Walls, M. L., and L. B. Whitbeck. 2012. The intergenerational effects of relocation policies on indigenous families. Journal of Family Issues 33(9):1272–1293.
Warne, D., and L. B. Frizzell. 2014. American Indian health policy: Historical trends and contemporary issues. American Journal of Public Health 104(Suppl 3):S263–S267.
Webster, P. C. 2015. Housing triggers health problems for Canada’s first nations. The Lancet 385(9967):495–496.
Woolf, S. H., L. Aron, L. Dubay, S. M. Simon, E. Zimmerman, and K. X. Luk. 2015. How are income and wealth linked to health and longevity? Washington, DC: Urban Institute and Virginia Commonwealth University.
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