The patient is large. Very large. At more than 600 pounds, he is a mountain of flesh
“My stomach hurts,” he says, his voice surprisingly high and childlike.
THE OTHER DAY, a colleague brought to my attention an essay from The Washington Post called “A morbidly obese patient tests the limits of a doctor’s compassion” written by a Dr. Edward Thompson. Just the first two lines of it above had me furious. Not only were they a study in the power of negative metaphors, but as a fellow physician, they felt all-too familiar. They were the way I had, on many an occasion, heard patients’ bodies talked about; ways that I, during my training, had perhaps referred to patients’ bodies. The simple words felt so easy, so unexamined, and in that very ease was embedded their violence.
Let’s recap the imagery used. A very large man is compared to a mountain of flesh. He has a high and childlike voice. You don’t need to be an MFA in creative writing, or a sociopolitical genius, to recognize these as metaphors of the grotesque and infantile. And importantly, the patient’s stomach pain is not a stated fact, but a complaint, framed by quotes. This makes clear to the reader that the patient claims his stomach hurts. He is potentially malingering. The implication being that the obese are, well, complainers. Indeed, although studies show that physicians are nicer to thinner patients, many of my medical colleagues don’t seem to realize that personal and institutional violence against fat people (and I use that term in solidarity with the fat activism and fat studies movements) is a thing. A real, grotesque and infantile thing. A real, grotesque and infantile thing that negatively impacts the health care that fat individuals receive.
The Washington Post essay goes on, describing the patient in this way: “He spends his days on the sofa at home, surviving on disability checks related to his back pain.” The implication being that the man’s weight is what led to his disability and not the other way around. And we all know what sofa-sitting is code for: slovenliness and laziness.
So let’s recap again. We have the grotesque, the infantile, the complaining, the slovenly and the lazy. The metaphors are piling up.
Yet, wasn’t George H.W. Bush’s signing the Americans with Disabilities Act supposed to relegate able-ism to a thing of the past? Weren’t we all supposed to recognize the rights of our fellow citizens, regardless of appearance, ability, size, number of limbs or other embodied differences? Apparently, this memo did not reach most American medical schools. At least not yet. Because, while a few medical schools have medical humanities programs, only a fraction of these programs systematically incorporate disability studies into their courses, and even fewer acknowledge what’s now known as the activist and academic field of fat studies.
Interestingly, size-as-disability is even explicitly brought up by Dr. Thompson’s patient himself, when he “indignantly” says, “The Americans with Disabilities Act says that [the paramedics] should have the proper equipment to handle me, the same as they do for anyone else… I’m entitled to that. I’ll probably have to sue to get the care I really need.”
And yet, the ER-physician/writer doesn’t seem to agree: “I don’t quite know how to respond, so I say nothing.”
Instead, Dr. Thompson’s essay launches into the difficulties of diagnosing the man’s gallstones, difficulties that are all attributed to his size: the physical exam which leaves the physician at first “not knowing where to begin,” and then noting that his “hands look small and insignificant against the panorama of skin they are kneading.” The author describes the ultrasound machine that “barely fits” between the oversize bed and the wall, the technician who declares, “this is impossible,” the chief of radiology who emerges from the room a half hour later “rings of sweat under his arms,” and the attendants who must “huff, puff, and grunt” in order to push the patient down the hall on a gurney. He writes of a surgical colleagues’ desires to “unload” the patient on a different hospital due to his size, and the continuous, cutting remarks from the ER staff: “Don’t put him in a room right over the ER…The floor won’t support him. He’ll come crashing through and kill us all.”
As a faculty member in the Master’s Program in Narrative Medicine at Columbia University, I know about the power of stories: stories told by physicians, stories told by patients. I know that having health care students read, write and analyze narratives can deepen their training in bioethics, medical professionalism, reflective practice, self-care and patient-centered care. Narrative study can help our students effectively diagnose, treat, and otherwise attend to the lives of their patients.
Yes, stories are powerful. But let’s not get too precious about them. Simply reading any story with a medical student or engaging them in a narrative writing prompt is not the same as actually educating them in structural issues of oppression and inequity. Those of us in the medical humanities professions must teach our students not only to listen to stories, but to listen to them critically; asking themselves questions like “who is speaking?”, “who is being spoken for?”, “what larger narratives is this story supporting?”, and “what additional stories are being silenced by this one?” In a brilliant TED talk, the writer Chimamanda Ngozi Adichie speaks about the dangers inherent in a “singular story.” Although Adichie is speaking of singular narratives about Africa and Africans, the idea can be easily applied to other issues. Singular stories can ensnare us, make us so accustomed to one way of thinking that we can no longer imagine there are alternative narratives possible.
Consider the words of Dr. Thompson as he describes the desperation of his patient,
The patient lies trapped in his own body, like a prisoner in an enormous, fleshy castle. And though he must feel wounded by the ER personnel’s remarks, he seems to find succor in knowing that there’s no comment so cutting that it can’t be soothed by the balm of 8,000 calories per day…I know why my colleagues and I are so glad to have this patient out of the ER and stowed away upstairs: he’s an oversize mirror, reminding us of our own excesses. It’s easier to look away and joke at his expense than it is to peer into his eyes and see our own appetites staring back.
As someone whose work in medical humanities is particularly concerned with narrative, health, and social justice, I find this paragraph deeply troubling. Although it is gesturing to, as Dr. Thompson says, “compassion,” the language itself creates a prison around the reader’s imagination. Referring to another’s body as “an enormous, fleshy castle” and suggesting that food is a “balm,” and “obesity” necessarily connected to out-of-control “appetites” is a singular story about fatness, a story oft told, particularly in medicine. It is a story that leaves no room for, say, the fat person who practices self-love and radical self-acceptance, the Health At Every Size movement, or the politicization of fatness – the assertion that, as author Susie Orbach has said, “fat is a feminist issue,” or that race, class and colonialist politics are written upon fat bodies. The fact that Dr. Thompson’s story ends with his patient’s death, and emergency crews being required to cut an enormous hole out of his roof to hoist him out, only adds to this particular, tragic story about fatness. This is not, of course, to say that this particular patient’s life story might not have been tragic, but rather, that this Washington Post essay reinforces a singular, expected cultural narrative about fatness and fat people.
As Susan Sontag famously argued in her Illness as Metaphor, certain bodily conditions have historically been associated with failings of moral character. In the past, this stereotyping was limited to diseases from tuberculosis to cancer, but now, this is most seen regarding those behavior-based characteristics considered high-risk factors for disease – from smoking to multiple sexual partners to IV drug use.
Bolstered by Michelle Obama’s Let’s Move! and other similar campaigns, the ‘obesity epidemic’ has become a favorite topic of neoliberal moralization. What this has resulted in is a kind of permission within the medical profession to engage in size-ism under the guise of encouraging good health. I’m not saying that physicians might not speak privately and respectfully to patients about weight, or that exercise and healthy eating are not a good thing. But physicians – and indeed, science itself – does not exist somehow outside of culture and sociopolitics. Consider that medical and public health anti-obesity messages have plenty of secondary narratives inherent in their images – other stories they’re telling about race, masculinity and femininity, parenting, poverty, disability, as well as the ‘right kind’ of (economic and nutritional) consumption. In addition, these messages dovetail perfectly with images in fashion magazines, on billboards, in movies and on TV about thinness, fairness, youth, beauty, and desirability (not to mention wealth, heteronormativity, able-bodied-ness, cis-gendered self representations, etc.). These medical and media messages create a kind of ‘toxic body culture’ that permeates all our consciousness (particularly young peoples’), leading to everything from disordered eating to low self-esteem to bullying to warped notions of normalcy.
What’s also troubling is that medical and public health messages focus almost exclusively on individual “shame and blame,” even asserting that we doctors somehow should shame our patients, regardless of evidence which shows that shame about weight is an ineffective motivator in behavior change. Despite assertions like this one on Gawker that “Your doctor is probably not fat-shaming you,” the fact, is, sometimes, intentionally or unintentionally, your doctor just actually might be fat-shaming you. The moral indignation evoked by fatness among physicians suggests that it satisfies some emotional function, some opportunity, in this era of health care consumerism and internet savvy patients, for physicians still to command a sense of superior power over patients. Consider that even after a study published in Pediatrics suggested that physicians no longer use words that are stigmatizing of childhood obesity, one physician blogger railed at kevinmd, “Political correctness and sensitivity training are interfering with medicine and healthcare.”
The problem is also American medicine’s myopic concentration on individual behavior over systemic constraints – a focus which is related perhaps to our cultural ethos of independence, personal control, and pull-yourself-up-by-the-bootstrap-iness. Perhaps instead of railing against “sensitivity training,” shaming patients, and yearning for the ‘good old patriarchal days’ of medicine, we physicians might do better to protest against systems-based issues like the lack of green, safe, outdoor spaces in many communities, the existence of food deserts, the prevalence of GMOs or the affordability of processed food products over whole fresh foods. Perhaps we medical educators should address how woefully lacking our systems of training are in what my colleagues Jonathan Metzl and Helena Hansen call “structural competency,” the notion that social inequities impact health as much as physiology.
Yet, sociopolitics is only part of my problem with Edward Thompson’s Washington Post essay. Granted, physicians – particularly ER physicians – often develop a sort of gallows humor to deal with the emotional and physical pressures of patient care. But that doesn’t mean we physician writers are exempt from privacy regulations (ie. HIPAA) or narrative ethics; nor do we need to publish each and every thing that comes out of our laptops. Over the years, after I myself published a medical school memoir in 1999 with quite a few ‘patient stories’ in it, I have come to realize that there is a big difference between writing privately for our own needs and writing for a mass audience; and the latter comes with certain responsibilities, particularly toward vulnerable subjects. The very least of these responsibilities is obtaining explicit permission from patients or their families before sharing their stories publicly. In this particular case, Dr. Thompson was apparently unable to obtain permission from the patient because he had already passed away prior to the writing of the narrative. Whether the author contacted his family to obtain permission, I cannot be sure.
There is, of course, a tradition of insightful, humble and self-critical confessional stories in medicine such as William Carlos Williams’ “The use of force,” or David Hilfiker’s “Mistakes,” tales of medical brutality and error which serve to implicate their physician-authors and shed light on the imperfections of the profession. I actually imagine that Dr. Thompson was seeking to similarly implicate himself and his colleagues in their size-ist bigotry. The problem is, the language and metaphor of his narrative actually serves to reinforce the self-same fat shaming that the essay seemingly seeks to address. Whatever the author’s intention, the narrative itself supports rather than undermines fat hatred and in doing so harms far more people than just the patient described or his family. Indeed, the narrative itself potentially “pulls the red handle” for a lot of people who identify or are potentially identified as fat.
As this insightful, and angry, commentary about Dr. Thompson’s piece from the blog Shakesville points out,
Fat people! They exist in the world and can hear you! They may even be entirely aware of your loathing, your disgust, your discomfort, and your judgment. They may even (probably) take these things into account when deciding if the acute pain in their side is bad enough to face the dehumanization, the hatred, the vitriol, and the humiliation of interacting with medical staff (you know, those compassionate care givers ostensibly tasked with giving a shit about their well-being and health and trying to diagnose and help them) or if they should just wait it out and see if it gets better.
Fat hatred kills people. Not least of all because sometimes living with pain and not knowing what it is may just be preferable to being dehumanized, hated, and sneered at by the people you have to trust in order to access medical care.
The resource-hogging “obese patient” has become the new version of the welfare queen in our popular imaginations. Such stereotypes about any community – that they are infantile, monstrous, unthinking, lazy, whiney and resource-wasting – isn’t only emotionally damaging but potentially physically harmful. As the blogger at Shakesville asserts: “fat hatred kills.”
Physicians cannot use concerns over health to legitimize bias. Medicine is not a moralizing stick with which we can beat our patients into submission.
Medical narratives are powerful. Let us use them not to ridicule, alienate, or demonize our fellow human beings, but rather, create a much-needed change to a more socially just health care.
Thank you to my colleague Dr. Daniel Goldberg for bringing both the Washington Post and Shakesville essays to my attention. Thank you to Drs. Tess Jones, Rebecca Garden and others at the ASBH LITMED listserve for their insightful thoughts and comments in the ensuing discussion.
Compassionate and wise
Thank you Dr. DasGupta. Unfortunately when a fat activist or simply a fat person writes a similar piece it is too often seen as rationalization. Coming from you it has more impact, and that is desperately important. As a writer of narrative nonfiction, and in particular the stories of fat people, I know the power of words. I also know that the story teller is an essential factor, so thank you again for your powerful perspective.
Thank you so much for this compassionate breakdown of why so many fat persons are terrified of/fed up with our doctors. When visiting with new doctors, I provide them with a packet of HAES(r)-related material; this article makes a perfect addition. :)
This is a powerful piece that I will share widely–thank you!
This is such a brilliant essay! How fat people survive our medical system, I’ll never know. Actually, I know a number of doctors who are embarrassed that their colleagues are so fat phobic.
–Bill Fabrey
Council on Size & Weight Discrimination
http://www.cswd.org
Mt. Marion, NY, USA
Thank you for such an excellent, honest piece. I can relate to so much of this.
Bill Fabrey: many of us don’t survive the medical system – in the UK either. We die from the shame piled on us as our organs are filled with it, or we live afraid to speak up, to be seen, to walk down the road…. in short, to live.
Please allow me to give you the brief outline of my own story as it is highly relevant to the topic and I am getting too old to not take a stand for myself and others.
In 2011 I went for treatment for an abnormal cervical smear result. The consultant’s words to me were –
” you are going to be a fat old woman in a wheelchair, because your joints will all fail you and not only that, you will be coming to my other clinic, oncology because you WILL get cancer – you know that don’t you?”
I was completely traumatised by this comment as the sister of the department sat accross the room listening to him ranting at me. He didn’t get of scott free – I went home and reflected for about a week on it and wrote an extremely strong letter to him. He replied a month later, basically apologising that I was upset at the appointment… & it was his duty to point these things out….. He ended with some snide comment even then.
Since that time, I had colon cancer, acute pancreatitis, gall bladder removed and an undiagnosed hernia for 9 months (Oh, because they said it was the shape of my body and not a hernia) Fortunately, one of my ex singing students is a leading stomach surgeon at Addenbrookes hospital in Cambridge….. he offered a second opinion, diagnosed an acute hernia and did the surgery putting in a sizable piece of titanium mesh. from 2011 to now I have gained about 30lbs… and my Fibromyalgia is exacerbated. Given the latter is possibly due to trauma originally, these added ‘bonuses’ from surgery and dealing with bigoted physicians such as Mr cervical screening, just make life so much more difficult to live.
It’s frightening to be a ‘FAT’ person in this society; I have been overweight since starting school at 41/2 (yes, very early in the UK in 1957) I lost a total of 7st (98lbs) in 2007 – on 525 cals a day, only to start gaining it all back in 2009 after a fall and knee ligament damage.
The shame I (we, probably) carry is toxic….. This is what kills, ultimately.
hi lady. my name is Rebekah alessi. I am the mother of a beautiful 13 yr old girl who was fat shamed by her dr. I tried to tell him what you so eloquently said, its the self hate not the flesh that is toxic. bless you, rebekah
Here is a brochure that can be shared with physicians.
NAAFA Guidelines for healthcare providers who treat fat patients
http://tinyurl.com/7gbevd6
I saw the link to this excellent essay on Facebook. It is being very widely shared. Thank you for such a clear, objective analysis of a most disturbing tale.
I have also encountered fat-shaming here in England, of a far more tentative variety, but it is always horrible to walk down the street and have abuse shouted at me from a passing van, simply because I am larger than average. At least my general practitioner has the manners and sense to look at medical indicators rather than simply decide I’m a walking disaster area and a drain on the NHS.
Size shaming does not help anyone of any size and results in poor medical care for all. Fat people are treated as if we all sit around doing nothing but consuming bucket after bucket of Kentucky Fried, washing it down with several 32 ounce Big Gulps of Mountain Dew, and following it all up with an entire cake or pie. We are told that all our health problems will be solved simply by losing weight. This results in actual health problems being misdiagnosed or not diagnosed at all.
Conversely, thinner people are believed to all be healthy based simply on their size. This too results in health problems being missed. Also, thinner people can have poor eating habits and poor overall health habits, but since they are assumed to be healthy based on their size, such issues are never addressed.
It is true that certain conditions are more prevalent in certain populations. Type 2 diabetes is somewhat more prevalent in larger people. Adipose tissue releases hormones that can trigger insulin resistance in genetically vulnerable people. What most people don’t acknowledge is that insulin resistance triggers weight gain and difficulty losing weight, as well as cravings for sugar. The heavy person is admonished to have “more self control” so they don’t “eat themselves into diabetes.”
Osteoporosis is much more prevalent in people with slender body types, but these people are generally not told to “gain some weight so you don’t develop osteoporosis.”
To sum up this rant, I was very pleased with this article. It gives me a little hope to see that some medical professionals still believe in helping their patients.
I have had several nasty encounters with physicians–including one who was morbidly obese himself (and I’m not obese, just overweight). Note that not one of these doctors actually bothered to help me figure out solutions (my weight is caused by having PCOS, exacerbated by my mood stabilizer). They just assumed that I was a slovenly glutton. Thank you, thank you, thank you for your compassion, and may your colleagues learn from you, for you have much to teach them.
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This is a brilliant article and I thank you for writing it. Personally, I think medical schools need to start teaching classes in understanding the obese patient. Why is it permissible to mistreat an obese patient’s lack of mobility when we wouldn’t THINK of mistreating or joking about someone with MS or the victim of an accident? Society as a whole is becoming more and more dehumanized by fat-shaming. Thank you again for your compassion and empathy.
BTW, I suffered from anorexia nervosa for 2 years in my teens, when I was absolutely skeletal — and then from bullimia for another 2 years, before I decided I’d rather cope with obesity. Why is it that anorexia and bullimia garner such sadness and compassion, but obesity only triggers hatred and loathing?
I shared your article with my friends on Facebook, with my comments:
I’m extremely fortunate that both my internal med doc and my ENT don’t look at my weight *first,* like so many other doctors before them. My biological mother was much heavier than I am, and she was discriminated against with such hatred, malpractice contributed directly to her death in 1983. I went to those same doctors and experienced their hatred as well.
Last year, a pain management quack actually withheld my meds in an effort to force me to lose weight. He was nothing but a pill pusher and NEVER once did he mention physical therapy or other modalities to help my pain. I decided I’d much rather deal with the pain that deal with him. (He literally looks like a drug addict; he’s filthy, his clothes look slept in, he comes in unshaven, and the other doctors in the clinic half-jokingly refer to him as the resident stoner. But so many addicts love him, they keep him on staff.)
When will the medical community begin to understand, as a whole, that obesity is a complicated issue made up of various factors? We’re just now discovering that what a mother does while she’s pregnant has a direct effect on whether or not her child becomes obese. While this is NOT an excuse, it is a factor that has a direct effect and should not be ignored.
Emotional eating requires psychological assistance and often medications for depression. Overactive appetite requires medical intervention with pills that can help alleviate constant hunger. Education — and in MANY cases, actual classes in shopping and cooking — can help with the switch from processed foods to ‘clean’ eating. (There are considerable economic and situational factors involved in this!)
Some people eat because they are bored. Too many people don’t exercise because no one has taught them how to get started at their ABILITY LEVEL, which will improve as they continue to move. It’s not about how much time you spend on a treadmill, it’s about doing what you LOVE to do to the best of your current ability.
PAIN is also a direct factor; pain pills and lying on the sofa is NOT the answer, but if pain is directly dealt with in a PRACTICAL way, it can lead the way to increased ACTIVITY on a daily basis. (This is MY fight every single day. I have at least one herniated lumbar disc and have had severe (inherited) osteoarthritis since the age of 12, along with serious injuries that have taken their toll.)
Bariatric surgery is not the answer, despite how many doctors PUSH that kind of alternative. I’ve spoken to at least 20 people who have said they would NEVER have had the surgery if they knew their life would be changed for the worse, because of all the complications they’ve suffered. (This includes people who’ve had lap band surgery through a radical gastrectomy, and everything in between.)
Last but not least, DEPRESSION has to be dealt with effectively. Most obese people have spent their entire lives being discriminated against, ridiculed, blamed, shamed, verbally slammed by their own family members over and over again, derided by their ‘friends,’ made to feel like hideous monsters by all types of media and the entertainment industry, and then stymied at every turn by incorrect nutritional information and medical personnel, before they’re pressured and discriminated against by their doctors. Who wouldn’t want to give up after all that?
People are all too often afraid to stand up to their doctors and say, “YOU don’t know what you’re talking about. This is a MUCH more complicated issue than you’re able to treat. I am NOT lazy, and you are NOT treating me with the same compassion you save for your thin patients.” I’ve confronted my doctor about this, and it’s about time every obese patient takes a hard look at their issues — and confronts their doctor, too.
We are all responsible for our own care, ultimately, ESPECIALLY if that means asserting ourselves to get equal compassion from those we’re paying to take care of us.
There are a number of things which concern me in your comments. Perhaps the greatest is the bit about teaching how to shop and cook! Do you understand that low income often forces people to a diet high in carbs, processed food, and so on. This is a diet that will produce obesity, but fresh fruits and vegetables are far, far more expensive. Also, many people are more than aware of the campaigns filled with solutions, like your response. Those dealing with obesity are well aware of their weight, and don’t want to hear a program to solve the problem that they’re told they are. I know I am overweight. It is the least of my problems, and not something I am currently willing to work on. The aftermath of deer tick bites, that fomented fibromyalgia and heart problems, the heart problems (all electrical, BTW), the 2 years fighting mycobacterium abscessus pneumonia (not weight related), etc. push the obesity to the bottom of the list. And, I remember the doctor who made faces to his MA while examining me–thinking I didn’t see him–and then blamed every single complaint I had on my weight. This man (hardly a physician) was affiliated with Potomac Hospital in Woodbridge, VA. Apparently, they were happy with him. No, I don’t want to hear of lists of “solutions”.
Thank you for this brilliant, gorgeously written, and incisive article! Every doctor should read this! Anna Mollow
Thank you for acknowledging that we fat people are human beings. That’s where it has to start, with the cessation of dehumanisation of fat people. Because the reality is, you cannot help someone you loathe.
LOVE this article.
You write, “Dr. Thompson was seeking to similarly implicate himself and his colleagues in their size-ist bigotry” …. an overly kind misinterpretation of his total train-wreck of an article.
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I think you meant “malingering”, not “maligning”.
I appreciated this commentary. Practicing compassion requires listening the other. This ER doc was unable to step out of his own narrative to hear the patient. I hope that the death was inevitable and not related to the insensitive care this patient received.
Thank you so, so much for this piece – deeply felt and sadly, much needed article.
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The UK lags behind in the inclusion of electric vehicles (EVs), it for just 1.38 percent of cars on your way in 2020. as opposed, 4.3 percent of cars in the netherlands are electric, 4% having Sweden, And in norwegian 22.1 the highest amount in the united states.
EV car sales amplified by 76.3 percent in 2021 and now be the cause of 420,000 of the cars on the highway, in order to Next Green Car. With far more electric cars on the road, in contrast, There is a distinct lack of public charging ports presented to use and, When drivers locate them, charmdate review They could be already in use.
in industry bodies, previously 21,000 plug in points are needed each month to maintain demand, But as of the beginning of 2022, Only 500 per month were being created. the united kingdom has under 30,000 public connect points, But as the sales of new cars and vans with petrol and diesel engines banned from 2030, A massive system overhaul is needed.
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some time ago, there are numerous instances of motorists receiving huge fines for overstaying the stated time limit like one motorist in Hinckley not paying for parking or not asking permission.
The key rules of public charging are listed below:
Public charging points will have explicit time limits and instructional materials to follow. along the lines of, if you are using a rapid charging station and maximum occupancy time of the port is 90 minutes, it’s necessary that you leave after or before 90 minutes. If the parking space is in a location where you make payment for for parking, You might need to pay for your time there plus the charging of your car. If you park on private property or home, Such as in a hotel car park, You must inform staff you are charging your car and ask for permission, If mindset a guest and have not paid for parking. Occupying a electricity vehicle plug in port does not usually mean you are exempt from normal parking fines.
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As sales of EVs increase while the number of charging locations fail to maintain demand, The competition for plug in ports might get worse. even so, Private plug in ports are now required to be included in any new build homes and non available buildings. It is hoped this will relieve the stress on public locations.
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