Welcome to the Evolution of Medicine podcast! In this episode, James sits down with Dr. Asfia Aftab, a GP partner in the National Health Service in the UK and founder of the Birmingham Functional Forum meetup group. She is also one of the heroes of James’s book, The Community Cure. Dr. Aftab is a dynamic person, with an energy and passion for her work that is inspiring. Her commitment to her practice and to her patients is leading the charge toward a new era of the NHS. There is so much to learn from her in this episode, and we think you’ll really enjoy it. Highlights include:

  • What inspired Dr. Aftab to pursue medicine and join the NHS
  • How Dr. Aftab is creating change in the NHS
  • Why the term “social prescribing” is trending in the NHS right now, and what it means for all functional medicine practitioners
  • How Dr. Aftab uses online tools to create offline connections with her patients and colleagues
  • How she implements group visits in her practice, and how she continues to grow and develop these groups with her patients
  • How Dr. Aftab has built a community around the Functional Forum meetup group she founded—and how this can be a model for all meetup groups to follow
  • And so much more!

Resources mentioned in this episode:
January 2020 Functional Forum
Prescribing Functional Medicine
Group Visit Series on EvoMed Podcast

Podcast by Asfia Aftab

James Maskell: Hello and welcome to the podcast. This week, we interviewed Dr. Asfia Aftab. She is a GP partner in the National Health Service in the UK. She is responsible for 80,000 lives in her series of practices across southwest Birmingham. She is also the founder and leader of the Birmingham Functional Forum meetup group. If you want to see the kind of things they’re doing, we did the Functional Forum that that was out in January. You can go back and watch that, but they are using that community built around the Functional Forum to put on education events for the local community, doing group visits, bringing people together, educating people. It’s an incredible model of what our meetup groups could be capable of. She’s super inspiring in person and is a pocket rocket leading to a new era of the NHS. Super inspiring to spend half an hour with her. Enjoy.

James Maskell: A warm welcome to the podcast, Dr. Asfia Aftab. Welcome, Doc.

Dr. Aftab: Hi, James. Thank you for having me.

James Maskell: So glad to have you here on the Evolution of Medicine podcast. I know that those people who are watching our content very closely would have seen you on the January Forum as the host of the Birmingham Functional Forum meetup group. What I wanted to do today was just go a little bit deeper into the story because I think there’s so much that practitioners all around the world can learn. Let’s just take it right back from the beginning. What made you want to be a doctor and how did you end up in the NHS?

Dr. Aftab: Wow. So I’ve been a doctor for more than 20 years in the NHS and I love it. It started on very, very young. We didn’t have many doctors in our families. We’re not from a family of doctors, but we’re a family that originally come from, we have Indian heritage, so we have a lot of sort of community spirit and sort of ideas about natural health and really health coming through being together and making a difference. I was always taught that, whatever you do, doesn’t matter what you do, but one, you’ve got to be really good at it and two, you’ve got to make a difference and it’s got to have some kind of meaning or purpose.

So I chose this. Everybody was quite shocked because there weren’t many medics in our family at all. But I did work experience in it and I thought, “Yeah, this is what I want to do.” So I did it and I loved every minute of it, of the training. I actually went into internal medicine first. I was there for nearly 10 years. Then I decided that the acute side of things are quite well-handled, I’ve noticed, in the NHS. But the chronic disease and a lot of the sort of health inequalities and the public health prevention didn’t have such a great handle on that. So I wanted to make a bigger difference to that.

James Maskell: Yeah. Tell us a little bit about the state of the NHS, specifically in the area that you’re responsible because now you’re a GP partner, you’re sort of like an independent contractor from the NHS taking responsibility for what? 80,000 patients, is it?

Dr. Aftab: Yeah. Yeah. The NHS, one of the biggest employers in the world. So that’s great; 1.6 million employees. A lot of great things that happen in the NHS. It obviously it has its stresses with being such a big system. There are a lot of vacant posts still, with a 100,000 vacant posts clinically, and that’s not to mention another 110,000 posts that are vacant in the social care. But we have 6 million heroic unpaid carers. That’s what we know of. There’s probably more as well. We need to look at the way that we are doing things. That’s one of the things that I was inspired by you James, to look at the things in different ways. So we’ve been doing this since 1948. We’re pretty much have the similar system since 1948, but you see with modern lifestyles, the whole thing has changed and I think we need to approach things in different way.

James Maskell: Yeah. Tell me a little bit about the 80,000 people that you take care of. How many clinics is it across and what is the kind of heritage makeup of those people and what is the socioeconomic status of those people?

Dr. Aftab: Okay. So they are in areas of South and Central Birmingham, which is in the West Midlands in the UK. The deprivation scores are high. There are pockets of sort of affluence as well. I personally am a GP partner for two of the practices. There are 15 practices altogether in a Federation. So GPs have come together to try and work at scale and I’m the director of all 15 of them, which would cover 80,000 of the population. It’s mixed culturally, but there are a lot of sort of Indians of continent, Asian patients, but probably half and half, 50-50 British, Caucasian and Asian.

James Maskell: That’s interesting. Okay. So you start to get a bit of a rumbling that you want to do things a bit differently with regard to chronic disease. We say, and I say in the book, you’ve got to use online tools to create offline connections. How did you get connected into this sort of functional lifestyle movement over there in the UK?

Dr. Aftab: Yes. When I became a director of this Federation, I had an opportunity to go on NHS leadership course and there I met the wonderful Dr. Mohan Pal Singh just by chance. He happened to be working in our area. I’d never met him before. Obviously, we clicked straight away with our passions being in the same areas of medicine and healthcare. He told me that he’d been to this Prescribing Lifestyle Medicine course run by a Dr. Chatterjee, Jeremy Holkey, and Ann and Michael Ash. He said, “You have got to go, Asfia. You just have to go to this. I don’t want to hear, ’No.'” And I did. I went to the next one. I know you went to the first one, I think, James.

James Maskell: Yeah. For anyone who’s listening to this, if you don’t know what we’re talking about, there is a Functional Forum. If you just Google, “functional forum prescribing lifestyle medicine,” I’ll put it in the notes, but we went to the first ever one, which is in January 2018 with the cameras. It was really an amazing event. It’s for GPs in the UK. It’s called, “Prescribing Lifestyle Medicine,” but it’s kind of like functional medicine light for GP practitioners and it’s been just really, really well-received. My experience of it is just seeing the energy in the room of doctors who sort have got the bit between their teeth and realize that this is the kind of medicine they want to practice.

Dr. Aftab: Yeah, absolutely. It was just the vibe in that room was amazing. There were hundreds of us with all in the same wavelength and we all thought we were alone basically, until now. We found our tribe as it were and we learned so much, so many things that we weren’t aware of. It was basically, the mission there was to say that we can do this in our clinic runs. We can do it on a one to one basis. We can start it from the next Monday, which I thought, “This is amazing.’ He says himself, Dr. Chatterjee, that it’s not rocket science. He hasn’t invented any wheels or anything. It’s just a framework of things that we’re already doing in terms of lifestyle counseling. But in the NHS, it tended to be a lot of, “So eat less and do more,” and he just made a bit more four pillars. So it was a bit more like, “Let’s have a look at how we sleep and how that affects our weight and our mood and things. Let’s look at how we’re really relaxing.”

There was a fifth kind of pillar that wasn’t so apparent, but as a thread running through it, which was our environment in our community and how we kind of get together to sort of bring about best sleep to relaxation, to nutrition and just moving better the way we are designed to move. It just struck a chord with all of us, really. It was just so well done, so well-delivered and a lot of us were inspired to do things that had already had an idea of how I wanted to do this in a kind of group way, even though I think the Prescribing Lifestyle Medicine was more sort of for a personal doctor to patient one to one, which is what happens in the NHS the majority of the time.

I met Dr. Chatterjee for the first time then. This is about one, two years ago. And I said, “I’ve got this idea for this Happy Hub.” And he said, “Oh my God, sounds amazing.” And I said, “It’s kind of based on your book, The Four Pillar Plan. And he said, “Go for it. Go for it. I’ll support you.” He has all the way and he’s come to it as well. You were there as well and he was there. He’s just amazing. He took my book and he just kind of made it alive. That’s what I’ve wanted to do. The patients were really taken to it, and the community’s taken to it, the practitioners who come up and give up their time for it. It’s just been amazing.

James Maskell: Yeah. Let’s just give everyone a little bit of a, you know, a little context because ultimately, we’re here talking about this whole series as being on group visits and group delivered care. This is one of the last ones in the series. What I saw there happening that day at the Happy Hub was somewhere between an education event and a group visit in that there were probably a hundred patients, there was a bunch of practitioners, circles and groups happening in this sort of church environment. How did you come up with it and what was experience thus far, and what was the experience of the patients?

Dr. Aftab: Yes. There was method behind my madness and it looked a bit like it was all happening. Originally, it was just for education. I thought, “I’m saying the same thing to people, whether it be about weight management or relaxation or mindfulness on a one-to-one.” And I thought, “Why am I saying the same thing to everybody? Why don’t I speak to more than one person at a time just for efficiencies of scale, really?” Also, because people said they would love to come to a meeting like this. So that’s how it started. It was just going to be a kind of like a TED-style talk on whatever it may be, healthy fats or whatever it was. It just developed from there.

Their ideas, there was like a feedback flip chart when people, whether it be practitioners or members, patients who came, they would just say, “How about we do this as well? How about if we also have a sort of an NHS health check and could check a blood pressure and weight while we’re here? How about we have one to ones.” Some people want a small group, some people want a bigger group, some people wanted a pillar, so they would just have like an eat station or sleep station. Over the period of 18 months, we tried everything out. It’s an open session and it was open to all 80,000 patients and hundreds of people signed up and it was really great.

James Maskell: Yeah. How did you get the word out to those patients?

Dr. Aftab: Well, what’s great about being a GP partner really is that we all have our lists, we have registered lists. We’re quite lucky and it’s pretty much cradle to grave and it’s generational. We have access to patients where we can make them aware of things, whether it be through the website for the Federation or we will have well TVs in the waiting rooms. We see hundreds of patients every day. We have thousands of patients in each of our lists. So we were able to get the word out and receptionists could refer, doctors could refer. They referred into assistance, or I had a team of people who would then handle the referral systems. It was a nice path, went smooth and very easy. So if people thought that, yeah, you could do with some wellbeing support. It could just be a general nebulous symptom like just being tired. It could be somewhere where you hit a wall from going to specialist to specialist trying every medication, and they’re at a point where they’d say, “I’ll try anything.”

James Maskell: Yeah, that’s really awesome. I’d love for you to tell a story of how we met because I feel like it was a…I know you’ve been centrally involved in the creation of the Birmingham Functional Forum and that a lot of the practitioners who come to that were the teachers on that day. One of the things that I’m really excited about is within this next era, is having these meetup groups that we built over the last six years really come together to create events for the public and work those kinds of things because ultimately, you have such a great range of practitioners at these events. Maybe we could just start with how we met because I think it’s a funny story, and what your hopes are for the Birmingham Functional Forum.

Dr. Aftab: Yeah. I remember that very clearly when I first met James. It was an amazing moment. It changed my life in a lot of ways. But how it started was I think Dr. Mohan, he had a WhatsApp group where we all were linked up. So everybody who’s interested in lifestyle medicine, everyone who had gone to the lifestyle course with Dr. Chatterjee were all linked together so that we could keep in touch and share ideas and share learning and ask each other questions about patients and things like that. So it was nice. It was like that was our tribe and we could keep in touch. It wasn’t just a one trick pony where we just went to this one course. We have kept in touch ever since. Katherine Steel is a great term psychologist and she lectures in universities. She’s also a health coach. She ran her own little Functional Forum just on the edge of Birmingham in a place called Worcester.

She was also on this group and she would always say, “Everybody’s invited to our little groups.” We’d have a group every month. One day, she said, “One of the group members, Tessa, her son’s coming to the group from America.” And we thought, “Oh, that’s nice.” And she said, “Yeah, and her son happens to be James Maskell of EvoMed” and suddenly, a lot of people came that time because James Maskell was coming from America. I came as well, not something I normally do, don’t venture outside my sort of Birmingham catchment area, but I was just intrigued. I thought, “I have to go to this” and a lot of people said to me, “You have got to go to this.” A great colleague of mine, Layla, who’s a clinical pharmacist, is very into functional medicine, strangely, lots of deep prescribe. She’s a pharmacist. She said, “I’m going to take you. I don’t care what you say.”

So she took me and it just obviously, we clicked straight away with the…you gave a little talk as well and then you asked about my Happy Hub. You’d already heard about it through Katherine and you said to me,” I’m going to come to your Happy Hub,” and I thought, “You’re not going to come to my Happy Hub from America.” And sure enough, you did and it’s taken off ever since. All these practitioners, I think it’s inspired them as well as in it’s been amazing journey since then. I just can’t believe that the level of passion and the interest and the knowledge really amongst these practitioners, that they’re from all different disciplines.

GPs make up a very small number, but there’s hospital doctors, there’s rheumatologists, there’s endocrinologists, there are physiotherapists, osteopaths, pharmacists, really everybody. But the main people there really are the health coaches and the nutritional therapists, who people that I had not really had a chance to encounter in my NHS journeys and are probably some of the best friends I have at the moment and have changed things for, not only me, but my patients and really, the whole model of how we are delivering health care now.

James Maskell: Beautiful. Well, look, I’d love to just get your thoughts on…the event that we put on was so awesome and it was such a beautiful location. The food was amazing. The situation was amazing. If you guys haven’t had a chance to watch. It was the Functional Forum this month came out on January 1st and I really enjoyed the time. The conversation was The Community Cure for the NHS. Since that night, Morris Johnson has been elected, which in my mind means there’s no big cash windfall for the NHS. It’s not like budgets are going to go through the roof. So we’ve got to work out how to do more with less. I guess I would just love to get your feedback on the event and just anything that has happened since or anything that sticks out to you about the event and what you feel like the future of the NHS looks like.

Dr. Aftab: Yeah. So the group of practitioners, I think we’ve always wanted to have a sort of regular meetups. Then with the framework, with your Functional Forum, I think it just tied in beautifully and it just came at the right time as well. We were having these regular monthly meetups where we would look at your EvoMed videos and then we’d talk about cases. It was just a really great time and to have great food, natural, healthy food. So we were having that at the one side and then we were having the patients, Happy Hubs also sort of running parallel to it and just trying to sort of educate ourselves and update ourselves and it was great. We had peer to peer and the patients had peer to peer support as well. So it was wonderful. Then yeah, the Functional Forum, I can’t believe that the first one, the decade was in the Hazelwell Hub in Birmingham, like a little town and so many people are going to see and it was just wonderful. It was a great event. I thought it was absolutely fantastic. It was thanks to you, really and to the people that came.

Mohan and Suzy were on the panel, just wonderful experiences that they’ve had and so many ideas. Then we didn’t know at that stage what was going to happen politically in the UK or for the NHS. But we are where we are and we do have to do more with less. I think there are ways of doing it. I think where there’s a will, there’s a way and I think we don’t really have any other choice. We do have to get on and do it. I think we’ve already been doing it. I think regardless of what happens politically, there is a real need to do this. I think people at GP partners who are involved with CCG, people have got levers in terms of funding and who are willing to take on new ideas and they are. We have this 10-year NHS plan and some of the things are quite incredulous. We have to reduce our referring rates by 50% and there are no methods of how to do it. There are just targets and I think it can focus your mind and that’s fine. I think that’s one of the ways.

James Maskell: Well, speaking of reduction by 50%, one of the things that I shared that night was just when you put people through this 10-week group visit training at the Cleveland Clinic Functioning for Life, half the people are so much better, they don’t need any doctors. So it just seems to me at that moment that here may be a step by step plan to be able to do it. And ultimately, you’re leading the way with getting groups of people together and it’s not that much of a stretch from what you’ve been doing to actually facilitate consistent group visits, have these nutrition therapists and health coaches help out, and to be able to recreate those kinds of results, especially given that there’s no barriers to entry.

One of the things we have in America is that, you do it on insurance, but then there’s copays and then have you met your deductible limit? People have high deductible insurance. The thing with the UK is that there’s no cost involved for the patient. So ultimately, if you can find ways to be able to see a lot of people at the same time, it seems like there’s a lot of potential for savings. If you look at someone like David Unwin who I know you’ve had talk at your Happy Hub, he’s literally sending tens of thousands of pounds of budget Metformin and insulin back to the NHS because so many type 2 diabetics are in full remission.

Dr. Aftab: Yeah, absolutely. We found that as well. We didn’t know what we were going to find to be honest, but I had some goals in mind. One of the things was wanting to unburden the NHS and I wanted to bring back the compassion, bring back hope to something that Dr. David Unwin talks about as well. It was becoming quite a hopeless situation, sort of helplessness. I wanted to give people health back in their own hands. I think we really manage that because one of the biggest problems we’re having at that time was this massive increase in the frequency of people attending any NHS appointment. Of course, as you say, there are no barriers. So anybody could come as many times as they want, as many hours there on the day. But there’s still finite amount of funding and we’d still get funded the same amount no matter if 10 people came, a hundred, 200 people came in a day and we needed to work in different ways. I think this is what really brought it to a head.

I think it’s worked because some of the initial figures are showing that definitely, the rate of patients seeing their GPs reduces when they become part of the system or engage in this way of working. Then on top of that, you also have the physical values, which don’t even matter to me as much as the increase in their sense of wellbeing and their sense of community and purpose. But we have seen blood pressures go down, weights go down, HbA1c diabetic monitoring becoming more optimized and this is with no medication. In fact, this is with de-prescribing a lot of the time. Something is working and it’s not just education because I don’t think you can just educate people and expect changes to happen.

James Maskell: Yeah. There has to be a certain amount of care and that the group structure really provides that kind of potential for accountability and just inspiration from other people who are going through that same process as you. So I think that’s great. One of the things I showed obviously in the Functional Forum towards the end was that video from Frome and how they’ve really engaged the community, not just the doctors and the health coaches, but actually getting bus drivers, and waitresses, and hairdressers, and policemen to wear green lanyards and collect lonely people to all of these kinds of groups. I’m excited just to see the potential of those ideas because they found a 20% reduction in emergency room visits as a result of it. That’s really where a lot of the money is spent. So I could see…what do you think are the barriers to something like that spreading into other GP partner territories?

Dr. Aftab: Yeah, I think that video was amazing and ideas like that are really good. I think they have to be tried out. We have something called Permission to Smile. I think it may be just West Midlands, Martin Graham, who I’m in touch with through it, but he’s got this kind of, I don’t know, he’s on a bandwagon where he’s got signs all over Birmingham just saying, “Permission to smile. Say hello.” When not a nation like the US is where we can just say, “Hi, how are you doing on the streets?” We are quite stiff upper lip and things and it’s really broken down a lot of barriers and he’s come to the Happy Hub as well and talked about some of the events that he’s done. It’s basically like a street party. He believes in having street parties, bringing back that kind of, what we had in the UK before where neighbors knew each other and threw parties for any excuse and everybody’s invited and everybody was very involved.

It’s that kind of thing, I think that kind of structure which people miss because they tell me this one of the best things I love about the Happy Hub and that the food is amazing. It’s locally made by a lot of local restaurateurs and cafes and things help us out with it. But it’s not food, it’s not the education, it’s not the great talks, it’s not the inspirational speakers, it’s just the people and it’s the fact that they eat together. A lot of them haven’t eaten with anybody for months and months. They’ve eaten alone. They tell me what it feels like to eat alone and it’s not nice. It’s not nice to have even think about what to eat when you’re just eating for one. And I thought, “Wow. There’s so many things that we don’t know about what’s going on out there in society, in the environments that we have created for ourselves,” and this is the place to make health creation, as you say. It’s not in the doctor’s office, it’s not in the prescription pads at all, and there’s not a pill for every ill because there’s no pills in here.

James Maskell: Yeah, absolutely. Yes, it’s really exciting just to see that the term, “social prescribing,” is hot in the NHS and it seems like that movement pad with some of the examples like Prescribing Lifestyle Medicine with all these doctors now, almost a thousand have gone through plus examples like Frome, plus like the movement. I know it’s not just Ranjan who’s putting on events out there. You’ve got all kinds of lifestyle medicine movements, culinary medicine movements. There’s definitely a sort of an energy inside the UK for change. It’s exciting to see that. How do you as a GP partner with this much responsibility sort of pick and choose your battles in the next decade here to get to that goal in 2030?

Dr. Aftab: Yeah, well I’m a big believer in trying to reduce the health inequality gap, which we’ve tried so hard and we have a free health service, which is absolutely amazing and everybody should be able to have access to it regardless of ability to pay. Yet, we still see these huge gaps of inequality, a deprivation and I think that’s one of my main priorities is try to do something to reduce that gap. We had the opportunities and things like social prescribing are one of the ways because people have asked me that, “What you’re doing, which is a mixture of I guess social prescribing, lifestyle medicine, functional medicine, is it just as easy to do this if you’re from a very deprived community, is this from an affluent community?” And I say, “Absolutely. In fact, it’s easier to do it in a deprived community. It doesn’t cost to do the things that we’re saying, which is eat more naturally, grow your own or do digital detox or come together. That doesn’t cost anything.”

But it’s a change of mindset, which is what I think we need to do, not only with patients, but with our staff and with our communities, public health at large, bringing the councils, bringing all sorts of policy makers, drivers and that’s what we’re trying to do. I think we are making a difference because people are speaking in different ways. So many people have come to us to talk to us about it. I often get asked, “Are you the Happy Hub lady?” So people are hearing about this in this and it’s quite a small scale if we look at what’s happening and there’s a lot of it happening in the UK at different levels. A lot of them are just looking at social prescribing, which I think is great.

I think we do need to look at the wider determinants of ill health, but I don’t think we can do it alone. I don’t think you can just look at that side or signpost or somewhere if there’s that gap that I think health coaches are the best people to fill, which is, how do we concentrate on our goals and how do we in increments step-by-step, make actions to reach those goals and realize the potential of what we can do in health creation?

James Maskell: Absolutely. Well look, I want to say I’m super proud of you guys and what you’re doing. I hope that the event in January was a way to kick-off an incredible decade for all of the…if you are able to take all of the enthusiasm for that night and channel it into something, I know that there’s such a realm of possibility and I hope that if anything, you could infect other GP partners because it does seem that that is a really worthwhile group of people to be going to connect with because they’re all facing the same problems, they’re all responsible for the same kind of budgets and it’s an exciting time to be able to be innovating, to try and save the NHS before it gets privatized. I think you can already see the sort of rumblings of that. You can also see that it’s not going so well in America. God knows why it’s the plan, but you understand that there are powers that be there.

But I think it’s really important and I really appreciate the NHS for everything that it’s done for my mother. I think that the issues that we’re discussing here are absolutely relevant for everyone in every country because ultimately, it’s how do we do more with less? There’s not going to be unlimited budget for chronic disease in any country. Those countries that have it together are able to maintain much lower levels of chronic disease through community and through lifestyle that is just part of the culture and that culture has changed so rapidly in America and the UK that we need to take action to reverse it.

As I shared in the event, there’s an urgency because the younger generations are more lonely and sicker than our generations. So I really appreciate all the work that you’re doing on the front lines. I can’t wait to see how this takes off in the next 10 years and thank you for being on the front lines. For everyone who’s listening, I would say, if the last 10 years for me was really about building the army. It was about building a network of practitioners, getting doctors to switch to functional medicine. There are other things that have happened. If you look at the whole functional medicine coaching movement where we’ve had health coaches and other allied practitioners learning about functional medicine and functional nutrition. The army is ready to really be of service. So how do we help the army to actually get in front of people?

Well, that’s really what this next phase of the meetup groups is about. You can see here the thing, the reason why I’m super excited to have asked me here more than anything, is because her meetup group that is basically on a WhatsApp group and meeting up once a month comes together to put on events for the public where the range of practitioners can be showcased and groups can happen and peer to peer delivery and value can happen, and people that are eating together and exercising together and you know, and meditating together, learning how to deal with stress, creating communities. Ultimately, these are projects that practitioners could be doing together, whether you’re in the NHS or in private practice, whether you’re in the US, the UK or anywhere around the world and sort of taking this from, “Hey, isn’t it nice for us to get to know each other?” To, “Let’s take this out to the people,” is the shift for this new decade and that’s why I was so excited to put out the forum on the first day of the decade.

If you’re listening to this and you haven’t watched it, please go back and watch it and we’ll keep you up to date with everything that’s happening in the South of Birmingham. Yeah, great appreciation from our end for you to take on the leadership and lead that group. It’s going to be an exciting 10 years. So this has been the group visit series as part of the Evolution of Medicine podcast. If this is the first episode that you’ve heard, this is the eleventh episode and you can go back and hear all of those on the website, but for the meantime, I’ve been with Dr. Asfia Aftab, GP partner in the NHS and my name’s James Maskell. I’m your host. Thanks so much for listening and we’ll see you next time.

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