Episode Transcript
[00:00:00] This Podcast is brought to you by the GOSH Learning Academy.
[00:00:04] SA: Welcome to the third season of GOSHpods Goes Green. In this season, we're going to be focusing on medicine sustainability. In 2021, Great Ormond Street Hospital was the first UK children's hospital to declare a climate and health emergency. The NHS as an employer is responsible for 4 percent of the UK's total carbon emissions.
[00:00:24] And medicines are responsible for 25 percent of that. We're going to explore this topic further, taking a journey through the life cycle of a medicine, covering everything from production and procurement, use of medicines in hospitals and homes, all the way through to medicines disposal, to properly explore how we can change the impact that medicines have on the environment.
[00:00:46] NW: Hello and welcome to the next episode of our series on Medicines and Sustainability. I'm Nicola Wilson, the head of Education for Sustainability, and the project Lead for the Born Green Project. Today we will be focusing on safer pharma, in particular, minimising pharmaceutical pollution and protecting against antimicrobial resistant.
[00:01:07] With me today is Erik Ruiz, from Healthcare Without Harm. Welcome, Erik.
[00:01:13] ER: Hello, Nicola. Thank you very much for inviting us.
[00:01:17] NW: Oh, it's lovely to have you. Could you possibly tell the listeners a little bit more about yourself and a bit about healthcare without harm and its goals for safer pharma?
[00:01:29] ER: Yeah, sure.
[00:01:30] My name is Erik and I lead the Sustainable Pharmaceuticals framework at Healthcare Without Harm Europe. This is an organisation that supports the healthcare sector to become more sustainable in essence.
[00:01:41] And we have a team working in Europe, but we have other offices in the US, in Latin America, in Southeast Asia. So we are a truly global organisation. We try to understand what are the challenges in terms of sustainability for the healthcare sector and for healthcare professionals in particular.
[00:02:01] And then we also try to test with them different solutions always with this mission of building a healthcare sector that is resilient, robust, and that does not harm the environment.
[00:02:16] NW: Amazing. That sounds fascinating. And I suppose the goals of safer pharma then come within that.
[00:02:23] ER: Yeah, exactly. In the organisation we are working in different topics and
[00:02:28] we focus on climate change mitigation and adaptation. We focus on plastic reduction as well. We focus on sustainable pharmaceuticals, which is the main goal of the Safer pharma program. And always that we work on these topics, we try to answer questions like, how can the healthcare sector reduce its carbon footprint? Are plastics needed in healthcare? What impact do pharmaceutical residuals have in environment? We work with our member hospitals to develop tools like the climate emissions calculator that we have, to develop different methodologies to conduct audits or to design also trainings that can help us in answering these questions that can help us in reducing the environmental footprint of the sector.
[00:03:17] NW: That's brilliant. I, for one, am fascinated by the overlap of the plastics reduction and the pharmaceutical pollution. What kind of work have you done in the UK and the NHS, or have you, I mean, is it sort of other areas of Europe have had a better uptake?
[00:03:33] ER: Well, I would say that the UK is one of the strongest countries in terms of sustainability in the healthcare sector, and they are also one of the leading voices in the European region. And we have seen that also in the past years with the commitments, in the cop that was hosted in the UK. And you know, there are many good examples at the UK level.
[00:03:55] So I would say that this topic is part of the culture of many institutions in the UK, including the NHS, and there is a real commitment and understanding of the importance of sustainability. We have as I explained, we, we are a global organisation that we work in Europe and one of our biggest network is our network of hospitals.
[00:04:19] And actually the UK is one of the strongest countries in this network. Like we have, I think over 40 members of the clean and Healthy Hospitals networking in the UK. And then we have also a series of different networks for healthcare professionals like the pharmacist for Greener Healthcare and Doctor for Greener Healthcare Network, or the Nurses Climate Challenge or the number of healthcare professionals from the UK is also quite large.
[00:04:47] So yes, we do have a very strong connection with the UK and healthcare professionals in the UK are actually very interested and they are also very, they work a lot on sustainability. They are interested, they are prepared and they want to move forward. They want to be sustainability champions.
[00:05:07] And then we also have some projects like one that you know very well, like the Born Green project that we implement together with some hospitals in different parts of Europe and also of course, including the UK.
[00:05:20] NW: Yeah, and I, for one, would recommend to any of the listeners to go and look at some of those groups, join them, get actively involved, and listen to the examples from other hospitals around Europe because it's fascinating what people are doing out there.
[00:05:33] It's amazing work. Why is safer pharmer so important and what impacts can it have on us and our patients' health?
[00:05:44] ER: We could have a whole podcast session on this question only. So I will try to be brief and I will try to go to the most important points. I think that it's important to highlight that pharmaceuticals can enter our environment during manufacturing, during use and during disposal.
[00:06:02] So when a product is being produced, when we take it, and when we excrete it. And pharmaceutical residuals have been actually detected in surface water, in sea effluence, in groundwater, in soil even in drinking water, so in the water that we drink. So that's something that we have to take into account first.
[00:06:26] As I said, the main sources are manufacturing delivery, but also food production because we have to consider that the pharmaceuticals that we use are shared to with animals as well, like veterinarians and doctors use the same antibiotics. So it's something that we have to take into account because the impact of food production in, for example, AMR, it's very strong and sometimes we don't think about that.
[00:06:54] It's also important to note that around between 30 and 90% of an oral dose, of a pharmaceutical, for example, ibuprofen is excreted in urine as an active systems. So it's not that when we take our pharmaceuticals, then our body, let's say absorbs or metabolises a hundred percent of the pharmaceutical product.
[00:07:17] It goes to the environment through water, basically. Through our urine, through our faeces. The pharmaceuticals that we take, all of them have an impact. Obviously. I'm not saying that we shouldn't use pharmaceuticals. They are very important and we need them and they are vital part of the modern healthcare system.
[00:07:39] But we need to be ul when we use them, and especially understanding when we have to use them and when we don't need to use them also. I've said that between 30 and 90% of the oral dose is excreted and once they reach the environment, they can have different impacts.
[00:07:58] So the environment is a connector, but it is also affected by a pharmaceutical pollution. It can affect Flora and fauna, like we know every, for example, documented process is the feminisation of fish. it can also have an impact. It can damage the liver of certain species of birds. But it also has a huge impact on public health with a contribution of the development of antimicrobial resistance or antibiotic resistance or resistant pathogens.
[00:08:27] It's this AMR where it includes a lot of things. And one big problem that we have with that, it's that waste water is not prepared to treat the system bacteria.
[00:08:38] And in an urban settings, wastewater from different kind of uses get together in wastewater treatment plants. So wastewater coming from industry, from agriculture, from urban uses, from our houses, they get mixed together, before they enter the treatment pot.
[00:08:55] So it's quite dangerous how we are missing different compounds, different contaminants with also bacteria. And other things like microplastics, like pfas, that we don't know how they react together, but we know that they get together to the wastewater treatment plant. So as a takeaway message, I would say that medicines are essential for our lifestyle.
[00:09:18] And sometimes we have the impression that we have like carte blanche to, to use them without really asking the same questions that we would ask ourselves with other products. Like for example when we buy clothes and we ask ourselves like, should I really buy this jacket? Well, should I really take this ibuprofen today?
[00:09:35] Because there are all the things that can. Can help. You know, in, many cases it's a chronic use of some pharmaceuticals. Like many people use ibuprofen for example, because they have back pain and sometimes a healthy lifestyle. Doing more sport, you know, walking to the office, that's something that can help as well.
[00:09:55] And can even, reduce the use that we have of these kind of products. I would say that as a takeaway message, I would ask myself if I need to take that pill or if I can change something in my life that can make me about using this kind of medicines. Yeah.
[00:10:14] NW: Yeah, everything that you say there is interesting and triggers thoughts in my mind.
[00:10:19] For instance, in the UK, a big headliner for the last few years in our papers and press is about our clean water. And our rivers and our seas and actually that our rivers are being polluted on a exponential scale. And so then to think about these medications and still being active and the microplastic going into these waters it really shows that it's not just the appearance of something being dirty or being immediately unwell from your fresh water, not actually being fresh. There's many things that we are not seeing there that are having an cumulative effect on our health and our health of our children to come. It's really quite daunting, isn't it?
[00:11:04] It's really overwhelming. You are right in saying there's an individual aspect to it of do I need to take that medication right now? But also there should be a reliance on us as healthcare professionals to know what we're doing to question and to optimise how we give medications and when we review them.
[00:11:24] And not just to have prescribing practices that we've always had but to really question if that's the most up to date and current practice. Let alone for the pharmaceutical industry before us, before it even gets to our shelves to think about their waste streams. Yeah, it's mind blowing the sort of depth that you could go into your right, that could be a whole podcast. I'm sorry for asking you in one question.
[00:11:49] ER: And if I may I think there is room for systemic change because this is, in essence a symptom of how modern societies have been building a bit life in a way that it's really unsustainable. And if we think of, cities for example, like cities are designed to, to host cars instead of people.
[00:12:11] So our movements are mostly in a vehicle. And this is something that it's fostering, obviously sedentary, and this brings back again the topic of the use of medicines. Like we walk less, we eat less healthy, we don't have like healthy habits. What you said reminded me of this concept of preventative medicine.
[00:12:35] Yeah. That it's something that I see more and more like how doctors, nurses, pharmacists they starting working around this concept and also helping patients to take healthy decisions or, to start promoting the healthy habits
[00:12:50] And I think that's key for medicines, but that's key for many other problems like air pollution and other things.
[00:12:57] NW: Yeah, definitely. And you look at the nutritional value of the food that we eat now, and it's completely reduced. And yet , we are probably taking medications to counter that rather than thinking of our soil health and things like that.
[00:13:08] Yeah. There's so much to it. Do you think you could explain about the global threat of antimicrobial resistance to listeners? And are there some examples of best practice on how it can be tackled within the healthcare system?
[00:13:24] ER: Yeah, so AMR is one of the main public health threats that we will face in the next few years.
[00:13:31] Right now, AMR, which is a very difficult word to pronounce, and it might sound a bit technical, so people are not afraid of AMR, but they might be afraid of , antibiotic resistance of antibiotic not working anymore. There are actually several studies talking about the impact of the word AMR in the way patients take seriously the threat. So yeah, however you want to name it. The antibiotic resistant is having a huge impact.
[00:13:59] AMR claims 35,000 lives annually in Europe, and without further action, this number could increase to 400,000 deaths per year which is equivalent to the entire population of cities like Leicester or Coventry in the UK. So imagine every year the entire population of these cities being wiped out. And this is because antibiotics are fundamental for modern medicine. So we think of antibiotics as the medicine that we take when we have an infection. But it's also medicine that is used to support other treatments like chemotherapy, for example. Or we also get antibiotics in a prophylactic way when we get the surgery.
[00:14:44] So imagine how big the problem would be if we cannot have access to effective antibiotics anymore. It would mean that many processes, many chemotherapies, many surgeries would be much more difficult to perform.
[00:14:57] And this is something really concerning because there is a consistent pattern, I would say in Europe and hospitals of an increase in the use of antibiotics that were not used in humans before.
[00:15:12] Like some antibiotics that due to their side effects, for example, due to their toxicity. They were not used in humans. It was dangerous. Not dangerous, but you could have other impacts associated, other impacts in your health associated to the intake of these pharmaceuticals.
[00:15:27] And now these are being used in European hospitals. And not only that, their use is increasing. There is one specific case, which is a Colistin, it's one antibiotic that it was not used in humans. And now in the last five years, there has been an increase of 67% in the use of Colistin in European hospitals.
[00:15:50] So these gives us a clue that other antibiotics are not working because otherwise Colistin would not be used at the hospital like they would prefer to choose other antibiotics. This is dangerous because now we have Colistin. But imagine if we don't have Colistin anymore. This means that many people would be at risk and the projections are really bad, I would say like they are not really encouraging.
[00:16:16] We obviously have time. We can work on that and we, still can do a lot of things to assess this, but it's obviously a growing concerning And then you asked me about best practices as well, or things that could be done. Well, I would say that first most important thing would be to train our healthcare professionals.
[00:16:37] That's the most important thing. I know that in some countries, like in Lithuania, training on AMR is compulsory every five years, so healthcare professionals must update their knowledge on antibiotic use. So That's fantastic because, from one year to another one there can be a huge change in the guidelines of antibiotic use because some antibiotics might not be working.
[00:16:59] And in line with this, we have designed a training on AMR we thought from Europe. In the framework of the AMR do care project , where to date we have already trained 2000 healthcare professionals across Europe. So we are very happy and very proud of this achievement. We are also setting up a platform in English so that healthcare professionals in the UK can also access this training.
[00:17:24] That's the first thing, training, understanding the issue and understanding what's the best way to tackle it from a clinical perspective then something that's working in many countries is having a strong antimicrobial stewardship teams in hospitals. In Spain, there is a very good example because they have these proa teams, which are multidisciplinary teams with different healthcare professionals. In the hospital and that produce guidelines, they are also liaison between the medicines agency and other institutions with the hospital. So that's one of the best examples at the U level. I'm not sure, but I think that in the UK you have something similar. I'm not a hundred percent sure of how it works, but I know it's, there is something similar.
[00:18:16] Something important and that it's often not a priority is understanding how to communicate with patients. Patients play a huge role. Patients are the ones that use antibiotics, all of us, and it's really important that they understand how, when, and why you have to use them in a wise way. In many cases, and this is something that we don't really think about but patients think many times that antimicrobial resistance gets produced in your body if you take many antibiotics. Antimicrobial resistant happens in the environment, happens in the farms, happens at the hospital level, in the operating theatre. So it's something much more complex than, no I won't develop it because I hardly never take antibiotics.
[00:19:11] You might develop it from someone else's use or even from the use, of antibiotics in farms nearby your place. So it's a very complex topic and patients need to be part of the actions to address it. And then food I just mentioned food, but prophylactic use of antimicrobials in animals, it's a huge topic that needs to be addressed.
[00:19:36] Right now, around 75% of antibiotics consumed globally. Are used in production which in Europe and in the UK it's a bit lower, the number, it's I think less than 50%, it's around 50%. But still the way they are being used is a bit concerning because the use of antibiotics in many cases is done in group treatment.
[00:20:02] I think it is equivalent to the 70, 80% at least according to the data published by the European Medicines Agency in the recent report. So this gives us a lot of clues on how antibiotics are being used. Many times, simple actions like improving animal welfare in the farms could lead to a reduction of antibiotic use in farming.
[00:20:29] But obviously this has some costs and it's something that would have an impact on farmers at least when trying to implement it. So it's a difficult topic to address. In the UK there is one organisation that is doing an amazing world called the alliance to save our antibiotics, and they try to work with supermarkets, with policymakers like trying to bring about change from different sites.
[00:20:57] So I, would recommend you to go to the website and to check what they are doing in the UK because they are doing amazing work.
[00:21:04] NW: I have to admit, even though I am into sustainability clearly in a big way. I've made it my living as it were. I'm a meat eater. And I guess, would you say that actually if we all reduced our meat intake that would also probably have an impact?
[00:21:21] We talk about it having a carbon impact, but actually if we weren't mass producing meat in factory farms and things like that, actually that would have an impact as well.
[00:21:33] ER: Yeah, absolutely. Like reducing the consumption of meat has a positive impact in many aspects. Also, in emissions, that's the sexy topic.
[00:21:44] Everyone knows about the reduction of emissions from eating less meat but also in antimicrobials. Although I'm not a huge fan of translating the responsibility to the consumer. Yeah, because we have been literally trained for years and years to eat meat. We have been, bombarded in television with positive image of eating meat, like how this will boost your energy, all the benefits that it has and never highlighting the negative impact.
[00:22:12] And there are many communities where eating meat is actually very important, even culturally. I agree, reducing our meat consumption is essential especially, in countries in the global north. But it's also dangerous setting a trap on, you know, blaming ourselves. But I do agree, I think it's a great action. Something that, it's also important. Since this is a consumer choice, if we want to eat meat, or if someone wants to eat meat, it's very important to select the, proper, let's say, producer. So there are a lot of schemes, that might be a bit misleading, some of them, but there are some seals of quality, some seals of animal welfare that for a person that wants to eat meat, but still is aware of, the impacts. They can also check that and help to shift the production from an industrial production, basically a factory to an organic production. Although, yes, the best option is not to eat meat, of course.
[00:23:18] NW: That's a tricky topic, isn't it?
[00:23:20] From the safer pharma work you do. Do you have any recommendations about what we should look out for when purchasing medicines? So as healthcare professionals, when we purchase them from pharmaceutical companies, any recommendations?
[00:23:34] ER: Well, many I would say that. Usually when hospital purchases medicines from a company, it's the hospital managers who do that usually.
[00:23:45] Something very important is to incorporate sustainability in the procurement strategies. And that means asking a lot of questions basically. The pharma industry is not known for being very transparent. So you have to ask for emission calculation, for example for pharmaceuticals and incorporate criteria that can benefit products that have a lower impact, not only in terms of climate, but also emissions even labour rights.
[00:24:13] Like we know that most of the pharmaceuticals that come to Europe are produced in India and China in the case of generics, for example, or antibiotics. And there environmental legislations might be a bit more weak than in Europe or other parts of the world. So it's key to ask questions, to set targets to help also the industry to become greener, like something essential for that, for example, is having common procurement guidelines in different EU countries or countries of Europe. In the UK of course, because if the same pharmaceutical company needs to apply in seven different countries and in each country they have a different requirement, in the end, they might be discouraged to apply.
[00:25:02] For a greener for the introduction in the market of a greener product. Or they might even prioritise one single country and go for it because the market is bigger. So that's something really important. Like we need to go hand in hand with the industry as well, and we try to work with them and to make them understand how important this is for us.
[00:25:24] If they understand that the healthcare sector is happier to buy products that are a bit more expensive probably, but also more sustainable. They will be producing that. It's like what we were talking about eating meat or not eating meat. I remember that 10 years ago being a vegetarian was like living in another planet.
[00:25:46] Now you have everything, or almost everything. Even vegetarian burgers are better than meat burgers. And this was something unthinkable 10 years ago or 15 years ago, and now it's a reality. Well, we have the opportunity to make a reality of green pharmaceuticals as well. Yeah, as I said, transparency is key.
[00:26:06] Like asking data to pharmaceutical companies that will help us also take the correct decisions. And when it comes to patients, I would say that their actions might be a bit more limited because they probably don't have the knowledge or don't have the resources to put pressure on the industry or to address directly the industry.
[00:26:27] But as consumers, I think that patients can research on alternatives or more like on more sustainable alternative products. And they can discuss that with the doctors or pharmacists. A good example of this is inhalers, these kind of products. There are many different kind of inhalers that are produced and that are used mainly by kids.
[00:26:55] And there is movement in many countries, in the UK for example, in Spain, very recently to go for more sustainable options in the case of inhalers. So, discussing this with your doctor, seeing according to your needs, what's the most sustainable option that won't compromise your clinical treatment. I think that's essential and that's something that all of us can be doing, especially with young generations that are really into sustainability and that are really, into making a better world. And this includes also young parents that are very committed also to this.
[00:27:30] So I think this is something that could be done when we address the purchase of medicines.
[00:27:37] NW: Definitely inhalers is a big topic right now in the UK. When it comes to pharmaceuticals and making that switch when they have the same benefit clinically, it seems absolutely nonsensical not to choose the greener option, doesn't it?
[00:27:51] I was fascinated by your point about us not just asking pharmaceuticals, companies for data and to be transparent, but it's really important that us as purchasers across Europe ask for the data in the same way. And I've definitely found that when I've been looking at plastics of the consumables that we use when we use pharmaceuticals.
[00:28:14] So we're talking about intravenous giving sets or syringes or needles. When you look at the packaging, it's definitely not transparent as to what plastics or polymers are in those products and, we all know that they're not necessarily the most stable things. So the nanoplastics and microplastics and the leaching certainly of the chemicals will happen.
[00:28:37] But as a group, we could definitely do with being a step more coherent in what we ask and how we ask for that data so that clinicians can make that decision. Yeah. It's going to be a tricky one to coordinate. Would you say you've probably already answered it. How could clinicians be advocates for greener health?
[00:28:59] ER: Well, in so many ways, healthcare professionals are usually trusted voices in society and a referent for the general population in many countries. Well, your general practitioner, obviously, it's a very important role in the community has a really important role in the community.
[00:29:16] Also, pharmacists have a very important role in the community, so it's really important that they are engaged. And I would say that the first thing. Become an advocate for sustainable healthcare would be to be informed. Be aware of what's happening. Be aware how they can have an impact because it's something that it's proven and it's something that we know, and that's why organiations like Healthcare Without Harm Europe or even your team exists because we want to get them engaged once they are informed and we want to help them also find, let's say the path to sustainability. And yeah. So being informed, being aware of the impacts of the daily practice it's something that will motivate a lot of their actions.
[00:30:08] Then I would say it's really important to join the forces. Sometimes you might feel like a crazy person knocking at so many doors with no one opening the door, but I promise there are thousands of crazy person like you knocking at doors of people that won't open the door. But if you get together, if you rally around and you work together with the same goal , you will have a biggest rate of success, and you will also learn what worked in other places.
[00:30:38] That's why we have this network of healthcare professional with pharmacists, with doctors, with nurses, because all these people are going through the same, and all these people have wonderful ideas that are working in their healthcare facility and could be exported in other places.
[00:30:55] That's why there are projects like the Born Green Project. thats why they are, projects like the AMR care as well, because we need to connect the healthcare professionals and we need them to be aware of what's happening outside. And then I would say also at the institution level, finding allies it's also important and understanding who are the decision makers that can have an impact.
[00:31:21] And this is a bit different, similar to the previous point about joining forces, but more in a strategic way. At our facility level, many times the change doesn't come from the top to the bottom. It comes from the bottom to the top, and many healthcare professionals with the same vision can change the way a service does things.
[00:31:41] So that's something that I would say is essential as well. Convincing the decision maker is a tough task, but with arguments, with solid evidence it's not impossible. And many times when we talk about sustainability, we talk about savings, for example, we talk about using less but wisely.
[00:32:03] It isn't necessarily something unpopular among decision makers if you are able to make them understand that this is a great opportunity not only to become more sustainable, but also to have a more robust and resilient sector or have to facilitate in the case of healthcare facilities. And the last thing that I would say thats important to become an advocate. It's transferring or being able to share this passion also with patients who are in the end the end users of in the case of pharmaceuticals or pharmaceuticals. So being able to, very clearly explain to them what's their role, what's their impact . It will make them also change the way they take medicines, for example.
[00:32:48] NW: Yeah. Oh, I could ask you a thousand questions from that, but I must move on. How can patients reduce pharmaceutical pollution at home? Any top tips?
[00:32:58] ER: Well, I think that there are some low hanging fruits when it comes to reducing your contribution to pharmaceutical pollution at home.
[00:33:06] That could be easily achieved. For example I think there are a lot of drug back programs that can have a very positive impact. Being able to bring your medicines, your unused medicines, expired medicines back to the pharmacy, it's something that is really impactf ul, especially because many times these medicines, they go to the general rubbish, or even in some cases they are flushed on the toilet. So we need to avoid that as much as possible, meaning that we need to bring them back to the pharmacy. Then a key point, and I think this would be the most important one, is take medicines only when you need them and follow your treatment until you are prescribed, like what you have to follow the guidance of your doctor, of your pharmacist, of your nurses that's really important. And it goes also for the other recommendations. Always check it with your doctors. If you are unsure, you can check the package leaflet.
[00:34:09] Some cases they will give you more information. There are some companies that actually bring back some medical devices. So that's also important to know when you have medicines you can check in, the package leaflet. And then I would say we have talked about this at the very beginning of the conversation, but, having an active lifestyle or incorporating healthy habits in your life can help you a lot in reducing the use of pharmaceuticals, especially the ones that are used almost chronically. Again, back pain is a very good example because all of us, we know what it is. We know how annoying it is, we know how relieving it is to have a pill, but also having a more active life can help us avoid using them and avoid, being so dependent of these kind of medicines. So these are the four, or five things that I would suggest people to focus on.
[00:35:03] NW: That is brilliant. I think a really lovely message to end on, isn't it? Is, you know, how can we make a difference? And it's investing in ourselves and trying to maintain our own health as much as we can and supporting those around us.
[00:35:17] It is definitely essential. Erik, thank you so much for giving us your time today. I have found this conversation absolutely fascinating. I feel I could talk to you for hours but I should probably stop there. Thank you so much again.
[00:35:33] ER: Thank you very much, Nicola
[00:35:36] SA: Thank you for listening to this episode of GOSH Pods Goes Green. We would love to get your feedback on the podcast and any ideas you may have for future episodes. You can find a link to the feedback page in the episode description or email us at digital. learningatgosh. nhs. uk If you want to find out more about the work of the GOSH Learning Academy, you can find us on social media on Twitter, Instagram, and LinkedIn.
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