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Health as if everybody counted blog

Ted Schrecker

Ted Schrecker

Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institute, a partnership between Bruyère Continuing Care and the University of Ottawa, and a member scientist of the Population Health Improvement Research Network (PHIRN). A political scientist by background and an activist by inclination, Ted has a special interest in globalization, political economy, and issues (such as health and human rights) at the interface of science, ethics, law and public policy. From 2005-2007, he coordinated the Globalization Knowledge Network of the WHO Commission on Social Determinants of Health, and subsequently was one of the lead authors of a report to WHO that examined the implications of the Commission’s findings for future research priorities. He is currently editing the Ashgate Research Companion to the Globalization of Health; a four-volume collection of major works in global health (http://www.uk.sagepub.com/books/Book235377) that he co-edited with colleagues Ron Labonté, K.S. Mohindra and Kirsten Stoebenau has just been published in the Sage Library of Health and Social Welfare.

Photo courtesy of Ron Garnett, AirScapes.ca

Code Red for maternal and child health: The BORN project *

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Thursday, 12 July 2012
in CHNET-Works!

In 1997, Ontario’s health ministry set a goal of reducing the percentage of babies born with low birthweight (less that 2,500 grams at birth) from 5.7 to 4 percent by 2010.  Such babies are at increased risk for poor health outcomes, and their care involves substantial health system costs.  The target was not met; in fact, by 2010 the figure had risen to 6.5 percent.   In a followup to the Code Red project, described in a previous posting, researchers at McMaster University and reporters at the Hamilton Spectator examined 535,000 Ontario birth records to find out why.  The results of the BORN project, which turned into a much larger-scale investigation into the socioeconomic influences on maternal and child health, offer a disturbing look not only at the reasons but also at the straightforward economic consequences.

The study found a strong socioeconomic gradient in low birthweight.  “Of the 20 neighbourhoods in Ontario with the worst,” i.e. highest, “rates of low-birth-weight babies, three of them are in the lower part of the former City of Hamilton” – in other words, the low-income downtown.  In one of the neighbourhoods, “74 percent of children live below the poverty line” and more than one family in four is headed by a single mother – statistically, one of the most important risk factors for poverty.  There are also some conspicuous outliers.  For example, the high-income Toronto suburb of Vaughan has the highest incidence of low birth weight in Ontario: 16.4 percent – emphasizing the complex causal pathways that may be involved.  McMaster researcher Neil Johnston, who was part of the study team, noted that there is “not a single smoking gun.  It’s almost a conspiracy of things that preclude [mothers] from ensuring the child they’re carrying will be as healthy as possible.”

born pic 1 prenatal care Ont1

One of those things is uneven access to prenatal care:  in some Ontario communities, like downtown Windsor, just over half of all expectant mothers receive prenatal care during the first trimester; in other communities, for the most part relatively wealthy, more than 19 out of 20 mothers receive first-trimester care.  Interestingly, although a socioeconomic gradient exists across neighbourhoods in Hamilton, levels of access are generally high.  Another issue is teenage pregnancy.   Within the region at the west end of Lake Ontario there is a steep socioeconomic gradient.  In one of Hamilton’s poorest downtown areas, between 2006 and 2010 one in seven babies was born to a teen mother.  In a wealthy area of nearby Burlington, where the median household income is three times as high, among a comparable number of births not a single one involved a teenage mother.  Comparable differences were observed across the province, with many of the highest rates (between 20 and 40 percent of births to teen mothers) observed in low-income First Nations reserves across northern Ontario.  Conversely, in 20 rural and suburban municipalities across southern Ontario, including high-income Richmond Hill and Oakville, the highest percentage of teen mothers was 1.8.  (The Town of Vaughan was one of these, showing the complexity of the low birthweight problem.)

born-pic-2teen-mom-rate2

As with the original Code Red series, the statistics are accompanied by interviews that should be required reading for every student of public health or health promotion.  Interviews with people like “Kristen,” pregnant at 16 after her boyfriend poked holes in the condoms because “he figured it would make me stay with him,” and researcher Lea Caragata, who points out the links among poverty, economic insecurity and lack of a sense of the future. “For those middle-class kids in Ancaster, pregnancy will ruin their prospects and their aspirations …”  It is critically important not to pathologize teen motherhood, but equally important to recognize that all too often it ensures the reproduction of patterns of disadvantage and marginalization across generations.

All of us concerned with action on health equity need to ask questions like the one posed at the start of the third and final instalment of the series:

born-pic-3-quotation

Turning around the Ontario situation will require coordination among a variety of service providers – a “symphony orchestra” rather than “a wonderful jam session,” in the words of McMaster’s Johnson, who emphasizes that the province “must take accountability for what happens” in the health system.  This is easier said than done – too often no one anywhere in the health care system seems accountable for outcomes, as shown by Ontario’s lacklustre performance in diabetes management – yet the challenges raised by the series are even bigger.  One set is summarized in Lea Caragata’s passionate critique of the “opportunity deficit” facing too many of today’s youth.   Another, related set is suggested by remarkable calculations that show the Gini coefficient – a standard measure of income inequality – at the neighbourhood level.

“It turns out that the Hamilton neighbourhoods with the greatest income inequality are also the same neighbourhoods with the highest levels of poverty. …. Perhaps it’s a coincidence,” said the final story, that these neighbourhoods “also happen to be the neighbourhoods that performed poorly for any number of health variables based on the findings of both Code Red and Born.

“Perhaps it’s not a coincidence.”

In Canada as in much of the rest of the world, economic restructuring and social policy retrenchment are driving an increase in economic inequality on every scale from the neighbourhood to the nation.  By failing to face up to this trend and address its consequences for health, we are betting the future of many Ontarians on its being just a coincidence.  We are also, of course, betting hundreds of millions, if not billions of dollars in future health care costs that could be avoided.    

Or, perhaps, we just don’t care?

born-pic-4-Gini coefficients

* Sincere thanks to the Hamilton Spectator and the Center for Spatial Analysis, McMaster University for the illustrations

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Good news and bad on health equity

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Friday, 06 July 2012
in CHNET-Works!

Herewith a selection of events from around the web, and the world. First, some good news. The Caledon Institute for Social Policy, a non-profit with a long history of progressive social policy analysis that is now headed by two accomplished alumni of the recently deceased National Council of Welfare, has announced that it will take over preparing and publishing two of the Council's most important data series: those on welfare incomes and the profile of poverty in Canada. These are core resources, and Caledon is to be congratulated on this initiative, which will be part of a new Canada Social Report. I hope that one or more Canadian academic institutions will offer to support them, financially and with other resources.

My current institutional home, the Bruyère Research Institute, has produced a valuable set of tips for keeping seniors safe in the heat. As I write we're at humidex 34 here in Ottawa, so the importance of such advice can't be overestimated. Eric Klinenberg's remarkable "social autopsy" of the 1995 Chicago heat wave reminds us that a clear socioeconomic gradient exists with respect to opportunities to stay safe in the heat. Many people can't afford air conditioning or a breezy cottage, and in Chicago the elderly on moderate incomes in particular found themselves isolated by fear of crime and other elements of the urban environment from locations that could at least have kept them cool.

In a world that may experience extreme heat and weather events with greater frequency as a result of human-induced climate change, such warnings assume special importance. They may also not be enough. On June 30, it was reported that a combination of violent storms and extreme heat had caused the deaths of at least 12 people in the United States, and millions more were "facing temperatures in the 40s without electricity, and without air conditioning." Record temperatures and wildfires in Colorado had forced the evacuation of 32,000 people and the cancellation of the iconic Pikes Peak Hill Climb, a motor sports event with almost religious significance for aging gearheads like yours truly. But not to worry, say the climate change sceptics; the evidence is insufficient and these may be natural variations from the mean. Everything will be fine.

Finally, a shift to the global frame of reference. A little-noticed resolution adopted in May by the World Health Assembly, the governing body of the World Health Organization, called on the "international community" to support action on social determinants of health and, more concretely, on WHO's Director-General "to duly consider social determinants of health" and to continue advocacy for their importance within the UN System. Supporting documentation pointed out that implementing the resolution would require an additional $33.6 million between 2012 and 2017, and that the cash-strapped WHO had no resources in its current core budget for these activities. To put the amount into context, it's equivalent to the cost of 22 of the 588 Tomahawk cruise missiles the US Department of Defense planned to buy between 2010 and 2012 ... and Tomahawk was just a drop in the United States' $1.5 trillion arms procurement budget over those years. What was it that the Commission on Social Determinants of Health had to say about "a toxic combination of poor social policies and programmes, unfair economic arrangements, and bad politics"?

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Suitable for framing

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Monday, 18 June 2012
in CHNET-Works!
Herewith a selection of quotations and images charting the path of social determinants of health in policy analysis. We start with a trip in the wayback machine, to 1983 and a review article(1)on hypertension in Canada by Helen Johansen, then with the Health Protection Branch of Health and Welfare Canada.

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Closer to the here-and-now, a team of researchers with Toronto’s Institute for Clinical Evaluative Sciences wrote in a 2009 report comparing public health policies across Canada’s provinces that:

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A similar point comes from an important new report on overweight and obesity from the Institute of Medicine south of the border (the quotation is from the web summary):

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More about this report, and about recent studies that have been quoted as casting doubt on the importance of “food deserts,” in a subsequent posting. I invite comments from readers on the latter point, in particular; meanwhile, some of the comments posted on the New York Times article that describes the studies  offer valuable insights into the real world of life on a limited income, where both money and hours in the day are in short supply.

Most recently, the authors of a May, 2012 report on income differences among patients using hospitals in Toronto began the study with a brief discussion of health equity in which they noted:

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The phrase currently used to describe the policies needed to address those core social determinants of health is “intersectoral action,” which was the topic of an earlier posting. The unequal distribution of opportunities to be healthy was central to the work of the WHO Commission on Social Determinants of Health. It was also central to the public health strategy proposed in a 2007 report to Norway’s Storting  (the national legislative body) by the country’s Ministry of Health and Care Services, and was communicated in an image that remains remarkably powerful.

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What we should learn from this brief journey was captured in a 2011 Toronto conference presentation by Nancy Edwards, director of CIHR’s Institute of Population and Public Health.

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Against the background of this accumulated wisdom, why is so much activity still focused on individual-level behaviour change and lifestyle modification, and so little on structural disadvantage? The question is, of course, too ingenuous by half. In a commentary written shortly after the World Conference on Social Determinants of Health in October, 2011, Sir Michael Marmot captured the underlying realpolitikof resistance as it played out at the conference:

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It should now be clear that “less safe” policy directions are the only ones that will generate meaningful progress toward reducing health inequities. How willing are those of us who profess a commitment to that objective, perhaps especially those with academic tenure or collective agreement protection (I have never had the former, and have not had the latter for two decades) to insist on those directions? Can viable coalitions for change be built outside the universe of health researchers and front-line workers, for example by making long-overdue common cause with the trade union movement? Such questions may decide the future of health equity in a Canadian political context that, at least over the short term, looks distinctly hostile.

(1)  Johansen H.  Hypertension in Canada: Risk factor review and recommendations for further work. Canadian Journal of Public Health, 1983;74:123-128.

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Social determinants of health: Glum tidings on the inequality front

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Monday, 11 June 2012
in CHNET-Works!

The Commission on Social Determinants of Health was emphatic about the role of “the inequitable distribution of power, money and resources” in sustaining socioeconomic gradients in health.  Such inequitable distributions do not just happen; they are the result of choices about how societies govern their economies and distribute the rewards they generate.  Globalization has undoubtedly narrowed the range of such choices – think about Eduardo Galeano’s “magic galleon that spirits factories away to poor countries” (1) and the shift of power in Europe from electorates to bond investors and credit rating agencies – but has not eliminated them.  Three recent publications offer important and sobering insights into how those choices have played out in Canada.

The most recent report on child poverty from UNICEF’s Innocenti Research Centre points out that: “It is now more than 20 years … since the Government of Canada announced that it would ‘seek to eliminate child poverty by the year 2000.’ Yet Canada’s child poverty rate is higher today than when that target was first announced.”  The poverty rate referred to here is not Canada’s Low Income Cut-Off, but rather a standardized relative measure referring to a household disposable income of less than 50 percent of the national median, after adjustments for family size.  Canada, as we can see, does not rank especially well on this measure.   Much of the report is devoted to comparing this measure with an alternative one constructed around 14 specific measures of child well being, for which data are available only for European countries, but among countries for which both measures are available there is a clear correlation between rankings.  

glum tidingsSource: UNICEF Innocenti Research Centre (2012), Measuring Child Poverty:
New league tables of child poverty in the world’s rich countries.
At the other end of the economic scale, a new paper by five Canadian economists explores some of the driving forces behind Canada’s steadily rising level of inequality –in particular, the growing share of income flowing to the top one percent of the income distribution.  “The top income share almost doubled” from about 8 percent in the late 1970s “to reach 14 percent in recent years.  Such an uneven distribution of income has not been seen since the dark days of the Great Depression.”   In a clearly written review of the issues, the report goes on to make a number of important points:

  • The range of occupations represented in the top one percent is far wider than stereotypes would suggest, with only 10 percent of top earners working in financial services as of 2005 (the date covered in the last compulsory Long Form Census, from which many of the report’s data are drawn)
  • Growing inequality is a function not only of changes in the distribution of market income but also, and crucially, of the retreat from redistribution that began in the 1990s
  • “Younger workers, especially those with limited education, face a world with worse earnings prospects than their fathers’ generation,” suggesting a future of further inequality in market incomes as older cohorts of workers who have maintained their wages retire
  • Revenues from increasing income taxes only on the top once percent would probably be relatively modest, even before considering the impact of strategies for tax avoidance that are available to many of the rich

The report also has, to my way of thinking, at least two shortcomings.  

First, and perhaps unavoidably given data limitations, it deals only with income and not with wealth.  Wealth distributions are often more unequal than incomes, and many forms of intergenerational wealth transfers (e.g. bequests of valuable principal residences) do not show up in income figures.  The report points out the role of assortative mating (of two high earners) in increasing household income inequality; its contribution to inequality in household wealth may be more significant.

Perhaps more seriously, the report takes the concept of ‘skill’ as entirely unproblematic, treating the education level associated with a particular occupation as a rough proxy.  However, there is often no clear connection between the intrinsic complexity of the tasks involved and the credentials of those performing them; in terms of labour market outcomes it makes more sense to ask what kinds of tasks, including some very complex ones, are amenable to ‘offshoring’ in low-wage jurisdictions.

Robert Evans, the iconoclastic health economist whose work was the topic of an earlier posting, likewise organizes a recent article around the one-percenters’ growing share of income and on that fact that “these trends,” both in Canada and the United States, “are to a considerable extent a consequence of conscious, deliberate agency by more or less organized and coherent interest groups.”  His most immediate concern is what the retreat from redistribution means for the future of Canadian public health insurance (“a casualty in the class war,” in Evans’ words) now that federal cash transfers to the provinces for health care no longer come with even minimal conditions.

Evans is, as always, playful with his literary allusions; Sherlock Holmes enthusiasts are directed to his endnote 11 and the accompanying text.

Outside the health care field, he emphasizes the health consequences of the “degrading” of environments where people live and work that is associated with rising inequality – a special concern in view of the prospects of a global economic realignment in which many ‘good jobs’ have simply disappeared from the high income world.  Reducing the effects of that realignment on health disparities will require more, not fewer redistributive economic and social policies – certainly not the austerity measures that are now worsening the current recession.  If one agrees with Evans’ analysis of the sources of successful resistance to such policies, then the precarious state of the social determinants of health agenda in Canada is hardly surprising. 

(1)  Galeano E. (2000).  Upside Down: A primer for the looking glass world.  New York: Picador.

Source: UNICEF Innocenti Research Centre (2012), Measuring Child Poverty:

New league tables of child poverty in the world’s rich countries.

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Hamilton, Ontario: “Code Red” for health equity?*

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Wednesday, 30 May 2012
in CHNET-Works!

For Canadians of a certain age, the southern Ontario city of Hamilton (now an amalgamation of an older core municipality with several suburbs and exurbs) will always be Steel City, after the industry that was once its economic backbone. Today the city's steel industry has shrunk dramatically, as part of the deindustrialization that has ravaged the city's economy. Steel producer Stelco, which employed 25,000 people as recently as 1980, employed (as US Steel) only 1500 people in 2011. Other industrial employers, such as Firestone Tire and Rubber, International Harvester, Procter and Gamble, Dominion Glass, Camco, Siemens Canada and Westinghouse have left the city altogether. These job losses combined with a pattern of migration (by those who could afford it) from the downtown neighbourhoods surrounding major industrial plants to the suburbs to produce drastic economic inequalities within the city's boundaries. Thus, median family income in 2005 in the affluent exurb of Ancaster, formerly an independent municipality, was almost twice as high as the average for the former core city of Hamilton.

The health gradient associated with these inequalities has been documented in a remarkable collaboration between McMaster University researchers Neil Johnston and Patrick DeLuca and Hamilton Spectator investigative reporter Steve Buist. Their work produced a series of stories in the Spectator in 2010, is summarized in a new journal article+, and provides a template that should be used by university-community coalitions in cities throughout Ontario and elsewhere.

code-red-pic-1-500Source: McMaster University and Hamilton SpectatorThe researchers started with 12,000 death records and 400,000 hospital admission and emergency room (ER) visit records from 2006 – 2008, for everyone listing a Hamilton home address. Identifying information was removed to ensure privacy, and a hospital research ethics board indicated that no formal review was required. Twelve health variables were identified, and patient records were sorted by home address into Hamilton's 135 census tracts, for which socioeconomic data from the 2006 census were also obtained. Local school boards provided information on high school completion. The data were then turned into a series of maps, only a few of which are shown here, that show census tracts grouped by quintile, but data are also available for each individual census tract.

As one of the articles in the original series put it: "Those neighbourhoods with high rates of emergency room visits, no family physician, respiratory-related problems and psychiatric emergencies are the same neighbourhoods, in general, that have the lowest median incomes, lowest dwelling values, highest rates of people living below the poverty line and highest dropout rates from school."

"In parts of the lower-central portion of Hamilton," the story continued, "where poverty is deeply entrenched, some neighbourhoods live with Third World health outcomes and Third World lifespans."

code-red-pic-2-500Source: McMaster University and Hamilton SpectatorSome specifics: in one high-income census tract on Hamilton Mountain, where only 4.1 percent of the over-15 population lived on incomes below the Low-Income Cutoff (LICO) in 2005 and median family income was more than $68,000, average age at death was 86.3 years. In one low-income downtown census tract (35 percent of people over 15 living below the LICO, median family income just under $40,000) it was 65.5 years – a difference of 21 years.

The journal article that summarizes Code Red findings adds: "Also, there was a 22-year difference in the average age of a patient attending hospital with a cardiovascular-related emergency—from 57 years at one extreme to 79 years at the other. With respect to acute-care hospital bed use, one neighbourhood in the lower inner city had a rate of 729 days of acute-care hospital bed use per 1,000 people between the ages of 16–69. At the other extreme, an affluent suburban neighbourhood had a rate of 46 days of acute-care bed use per 1,000 people between the ages of 16 and 69. Other statistics presented included one inner-city neighbourhood having a rate of children living below the poverty line of 68.5 per cent while there were seven neighbourhoods where the rate of children living below the poverty line was 0 per cent."

code-red-pic-3-500Source: McMaster University and Hamilton SpectatorIn addition, a composite of all health and socioeconomic indicators was generated to produce a single ranking of each of the city's 130 census tracts. This ranking, too, was mapped by quintile. Combined, the two adjacent census tracts that placed lowest in this ranking had more than 40 percent of their population living below the LICO and the highest rates of hospital use – more than 1400 bed-days per person, or more than 17 times the rate for one suburban census tract. They also ranked near the bottom on many other health indicators.

The study also considered cost issues. Based on figures provided by Ontario's Ministry of Health and Long-term Care, it found that ER, hospital and ambulance use over the two years covered by the study cost $2,060 for every person living in one low-income, downtown neighbourhood. In one suburban neighbourhood, these costs added up to just $138 per person – raising the question of whether resources could be better used to eliminate social and economic conditions that make the ER and the hospital frequent ports of call for people with extensive health care needs, limited resources, and (often) no family physician.

That question is central to efforts to advance health equity, and it came up often in the course of research for Code Red, which was much more than a statistical exercise. The Spectator series included interviews with Hamiltonians as diverse as the head of a community foundation, a young paramedic whose role is that of a first responder to health emergencies, a family physician operating a one-person practice in the downtown neighbourhood where he grew up, a woman recovering from homelessness and crack addiction and the chief of emergency medicine at one of the city's hospitals. The stories told add to the statistics, as disturbing as they already are, what philosopher Jon Elster has called the texture of everyday life.

code-red-pic-4City of Industry, March 2007; photo by Chip Walsh,
reproduced under Creative Commons 2.0 licence
At least in Hamilton, the health gradient has an environmental dimension. The Niagara escarpment divides the city by elevation between the low-lying downtown and Hamilton Mountain (as the escarpment is called locally) and surrounding suburbs. As one story in the series pointed out, the escarpment "acts like a catcher's mitt for offshore breezes from Lake Ontario, trapping pollution over the lower city, particularly the northeast" – where the city's major industries were historically located, and where current levels of deprivation are highest. The story went on to note that despite deindustrialization, pollution levels in this part of the city still exceed recommended levels far more often than in rural areas. An earlier study, covering the period 1985-94, found that total suspended particulate (TSP) pollution exposure levels and dwelling values (a useful proxy for neighbourhood socioeconomic status) were inversely related – an important finding, since smaller particulates in particular are linked to respiratory damage.

In academic terms, some are likely to critique the study for not using age-standardized measures of mortality. However, the authors made "a conscious decision ... to treat the data in the simplest fashion possible so as not to confuse a lay audience," and unadjusted data may actually be more meaningful from a health equity perspective, because of what they reveal about the extent of health disparities 'on the ground'. The same is true of objections related to the difficulty of disentangling causation from selection, which was not the objective. As an associate medical officer of health interviewed for the series put it: "People don't move to a neighbourhood and then the neighbourhood makes them poor. They're often in those neighbourhoods because they can't afford to live other places." From an equity perspective, that's the point.

In the words of one of the authors, the Code Red stories "really seemed to strike a nerve in Hamilton." They influenced the subsequent municipal election campaign; played a role in decisions to locate two new hospital treatment centres in central areas of the city where need is greatest; led to the creation of a new staff position in municipal government; and have attracted extensive interest from various audiences. Against a background of fiscal austerity that often proceeds on irrational lines, it may be too early to assess (or to expect) more systemic effects. The study nevertheless represents a critical advance not only in our understanding of health equity in Canada but also in our knowledge transfer capabilities – the kind of work that health research funding agencies should be supporting and encouraging.

* Neil Johnston and Steve Buist provided valuable assistance with this posting. All non-attributed views are exclusively my own.

+Contact Neil Johnston, This e-mail address is being protected from spambots. You need JavaScript enabled to view it for a copy

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