|ONE NATION, ONE HEALTH SYSTEM - SPECIAL ISSUE
|Year : 2023 | Volume
| Issue : 1 | Page : 69-76
The prospect of an integrated approach to One Nation One Health policy—Cancer treatment as a potential case
Sunil K Joshi1, Ashutosh Chauhan2, Deepak K Semwal3
1 Uttarakhand Ayurved University, Harrawala, Dehradun, India
2 Department of Biotechnology, Faculty of Biomedical Sciences, Uttarakhand Ayurved University, Harrawala, Dehradun, India
3 Department of Phytochemistry, Faculty of Biomedical Sciences, Uttarakhand Ayurved University, Harrawala, Dehradun, India
|Date of Submission||06-Oct-2022|
|Date of Acceptance||15-Nov-2022|
|Date of Web Publication||08-Dec-2022|
Prof. Sunil K Joshi
Uttarakhand Ayurved University, Harrawala, Dehradun 248001, Uttarakhand
Source of Support: None, Conflict of Interest: None
Today, every medical system in India is working unconnectedly without associating with one another. Moreover, many lifesaving procedures and medications are not affordable and easily accessible. Hence, the concept of One Nation One Health is a wonderful idea to improve the healthcare sector in India. The present article highlights selective ideas to make the One Nation One Health policy more effective, with a particular focus on cancer treatment. The relevant articles and books based on this theme were reviewed, and their crucial information was included in the present article. In the current scenario, when healthcare facilities are not easily accessible, mainly in rural areas, the One Nation One Health policy should be implemented strongly. The integration of modern and traditional systems of medicine can be more effective in treating diseases, including cancer, because of own strengths of each medical system.
Keywords: Ayurveda, Ayush system, cancer, traditional medicine, Western medicine
|How to cite this article:|
Joshi SK, Chauhan A, Semwal DK. The prospect of an integrated approach to One Nation One Health policy—Cancer treatment as a potential case. J Res Ayurvedic Sci 2023;7:69-76
|How to cite this URL:|
Joshi SK, Chauhan A, Semwal DK. The prospect of an integrated approach to One Nation One Health policy—Cancer treatment as a potential case. J Res Ayurvedic Sci [serial online] 2023 [cited 2023 Mar 27];7:69-76. Available from: http://www.jrasccras.com/text.asp?2023/7/1/69/362944
| Introduction|| |
The main objective of the “One Health” policy is to frame such a medical system that integrates all healthcare systems. This would ease patients to opt for the best treatment from any system based on the disease pathology and previous results to cure it. Its motto is to offer uniform and best therapy to every needy patient residing in any part of the country or even the world. Thus, no person should be deprived of necessary treatment or lifesaving medicines. All these medical facilities should be readily available, affordable, and accessible to all.
A recent editorial written by Rastogi and Singh on this topic emphasized that the “One Health” policy should be based on the integration of Indian traditional medical systems (AYUSH) at the level of fundamental knowledge by validating their therapies and approaches of health care. To achieve this goal, there is a need to develop integrated medical courses in which the strength of each system needs to be focused. Successful integration of modern and Ayurvedic systems of medicine was seen in the National Mental Health Care Act 2017, in which Ayurveda, Yoga and Naturopathy, Unani, Siddha, and Homoeopathy were duly recognized for their potential for mental health. A meaningful integration can be best pursued when all healthcare systems are at the same level. Safety and efficacy are the key points to be adopted before effective integration. In this direction, integrating Ayurveda and Western medicine can become a boon for cancer treatment.
Serving a population size of 1.4 billion, nearly 20% of the planet’s entire population, is a Herculean task. India’s healthcare industry has been growing at a compound annual growth rate of around 22% since 2016. This rate is expected to reach USD 372 billion in 2022. Health care has become one of the largest sectors of the Indian economy in terms of both revenue and employment. There are public and private components of the healthcare delivery system in India. The public healthcare system comprises limited secondary and tertiary care institutions with maximum primary healthcare centers (PHCs) in rural areas. The private sector provides most secondary, tertiary, and quaternary care institutions. India’s health system is further divided into a Western system of medicine with a total stock of 5.76 million health workers, which included allopathic doctors (1.16 million), nurses/midwives (2.34 million), pharmacists (1.20 million), dentists (0.27 million), and Ayush medicine consultants (0.79 million).
| Concept of One Nation One Health|| |
The National Health Policy (NHP) was endorsed by the Parliament of India in 1983, updated in 2002, and then updated in 2017. The main updates in NHP 2017 focused on the growing burden of noncommunicable diseases, the emergence of the robust healthcare industry, growing incidences of unsustainable expenditure due to healthcare costs, and rising economic growth enabling enhanced fiscal capacity. It also noted that well-considered steps must be taken to move toward meaningful phased integration of the Ayurveda and modern medical systems. However, at a functional level, such integration did not happen in India, culminating in a separate ministry for traditional, complementary, and alternative medicine (TCAM), thus formalizing the creation of a parallel structure in an already fund-starved sector. Another National Medical Commission Bill 2017 tried to introduce specific educational modules or programs for developing bridge courses across various systems of medicine, thus promoting medical pluralism, but faced stiff opposition. Soon after, a parliamentary panel on health recommended that the government scrap the bridge course proposal to allow AYUSH practitioners to practice modern medicine, citing patient safety. The center government plans to roll out a “One Nation, One Health System” policy by 2030, which would integrate modern and traditional systems of medicine such as allopathy, homoeopathy, and Ayurveda in medical practice, education, and research. The policy aims to formulate an integrative health system under which patients would get treatment from any medicinal system, depending on what ails them and their current condition. In many states, mainly at the PHC level, a doctor has permission to prescribe allopathy and Ayush medicines based on the better efficacy of the drug.
China’s health policy has been unique in the developing world as it tried to organize its health system around four basic principles in delivering healthcare services to its people. They put prevention first, combine Western and traditional medicine, combine health with mass movements, and concentrate on rural areas. China has used science-based approaches and successfully integrated traditional Chinese medicine (TCM) into the national healthcare system and hospitals by providing TCM treatment to 200 million outpatients and almost three million inpatients annually.
Although seeming idealistic, integration is a utopian thought with advantages and disadvantages. Such integration in health care has previously been attempted; erstwhile, attempts could not avail much for want of clarity of approaches and objectives. But, importantly, note that similar ideas were earlier. In this context, exploring the possibilities of intra- and extramural integration within the existing framework will also be essential. In a country like India, with its multiple functional healthcare systems, determining which works best in real clinical situations will be of the utmost importance in prioritizing each system. When integrating two systems, assessing their mutual influence on each other will be crucial. Equally, two systems that work excellently in a given situation may not retain their advantages when combined. Many examples reveal serious herb–drug interactions when traditional medicine is combined with modern medicine. Evidence of efficacy and safety is of paramount importance to any integration exercise. In the Ayush health systems, there is a severe shortage of meaningful evidence, which can pave the way for integration. Within this model, clinical services could be offered to various distributional resources (e.g., hospitals, clinics, and community programs) to maintain and improve the health and wellness of the population served.
The main reforms in policy should ensure:
- Social health security for all
- Primary health care should be free to all
- Secondary, tertiary, and quaternary health care should be accessible and affordable
- Essential medicines should be free.
| Integration of Ayurveda and Western Medicine|| |
To make it a reality, integration must first be confidently adopted in mind, rather than at the physical level, with questioning skeptical minds. In 2015, TCAM in China accounted for 16% of total medical care, up from 14% in 2011, as the economist observes. TCAM accounts for a much lower proportion of overall medical care in India. Data from National Sample Survey in 2014 indicate that only 6.9% of patients seeking outpatient care opted for TCAM. In the case of hospitalized care, the proportion is less than 1%. Indian and Chinese health systems privilege biomedicine over TCAM, but the latter is recognized by the state and receives sizable state support. Health being a state subject adds an extra layer of complexity to any national-level initiative. Indeed, states such as Maharashtra have adopted a realistic approach where TCAM professionals are allowed to practice modern medicine and prescribe drugs after completing a 1-year course. There is a strong resistance to any such initiative by professional bodies representing modern medicine. As China has demonstrated, the integration of TCAM into the national healthcare system needs to be accompanied by integrated training of health practitioners. Both need to be officially promoted for optimal impact.
The foundation of Ayush, while relatively simple, is substantively different from much of allopathic medicine. Such differences are difficult to explain using a Western medical vocabulary and extend beyond linguistic foundations. This proves challenging when trying to identify appropriate teaching and research methods sensitive to the Ayush paradigm and relevant to a public health orientation. Given the increased use of Ayush, it becomes essential to address possibilities that would ensure the successful integration of Ayush into a public health framework. Hence, we propose a model in which allopathy and Ayurveda should work together under One Nation, One Health concept to strengthen the national healthcare system.
The government of India has already taken various initiatives for the harmonization of both sectors of modern medicine and the Ayush system of medicine, as given below.
- Colocalized Ayush facilities at PHCs, community health centers, and district hospitals, thus enabling the choice of patients for different systems of medicines under a single window
- The Ministry of Ayush has collaborated with the Ministry of Health and Family Welfare for noncommunicable diseases or lifestyle-related disorders such as cancer and diabetes
- Central Council for Research in Ayurvedic Sciences (CCRAS) has conducted integrated clinical research with institutes such as All India Institute of Medical Sciences (AIIMS), New Delhi and Banaras Hindu University (BHU), Varanasi
- Central Council for Research in Homoeopathy (CCRH) has conducted studies on the setup of modern medicine on different clinical conditions such as dengue, and acute encephalitis syndrome
- Integrating Yoga with mainstream medical care is being practiced; the Ministry of Ayush is running four Yoga therapy centers in different government medicine hospitals in the country
- The established synergy between the Siddha system and modern medicine, the National Institute of Siddha, has entered into memorandum of understanding (MoU) with institutions such as the National Institute of Epidemiology (Indian Council of Medical Research [ICMR]) and AIIMS, Raipur.
| Government Initiatives for the Development of Ayurveda|| |
During Mughal and British rule, new medical systems were introduced in India by discouraging Ayurvedic practice. Fortunately, from the 1920s to the mid-1940s, provincial governments and famous leaders such as Mahatma Gandhi made various efforts to reverse this trend. However, in 1946, when the Bhore Committee outlined India’s first national healthcare policy, traditional practices were ignored entirely. The World Bank has recently recommended that tertiary curative health care should be left to the private sector, concentrating only on primary health care in rural areas. This would ensure the death of these other systems. This global knowledge center for traditional medicine, supported by an investment of $250 million from the Government of India, aims to harness the potential of traditional medicine from across the world through modern science and technology to improve the health of people and the planet.
A budget of ~Rs. 3,400 crores ($464.68 million) is set aside for the next 5 years under the National Ayush Mission for Ayush Wellness Centers. The center has contributed to the wellness sector by revamping the existing 1.5 lakh health centers across the country. India has the potential to become a health and wellness hub, attracting investments and creating additional jobs. The government has set a target of increasing spending on the health care from the current 1.3% to 3% of its gross domestic product (GDP) by 2022. The Ayush industry has seen tremendous growth in the last 7 years, growing by six times from $3 billion in 2014 to $18 billion now. The budget allocation to the Ayush Ministry has also increased by over four times in the past 7 years. In the Union Budget 2022–23, the Ministry of Ayush was allocated Rs. 3,050 crores, an increase of 2.69% from the last year’s budget (Rs. 2,970 crore).
| Treatment of Cancer with an Integrative Approach|| |
It is well known that cancer is a group of diseases characterized by abnormal cell growth that has the potential to invade or spread to other parts of the body. Most cancers are due to genetic mutations from environmental and lifestyle factors. Cancer ranks the first or second among the leading causes of death before the age of 70 years across 91 out of the 172 countries worldwide. By 2040, cancer incidence and mortality are expected to rise to 29.5 million and 16.3 million, respectively. Cancer incidences are increasing mainly because of the current lifestyle contributing to growing cancer incidence, limited access to cancer treatment, and a lack of survivorship and palliative care. The principal strategies of cancer treatment include surgical resection, radiotherapy, and chemotherapy. Other means of cancer therapy, such as immunotherapy and targeted therapy, have led to significant breakthroughs in curing cancer in recent years.
Around 80% of the world’s population is estimated to use traditional medicine, including cancer treatment or its associated complications. To date, 170 WHO member countries have reported the use of traditional medicine, and their governments have asked for the support of the WHO in creating a body of reliable evidence and data on traditional medicine practices and products.
Traditional, complementary, and integrative medicine (TCIM) is widely used by patients with cancer in Latin American countries. This is estimated that between 50% and 90% of adult or pediatric patients with cancer use TCIM. More recognized mind and body therapies, such as meditation, Yoga, tai chi, acupuncture, massage, music therapy, dance therapy, mandalas, and horticultural therapy, are also used across Brazil, Argentina, and Chile. In Africa, traditional medicine is used as the first line of treatment, which is accessible and is introduced as soon as the disease is identified.
Approximately 75%–80% of patients in China use TCM after a cancer diagnosis, with Chinese herbal medicine (55%–75%) used most often, and tai chi/qi gong (7%) and acupuncture (1%–5%) used less frequently., TCM is widely integrated with oncology departments within China’s hospitals in conjunction with conventional cancer treatment. Furthermore, conventional oncology diagnosis (e.g., pathology and imaging) and treatment (e.g., surgery, chemotherapy, radiation, and hormonal treatment) are available in elite TCM hospital oncology departments in addition to TCM approaches. One medical insurance analysis of oncology inpatients in China showed that 42% used TCM herbs and 25% combined herbs with conventional cancer drugs.
Over 20 years ago, leading North American academic cancer institutions, including Memorial Sloan Kettering Cancer Center, Dana-Farber Cancer Institute, and the University of Texas MD Anderson Cancer Center, developed clinical, educational, and research integrative oncology programs in response to the growing demand from patients with cancer to incorporate TCIM into conventional cancer treatment and survivorship care. The National Cancer Institute (NCI) also established the office of cancer complementary and alternative medicine to coordinate and enhance activities in TCIM research related to the prevention, diagnosis, and treatment of cancer, cancer-related symptoms, and side effects of conventional cancer treatment. By 2016, the majority of the 45 US NCI-designated cancer centers provided integrative medicine information to patients on their websites, including acupuncture/massage (73% each), meditation/yoga (69% each), nutrition consultations (91%), dietary supplements (84%), and herbs (67%), and the most also offered these services..
| Ayurveda in Cancer Prevention|| |
Many Ayurveda experts correlated Granthi and Barbuda (as mentioned in the classical texts) with the modern concept of cancer. However, some experts differed with this correlation and felt that the pathophysiology of Granthi and Barbuda is not precisely like cancer. In Ayurveda, the pathogenesis of cancer occurs due to various causes, including exposure to environmental toxins, which can provoke pitta at the cellular level and hence cause microinflammatory changes in cells. These changes disturb the cellular components of Agni and may cause poorly formed tissues. It is believed that Vata involves in metastasis, Kapha in the abnormal growth of the cells and creates the malignant tumor, and pitta enhances the metabolic activity of cancer cells. The weakened Dhatus and Dhatu Agnis were highlighted as critical Ayurvedic concepts in cancer pathophysiology. The Vaidyas suggested that when the Dhatus are weakened, patients are vulnerable to disease and that, in particular, a weakened Dhatuagni redisposes them to cancer in that Dhatu. This concept is unique to Ayurveda. However, a parallel exists in biomedicine in field cancerization, in which particular tissues (e.g., sites in the aerodigestive tract after tobacco exposure) are vulnerable to cancer.
In terms of cancer, the first and most important thing to know is its causative factors. Half of the treatment is done when you alleviate the causative factors. According to the Ayurvedic principles, each meal should balance the six significant flavors (sweet, salty, sour, bitter, spicy, and astringent). Ancient thali or Ayurvedic diet has small portions of meals, which also easily incorporate variety. A variety of flavors in a meal often indicates the presence of many bioactive compounds. Although these substances may not be macronutrients, vitamins, or minerals, they still impact human health. Polyphenols are the most prominent bioactive compounds, containing subclasses such as flavonoids, isoflavones, stilbenes, lignans, and tannins. Recent research provides preclinical evidence that phytochemicals, especially anthocyanins, promote gut microbial health, reduce inflammation, and lower the risk of colorectal cancer. Clinical evidence is sparse but indicates that anthocyanins and other bioactive compounds affect colon cancer.Aegle marmelos (L.) Correa (Bael) and its phytochemicals are used in the treatment and prevention of cancer. Similarly, Emblica officinalis is also reported to possess radiomodulatory, chemomodulatory, and chemopreventive effects and is also found effective in treating and preventing cancer. Withaferin A has also been found in the chemoprevention of breast cancer in animal models.
| Integration of Ayurveda and Western Medicine Can Provide More Effective Treatment|| |
Indian cancer patients are not very much awarded for cancer diagnosis and management because of poor socioeconomic conditions and inaccessibility to hospitals. As a result, most Indian cancer patients have late-stage incurable diseases (75%–80%) when first diagnosed. Presently, in India, out of a million newly diagnosed cancer patients each year, more than 50% die within 12 months of diagnosis, and another one million cancer survivors show progressive disease within 5 years of diagnosis. Although in Ayurveda, the correct diagnosis of a disease is made through the observation of signs, experimentation, interrogation, comparison and contrast, inference (from the clinical examination, physical examination, chemical examination, and physiological functions of patients), and aptopadesa, none of these are being actively practiced in cancer diagnosis at present. Most Ayurveda practitioners are dependent on modern radiodiagnostic tools. Moreover, most cancer patients visit Ayurveda practitioners in the late stage of the disease. However, Shatkriyakala-like concepts can be helpful in early diagnosis.
Various reports reveal the effectiveness of Ayurveda treatment in different cancers. Patients with head and neck cancer treated with Varunadi Ghritha (polyherbal compound) were recorded to increase cell count. Some preclinical studies have also shown that the aqueous extract of the Tulsi leaves and its flavonoids orientin, vicenin, and eugenol, the principal nonpolar constituent present in Tulsi, prevent radiation-induced clastogenesis. The administration of either Brahma Rasayana or Chyavanaprash (1 and 2 g/kg) maintained the antioxidant status in the heart, thereby preventing tissue damage and the release of marker enzymes. Doxorubicin-induced variation of cardiac architecture was also prevented by Brahma Rasayana or Chyavanaprash administration.
Despite pluralistic healthcare systems in India, policies to facilitate cooperation and integration between TCIM and conventional medicine still need to be made. Practitioners of these different systems work independently, and integration still needs to be up to mark, mainly due to challenges because of fundamental distrust in the other. For this reason, integrative oncology needs to be well developed in India. There have been many scattered and isolated attempts to integrate AYUSH treatments for cancer care in public and private hospitals. For example, several conventional oncology hospitals have established adjunct Ayurveda/Ayush clinics to integrate relevant treatments to improve the quality of life among patients with cancer, although some Ayurvedic cancer care hospitals, like in Pune, India, integrate Ayurvedic drugs in coordination with modern oncology treatments such as chemotherapy, with some reported preliminary benefits.
In this direction, many things need to be done to implement the One Nation, One Health policy. It should start by generating and collecting evidence of the efficacy of Ayurveda drugs through various observational studies and later with Western medicine. There are many clinical and preclinical studies on the combination of TCM treatment and chemotherapy. When combined with clinical drugs, the compounds exhibited synergetic effects on cell death, cell cycle arrest, drug resistance, metastasis, etc. Therefore, investigating the effects of natural compounds and clinical drugs in combination is a promising strategy. Herbs and formulations, with Curcuma longa and Withania somnifera, are the most studied. In addition, Tinospora cordifolia extract has been studied for its hepatoprotective activity. Several in vitro and in vivo studies on cancer treatment over the last decade have provided experimental evidence that curcumin contains antiproliferative, antiangiogenic, and apoptotic properties. Similarly, curcumin with mitomycin C and docetaxel in breast cancer and lung cancer induces cell cycle arrest by inhibiting cyclin D1, cyclin E, cyclin A, cyclin-dependent kinase 2 (CDK2), and CDK4 and also reduces toxicity to bone marrow and liver., Berberine with 2-deoxy-D-glucose helps adenosine triphosphate (ATP) energy depletion and disruption of unfolded protein response (UPR) in the cancer cells.
Preclinical studies demonstrate that Triphala effectively inhibits the growth mediated by the activation of ERK and p53 in human pancreatic cancer cells in both cellular and in vivo models. A combination of turmeric with capecitabine produces a lower rate of hand–foot syndrome, especially in grade 2 or higher cancer patients.Withania somnifera enhanced the antitumor effect of paclitaxel on benzo(a)pyrene-induced experimental lung cancer. Curcumin is due to the negative regulation of inflammatory cytokines, transcription factors, protein kinases, reactive oxygen species, and oncogenes. Hence, it inhibits the initiation and progression of cancer.
| Ayurveda as Supportive Care to Cancer Patients|| |
One of the aftermaths is that the whole body will feel devitalized, exhausted, and unable to cope with the day-to-day maintenance of its vital functioning. Nutrition is going to be affected because cellular fires will almost be flickering. You have to eat food that is intelligent food, which is filled with Prana (vitality). Chemotherapy or radiotherapy has side effects like dryness and burning sensation in the skin. There will be a chronic state of low-grade inflammation in the system. Allopathic treatment of cancer is lifesaving, or it is emergency management. In many cases, it is necessary. We kill the cancer cell, but the outcome damages the systems. When the damage happens, our efficiency goes, and degeneration occurs. When one system is weak, it will contribute to weakness in other systems because all the systems are interconnected.
The physical strength and mental strength postchemotherapy and postradiation become low. Once they are low, recovery is not easy. According to Ayurveda, food and lifestyle are the two controllable reasons for health problems and health creation. When you follow an appropriate diet and routine, you enhance your health. There are many items available for every patient in their kitchen. They can practice pranayama, yoga, and meditation. After that, specific herbs and customized formulations can be made. That is how herbs and formulations in Ayurveda strengthen the physical, mental, and immune systems. Because Ayurveda provides personalized care, the formulations are made according to the type of cancer and the affected system or Dhatu. The Vaidyas give Ayurvedic cleansing therapies (Panchakarma) therapy in most cases, not immediately after the completion of the allopathic cancer treatment. Patients must first regain their strength before undertaking panchakarma. A patient who underwent chemotherapy, radiotherapy, or target therapy has to go for shaman or palliative measures. Ama is formed in the body due to therapy. That ama can be neutralized by the Shamana protocol and then the main line of treatment, Shodhana, possibly after 6 months or 3 months, depending on Prakriti. Kapha Prakriti people usually detox quickly, pitta takes time, and Vata takes still more time.
Particular preparations are available to improve the quality of life in patients. Indukantha Ghritha is a polyherbal preparation consisting of 17 plant components, induced leukopoiesis, and enhanced median survival time and life span in tumor-bearing animals. Macrophage phagocytic capacity was also elevated.Rasayana Avaleha has proved to be an effective adjuvant therapy in protecting patients from the adverse effects of chemotherapy and radiotherapy. Similarly, Asparagus racemosus and Withania somnifera extracts can be used as adjuvant therapy in paclitaxel-induced myelosuppression., One study carried out on 36 patients with cancer who underwent chemotherapy and radiation showed that the Ayurvedic formulation Rasayana Avaleha could reduce adverse events such as vomiting, mucositis, alopecia, and ageusia when used as an adjuvant. Herbomineral and metallic Ayurvedic drugs Mauktikyukta Kamdudha and Mauktikyukta Praval Panchamruta, along with an entire course of chemotherapy, improved the toxic side effects of chemotherapy drugs in cancer patients.
| Conclusions and Recommendations|| |
One Nation, One Health System strives hard to ensure that every citizen of India gets free and quality health care. Put prevention first, combine Western and traditional medicine, combine health with mass movements, and concentrate on rural areas. India’s integration of Ayurveda into the national healthcare system may provide comprehensive healthcare services to the general population, mainly for chronic diseases such as cancer, where treatment options are limited and expensive. This needs officials trained in modern medicine and Ayurveda for integration. They should follow a science-based approach to the education of Ayurveda, emphasizing research. Here, integrating Ayurveda into cancer management can be a driving force. Before a critical mass of qualified practitioners providing evidence-based care can be established, viable practitioners to train them must be made available. The biggest challenge is the key to delivering health care at a minimum cost in India without compromising quality. Considering these practically successful models, the following steps are recommended for achieving the goal in developing and aspiring countries:
- Need for a permanent commission to form a policy focusing on education, standardization, health care, research, and developments. The commission should also take care of issues related to recognition, regulatory status, educational standards, assessment of safety and efficacy, quality control, intercultural approach, value addition sustainability, and integration challenges
- Government should allocate a separate budget to establish new labs for quality control and evidence generation
- There should be the establishment of an institution that deals with intellectual property rights and make coordination with international agencies.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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