Complementary and alternative medicine Evolution Medicine Science

Selective pressures and the evolution of alternative medicine

i-e7a12c3d2598161273c9ed31d61fe694-ClassicInsolence.jpgEvery so often, real life intrudes on blogging, preventing the creation of fresh Insolence, at least Insolence of the quality that you’ve come to expect. This is one of those times. So enjoy this bit of Classic Insolence from back in November 2007 and be assured that I’ll be back tomorrow. Remember, if you’ve been reading less than two and a half years, it’s new to you, and, even if you have been reading more than two and a half years, it’s fun to see how posts like this have aged.

I wish I had thought of this one, but I didn’t. However, I never let a little thing like not having thought of an idea first to stop me from discussing it, and this particular idea is definitely worth expanding upon because (1) it’s interesting and (2) it combines two of my interests, alternative medicine and evolution. I agree with parts of the idea, but it’s not without its shortcomings. Indeed, I’d very much welcome any of the evolutionary biologists who read this blog to chime in with their own ideas.

Fellow ScienceBlogger Martin Rundkvist over at Aardvarchaeology has proposed a rather fascinating idea regarding the evolution of alternative medicine in which he argues that alternative medicine evolves according to certain selective pressures. As you may or may not know, evolution is not just for biology, but has been proposed as a mechanism in cultural memes, for example. Since alternative medicine is a cultural phenomenon, it is not unreasonable to look at such non-evidence-based medicine and hypothesize what might be the selective pressures that shape its popularity and evolution. After all, if we’re going to discourage the use of non-evidence-based medicine or even quackery, it’s helpful to understand it. We already know that alt-med terminology has evolved considerably into the current politically correct term “complementary and alternative medicine” (CAM).

Martin primarily considers what the selective pressures are on various alternative medicine modalities and comes to a startling conclusion: Namely, that the selective pressure on such modalities is primarily to select for ineffective treatments. He bases this on two primary forms of negative selection. First, he hypothesizes, there will be selective pressure against modalities that cause obvious harm. According to this concept, such modalities will tend to be eventually recognized as harmful and shied away from by alternative medical practitioners due to fear of lawsuits and government regulations. The second form of selective pressure will come from conventional medicine. In essence, alternative medical therapies that can be shown to have a reasonable degree of efficacy will risk being co-opted by us “conventional” practitioners of evidence-based medicine and thus taken out of the armamentarium of alternative practitioners, whose setting themselves apart from mainstream medicine is very important to their livelihood. This leads Martin to observe that homeopathy is the ultimate CAM therapy:

So, there is evolutionary pressure on alternative therapies to achieve near-zero effect. This is why homeopathy is still around: its main method being the administration to patients of small amounts of clean water, it’s uniquely suited to surviving indefinitely in the alternative-therapy biotope. Homeopathic remedies can neither harm nor benefit patients.

This is a fascinating and lucid insight. Clearly it has some merit. However, it is incomplete. The reason, I would argue, is that the negative selective pressures Martin identified are almost certainly not as potent as he thinks they are, as evidenced by how rare it is for an alternative medical therapy to actually go “extinct.” Indeed, I would argue that selection against harmful or potentially harmful remedies is actually fairly weak and perhaps even nonexistent. After all, black salve is still around after many decades, if not hundreds of years, and it can produce some truly horrifying complications (not for the squeamish). Even though the FDA banned importation of black salve products and they can be demonstrably harmful, they are still around and show no sign of disappearing. Another example is Laetrile. Multiple well-designed clinical trials demonstrated that Laetrile is ineffective against cancer, and it has the well-known potential complication of cyanide toxicity. It, too, shows no signs of disappearing. Of course, perhaps the most popular ineffective CAM therapy that has potentially deadly complications is chelation therapy, which remains widely used among CAM practitioners to treat cardiovascular disease and autism, despite of the extreme biological implausibility of the argument that it should work for either condition and despite there being no good evidence that it does. Indeed, there was even a well-publicized case of an autistic boy who died as a result of hypocalcemia as a result of chelation therapy for autism causing a fatal cardiac arrhythmia. His quack–I mean doctor; no, I mean quack–Dr. Roy Kerry is only now being brought up on charges for his negligence and quackery.

No, there are lots of potentially harmful CAM modalities out there that show no signs of going away.

Let’s look at the flip side of the negative selection, co-optation of “effective” alternative therapies into mainstream medicine. Once again, this is probably a weaker negative selective force than it might seem. Herbal medicines, for example, are probably the most common of the CAM-type modalities to show some evidence of efficacy in randomized clinical trials. This is mainly because they are drugs. Impure and dirty drugs with widely varying levels of active ingredient from lot to lot, but drugs nonetheless. The problem for the co-optation of these drugs by conventional medicine is that practitioners of scientific medicine do not like unpredictability in their drugs. They like drugs with a predictable effect; herbal medicines “in the raw,” so to speak, do not fit the bill, particularly when pure pharmaceutical alternatives that lack the contamination and unpredictability of herbs exist. Even if conventional medicine co-opts an herb, for example, it is usually in the form of the pure active ingredient purified from that herb. For example, if you have breast cancer, you could try to chew on the bark of the Pacific Yew tree for its anticancer properties, but you’d be a whole lot more likely to do better if you took pure Taxol derived from that bark–and took it intravenously. The example of Taxol also suggests that once conventional medicine co-opts an herbal or plant-based remedy, it usually does not supplant the original alternative therapy. After all, all of the “natural goodness” has been extracted from it during the purficiation of the active ingredient! CAM mavens would often rather take the raw herb or the herb chopped up and compressed into an herbal pill because it’s more “natural.”

As for other non-herbal CAM therapies, even when they’re co-opted by modern medicine (although it’s often arguable whether conventional medicine or CAM did the coopting), often an “alternative” version remains. The scientific version will be stripped of all the woo, while the “alternative” version will retain it. Think massage therapy and perhaps even chiropractic, which, as I’ve said before, stripped of its woo is nothing more than physical therapy with delusions of grandeur in the form of claims of being able to cure all manner of illnesses that have nothing to do with the spine or the musculoskeletal system.

Finally, there is one last aspect of Martin’s concept that argues against it. Martin states:

Evidence-based medicine, alternative medicine and weaponry change through time because of selection pressure. This means that they evolve and produce a fossil record of discontinued methods and therapies.

Here’s the problem: There actually is no “fossil record” of discontinued CAM methods and therapies. The reason is simple: CAM does not abandon its methods, regardless of evidence and, to a large degree, regardless of harm. Yes, individual treatment modalities may wax and wane in popularity, but they never go away completely. They never go extinct. Think about it a bit. Can you think of a single “alternative medicine” treatment modality that’s ever been abandoned because it either doesn’t work, is too harmful, or has been co-opted by conventional medicine. I can’t. CAM is, in the words of James Randi, an “unsinkable rubber duck.” It just won’t disappear. Martin is quite correct that homeopathy, for example, has persisted 200 years despite no evidence for its efficacy. Aryuvedic medicine has persisted at least a couple of millennia, despite a similar lack of evidence. Ditto traditional Chinese medicine. Never mind that these systems were developed in a time when very little was known about how the body actually works and are infused with spiritual and religious beliefs. They are still used my many millions, if not billions, of people worldwide. They have left no “fossils.” Of course, as in evolution in biology, this selection, applied over long periods of time, may ultimately eliminate such modalities, but if I were somehow able to call the Doctor to give me a ride in his TARDIS a couple of hundred years in the future, I bet that virtually all of these CAM modalities would still be in use. Part of the reason, I suspect, is that, as Martin pointed out, most CAM modalities do little; there is usually no CAM modality that can supplant existing modalities.

In any discussion of the evolution of CAM, I would be remiss not to look at its primary competition for resources (i.e., patients) in the ecosystem of medicine, namely scientific, evidence-based medicine. EBM has been hugely successful in many areas. Indeed, it can be said to have driven back CAM to a much smaller “ecological” niche than it once occupied. These days, relatively few people rely on CAM modalities when faced with a truly life-threatening illness, such as cancer. The Katie Werneckes, Abraham Cherrixes, and the Chad Jessops of the world (if the latter even had cancer), who treat life threatening cancers with high dose vitamin C, the Hoxsey concoction, or nasty, burning goo like the infamous “black salve,” respectively, are pretty uncommon. The main ecological niches for CAM these days have contracted to two areas. First are “diseases of living.” In other words, CAM has been for the most part relegated to the treatment of what are generally vague complaints that are not exactly diseases or to self-limited conditions. Indeed, one could argue that the strongest positive selective pressure for CAM modalities is how well each one gives the appearance of doing something therapeutic for such conditions, whether it actually does anything or not. In other words, how good of a placebo is it? Or is its timing or method of administration optimally adapted to correlate with the patient’s improvement anyway, allowing the confusion of correlation with causation? The better the adaptation, the more likely a CAM modality will thrive and expand.

The other remaining ecological niche for CAM, I would argue, is in serious diseases for which conventional medicine does not have much to offer. These conditions include diseases such as terminal cancer that has passed beyond our ability to treat it, as well as any manner of chronic diseases for which conventional medicine does not have a cure, such as Parkinson’s disease, chronic pain syndromes, multiple sclerosis, etc. Conventional medicine can treat and often palliate such conditions, but it cannot cure them. In this latter niche, I would argue that the primary positive selective pressure would be how well the CAM modality can inspire belief in its practitioners and hope in its users. The two are related, of course; the more the practitioner believes in the modality the more he or she can sell the patient on it.

Of course, applying evolutionary principles to CAM only goes so far. It’s a highly complex situation, and there are a number of positive and negative selection pressures that one could postulate. Certainly, the marketplace and how much of a feel-good aspect there is to CAM therapies are important. Finally, no doubt, like evolution, there are aspects to CAM proliferation that do not depend upon selection, a CAM equivalent of genetic drift, for example. I’m not sure how far this application of these principles will take us, but I suspect that they can be used, along with other disciplines such as psychology and anthropology, to explain to some extent the insinkable persistence of these non–evidence-based therapies.


  1. Orac: Applying evolutionary principles to alternative medicine again
  2. Steve Novella: Alternative Medicine and the Evolution Analogy

By Orac

Orac is the nom de blog of a humble surgeon/scientist who has an ego just big enough to delude himself that someone, somewhere might actually give a rodent's posterior about his copious verbal meanderings, but just barely small enough to admit to himself that few probably will. That surgeon is otherwise known as David Gorski.

That this particular surgeon has chosen his nom de blog based on a rather cranky and arrogant computer shaped like a clear box of blinking lights that he originally encountered when he became a fan of a 35 year old British SF television show whose special effects were renowned for their BBC/Doctor Who-style low budget look, but whose stories nonetheless resulted in some of the best, most innovative science fiction ever televised, should tell you nearly all that you need to know about Orac. (That, and the length of the preceding sentence.)

DISCLAIMER:: The various written meanderings here are the opinions of Orac and Orac alone, written on his own time. They should never be construed as representing the opinions of any other person or entity, especially Orac's cancer center, department of surgery, medical school, or university. Also note that Orac is nonpartisan; he is more than willing to criticize the statements of anyone, regardless of of political leanings, if that anyone advocates pseudoscience or quackery. Finally, medical commentary is not to be construed in any way as medical advice.

To contact Orac: [email protected]

27 replies on “Selective pressures and the evolution of alternative medicine”

One of my classmates told us today he wants to become a doctor so he can use integrative medicine to harness the body’s own healing power, and how GREAT it is that they use placebo effects instead of nasty drugs. I don’t think he realizes he doesn’t have to go to med school if that’s all he wants to do.

He’s also thinking of becoming a psychiatrist so he can help people solve their problems by prescribing them time-honored, safe, traditional psychedelic drugs. Our professor tried to explain that this absolutely isn’t possible, but the student gave him some story about a Brave Maverick Psychiatrist doing psychedelic research.

Not that there might not be some applications for these drugs, but that with all the Drugs R Bad paranoia in the USA, it’s nearly impossible to get funding and definitely impossible to get a study past your IRB. The student doesn’t want to do research anyhow… he just wants to talk to people who don’t have serious mental conditions (he doesn’t like crazy people) and prescribe mescaline.

One of my more sensible undergrad friends wants to be an osteopath because she volunteered in a DO’s office and the lady is so nice and cares so much about her patients. Unfortunately, she hasn’t had enough biology yet to understand *why* osteopathy isn’t science-based medicine.

When do I get to move somewhere that isn’t wall-to-wall magical thinkers?

Toxicology Kat, I feel your pain. I can’t stand the self-healing stuff. If the body can heal everything, then what is the doctor even for? And I love how they completely gloss over anytime the self-healing capacity of the body (the immune system) goes overboard with autoimmune diseases or is seriously crippled by cancer or HIV. Thus, they typically have to combine their self-healing nonsense with germ theory denial and “cancer is a fungus/acid problem/pent up emotions” type statements.

To be fair, I think a majority of osteopathic physicians do not take manipulation all that seriously. Only 5% of DO’s actually use the manipulation according to the American Osteopathic Association. They think this is a crisis, I think it is a good thing. None of the DO’s I work with use manipulation and they are all fantastic, brilliant doctors in various specialties.

Of course, this begs the question, if they do not manipulate then what is really different between MD’s and DO’s? I do not really see a difference anymore and I think DO’s should just capitulate and become MD’s.

I do not really see a difference anymore and I think DO’s should just capitulate and become MD’s.

Wouldn’t the AMA have to allow the osteopathic professional schools to give MD designations? The great part about osteopathy is that it keeps showing that Palmer’s acolytes could have gone the right way, but failed to and are now nothing but quacks.

Free Lunch, I am unsure of the legal/logistical aspects. In the early 1960’s the California Medical Board allowed DO’s to purchase an MD degree for a fee. I don’t see why that couldn’t be done on a national level.

Preferably, the AAMC (MD association of medical colleges) would just go around and license the good DO schools and close any bad ones that don’t meet standards, like you said. I am sure that would take time, but it would the best to ensure high quality doctors.

Nice article. I fear Martin Rundkvist falls into the same trap that awaits many of us rational types when considering irrational beliefs. As we see in health, politics, religion, etc., memes too often seem indifferent to evidence for or against. It just seems to be a crazy feature of how our brains work.

If we rationalists are to tackle these harmful alt-med beliefs we first need a much better understanding of the psychology of irrationality.

I’ve always thought of alternative medicine as a series of “fashion trends” dependent on market demands and effective(or ineffective)advertising.**A new method(or “style”)is publicized,more “providers” learn how to incorporate it into their current practice,it becomes more commonplace,becomes *passe*,etc.For a while,Candidiasis was *it*,now it is definitely not *au courant*.Like fashion, belief in/use of a particular alt med concept/treatment, can designate group membership.I have a 1960 edition of Prevention Magazine’s selected articles,some ideas(Vaccines are bad!)seem timeless while others appear to be quaint ptoducts of the era.**(it also illustrates the monetary basis of alt med)

There actually is no “fossil record” of discontinued CAM methods and therapies.

The “fossil record” is the therapies themselves.

life element = that which you need to live, i.e, light…

Einstein puts the final nail in the coffin of atheism…



atheists deny their own life element…

add some comment moderation to your blog of blasphemy…idiot…

Is that a troll I see @8? It’s hard to tell because it doesn’t make sense or even resemble sentence structure. It could just be the fossilized bones of a troll.

Moving on.

CAM does display one evolutionary aspect – it gains new features as new badly misunderstood scientific ideas emerge. For example, Einstein’s relativity theory appears over and over in CAM. And then there’s quantum physics. The inclusion of misused ideas less than 200 years old helps CAM camoflauge itself as something other than 19th Century nuttery, so it can simultaneously lure prey with appeals to tradition and appeals to novelty.

Of course, CAM never lets go of any of its wooy parts, so it’s never going to evolve into a snake. That’s some seriously missing adaptive radiation.

Scott Cunningham: “Is that a troll I see @8”

Careful. That post to which you referred will probably be removed soon, and your post will be #8. 🙂 It’s just our old fiend Dave Mabus again.

No hyperlinks? You mean I have to cut and paste those URLs myself? Screw that…

Lol. I did, for the first one at least, it just leads to a forum post where he stuck in some other links which prove nothing.

To be honest I think he has some mental health issues, his posts have that triumphant declarative style so often favoured by those slightly unbalanced or deluded. Lots of bold affirmative statements, links to vaguely unrelated sites that purport to ‘prove’ the point that he hasn’t even made. (Except obliquely in his bold incomprehensible statements)

It’s this suspicion that caused me to hold off mocking his incoherent ‘points’ and his lack of understanding of science, the word ‘element’ and atheism.

Hmmm. The poster’s name changes every time, but that content looks exactly like something I’ve seen fossilized all through the archives. It looks like a troll morphing to re-post the same screed. In fact, haven’t I seen those fossilized lines that are in both these posts posted by a… Dennis Markuze?

No doubt it is Markuze.

I am loving the comment moderation line though. That is something I have not seen before. Is he begging to be banned?

News flash David, this blog has comment moderation but only in some cases, like having many links in a posting. Not everyone wants to discuss things in a forum where everything is moderated and not everyone wants to run a place like that. Some people like people to be able to say what they want, even if it is stupid.

You should be thankful that people are willing to let those stupid things through.

I probably sound cranky. That would be because I am today.

It may be a little early but – Called It

The guy’s not well. He’s spamming because his brain is stuck in a loop, he claims “we prove basically that you are a bunch of f*cking liars who mad some serious enemies…”, which is a complete non-sequitur that he feels proves… something.

He’s addressing ‘you’ who are a ‘bunch of fucking liars’ and suggesting that they have ‘mad[e] some serious enemies’, it’s nonsense. It probably means something to him, but not necessarily anything that is internally coherent because he is unlikely to be internally coherent.

It would be easy to state that a) there are many elements that are required for life (some of which are actually elements, unlike light), b) no atheists deny light… whatever that means.
But that’s the thing, we’re only getting the verbal version of his madness, whatever he means by “Athiests deny light” is unlikely to have anything to do with the literal or scientific definition of those words, so really there’s no way to engage with him – smacking him down on what he says will have no effect since you’re not touching the core of what he meant – and you can’t derive what he meant from what he said because he’s not balanced and not using words the way they’re usually used.

P.s. I’m a Consultant Internet Psychiatrist so I know what I’m talking about.

Dead? That’s interesting…pulse? Check. Breathing? Check.

I’m pretty sure I’m alive and well, thankyouverymuch. And I don’t even believe in god!! *gasps*

Bizarre troll needs to use periods at the end of sentences instead of ellipses.

The reasons that people cling to CAM therapies is the same reason people cling to religion – the world is a random, scary place and understanding it takes a lot of work and effort. It’s far easier to appeal to things that feel like they could be true, which prevents you from having to deal with the much harsher reality – cancer drugs CAN make you sicker, surgery CAN kill you, and it’s not possible to prevent all disease.

Just like religions haven’t gone anywhere in the past 1500-5000 years, CAM has that same potential longevity. However, I’m a bit more optimistic than Orac: as we increase scientific literacy we’ll see people reduce the extent to which they lean on heuristics and superstition as a way to explain a random universe. Or, we’ll get even BETTER cell phones. Either way, Brickbreaker!

David Mabus/Markuse is infamous, in his own web comments kind of way.
Oddly, if you follow his links, you end up with at an endless page with a couple of rather good videos. A satire of proving Atheism wrong (Checkmate) that’s got real religious ads plastered all over it, and a 10 min panel discussion of bloggers talking about their hate mail. (Mabus/Markuse is mentioned at about the 1 min mark.) I’d call a Poe, if he wasn’t so obviously devoted to the crazy.
I just wish he didn’t live in Montreal, which makes him a fellow canadian. He’ll flip out completely one of these days, and hurt someone.

I think another reason people cling to CAM is because it enables them to feel like they’re taking action. From what I’ve read here, many of these modalities give their ‘patients’ plenty of work to do: herbs to take, they must work on their positive thinking, repeat visits. So it isn’t just the attention and caring interest, which is often mentioned, but the continuous action that make them feel like they’re actually doing something useful.

Agreeing with English Rose.

I’m hot and about to blow more steam in the UCP group for allowing and supporting advertisers of HBOT and stem cell treatment in China on LinkedIn. (United Cerebral Palsy)

I think another reason people cling to CAM is because it enables them to feel like they’re taking action. From what I’ve read here, many of these modalities give their ‘patients’ plenty of work to do: herbs to take, they must work on their positive thinking, repeat visits. So it isn’t just the attention and caring interest, which is often mentioned, but the continuous action that make them feel like they’re actually doing something useful.

Exactly. The reason they feel so helpless is that science has got so complex that it’s easy for even intelligent layfolk to feel left in the dust.

Here’s a basic example from John Hawks’ blog, where he, using mathematics, argues against the claim that humans suffered a near-extinction event 70,000 years ago.

Imagine the reaction of a typical layperson, whose last encounter with math above pocket-calculator level was sometime in high school, and who picked his or her courses — and careers — with a view to avoiding fancy maths as much as possible. He or she sees the hieroglyphs and freezes up: There’s no way this can make any sense; he or she will just have to take it on faith.

Yes, they have to take CAM on faith, too; but that’s generally much simpler — they feel that they have a fighting chance of understanding it.

Just like religions haven’t gone anywhere in the past 1500-5000 years, CAM has that same potential longevity. However, I’m a bit more optimistic than Orac: as we increase scientific literacy we’ll see people reduce the extent to which they lean on heuristics and superstition as a way to explain a random universe. Or, we’ll get even BETTER cell phones. Either way, Brickbreaker!

To BluedevilRA: Funny you should mention AIDS. As a treatment advocate for patients living with HIV/AIDS, I have had to analyze and explain to lay people more than my fair share of “evidence-based scientific studies”. A lot of good ones and a lot of crap. As to the crap ones, just because the pharmaceutical reps provided good food and wine didn’t make the claims any more legitimate.

I have watched my patients use all kinds of CAM to stomach the gut wrenching (literally and figuratively) medicines that were available to them in the 1980s and early 1990’s. Who cares why therapeutic touch or acupuncture worked for them, if it kept them from puking up their meds.

And that was after western medicine developed something. Prior to that the only thing available was CAM, and CAM kept many people alive long enough to benefit from the drugs that did come years later.

Let’s not forget that when AIDS medicines were first introduced they were given in mono-therapy, which meant most patients developed resistance within six months. As one of the better (and humbler) AIDS docs in town years later was heard to say, “Our patients who are doing well now are the ones who have lived long enough to find out that everything we told them to do was wrong.”

We have learned more about the human immune system in the last thirty years than we did in the previous three hundred. And guess what? A lot of what we knew “scientifically” was wrong.

I have now lived long enough to see AIDS become a chronic manageable disease in the developed world. Thank God & Big Pharma. Now I see the same issues with my friends who are dying of cancer.

Along the way I have seen every kind of snake oil pitched to “cure” my patients. And I have seen things that didn’t come out of a pharmaceutical company that did help them. As of yet, I have not seen a “cure” from either side of the fence.

A little humility is in order folks. No one knows why one individual person lives with a disease and another one dies. There will always be a percentage of patients who do not respond to any “evidence-based” treatment and a percentage of patients who will only respond to CAM.

I am all in favor of using scientific method to prove the value of CAM approaches. Anyone who says there is none is refusing to see evidence that exists. Some CAM works for some things for some people. Some pharmaceutical and surgical interventions work for some things for some people.

To try to say that CAM by definition is non-evidence based and that if something is evidence based it somehow magically stops being CAM, is absurd. When an herb used in Traditional Chinese Medicine is shown to be effective in an evidence based study, it does not stop being Traditional Chinese Medicine.

In my time, the people I have seen who have the best clinical outcomes are those who have taken the best of both. To me asking whether you use modern western medicine or CAM is like asking whether you wear pants or shirts. Each has its role to play and they can actually go pretty well together. But by all means, make sure they don’t clash!

as i was going through this article there are some good point in it. and yes alternative medicine is here to stay, and as the author mentioned medicine may be predictable but unfortunately our bodies are not so that is way more people prefer the alternatives

as i was going through this article there are some good point in it. and yes alternative medicine is here to stay, and as the author mentioned medicine may be predictable but unfortunately our bodies are not so that is way more people prefer the alternatives

[i]None of the DO’s I work with use manipulation and they are all fantastic, brilliant doctors in various specialties.[/i]

The ones I have worked with use manipulation for very specific reasons. If a person has back pain, they will sometimes do manipulation, but they also order x-rays and prescribe medication. For this type of thing, it is quite effective (and I believe there are studies showing that, but I do not have them handy.

[i]The great part about osteopathy is that it keeps showing that Palmer’s acolytes could have gone the right way, but failed to and are now nothing but quacks.[/i]

I guess that part that is exactly like allopathic medicine is quackery? Today’s students are much more skeptical and willing to question. While the “old guard” is going on about restrictions and this or that organ, they are doing a quiet eye roll and moving on to how to treat plantar fasciitis.

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