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© 2001 American Public Health Association
COMMENTARY |
Shiriki K. Kumanyika is with the Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia. Christiaan B. Morssink is with the Department of Health Policy and Administration, School of Public Health, University of Illinois at Chicago. Marion Nestle is with the Department of Nutrition and Food Studies, New York University, New York, NY.
Correspondence: Requests for reprints should be sent to Shiriki K. Kumanyika, PhD, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, 8th Floor, Blockley Hall, 423 Guardian Dr, Philadelphia, PA 19104-6021 (e-mail: skumanyi{at}cceb.med.upenn.edu).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONEMANCIPATION AS AN UNDERLYING...DIFFERING EVOLUTION OF HEALTH...WHITE VS MINORITY WOMEN:...ADDRESSING MINORITY WOMEN'S...TOWARD A UNIFIED PERSPECTIVEReferences |
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US minority health issues involve racial/ethnic disparities that affect both women and men. However, women's health advocacy in the United States does not consistently address problems specific to minority women.
The underlying evolution and political strength of the women's health and minority health movements differ profoundly. Women of color comprise only one quarter of women's health movement constituents and are, on average, socioeconomically disadvantaged. Potential alliances may be inhibited by vestiges of historical racial and social divisions that detract from feelings of commonality and mutual support.
Nevertheless, insufficient attention to minority women's issues undermines the legitimacy of the women's health movement and may prevent important advances that can be achieved only when diversity is fully considered.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONEMANCIPATION AS AN UNDERLYING...DIFFERING EVOLUTION OF HEALTH...WHITE VS MINORITY WOMEN:...ADDRESSING MINORITY WOMEN'S...TOWARD A UNIFIED PERSPECTIVEReferences |
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WOMEN'S HEALTH ADVOCACY in the United States does not consistently address problems specific to women in ethnic and socioeconomic subgroups. Numerous differences in the health concerns of minority and majority women have been documented.1-6 As shown in Table 1
, Black women have a shorter life expectancy than White women by 5 years, 50% higher all-cause mortality rates, and death rates from major causes such as heart disease, cerebrovascular diseases, and diabetes that are often 2 to 3 times higher than those for White women. Breast cancer incidence is similar for Black and White women, but Black women have higher breast cancer mortality. Among younger and reproductive-aged women, maternal mortality and homicide rates are 4 times higher for Black women than for White women, and the rate of HIV-related deaths is 12 times higher for Black women. The complexity of women's health advocacy emanates, in part, from the fact that the inequities at issue do not carry over into mortality disparities vis-à-vis men. This is generally true across ethnic groups (Table 1). In contrast, minority health advocacy has been organized primarily around attempts to leverage the data that show striking ethnic disparities in mortality. Thus, taking a minority perspective on women's health may "confuse the issue" to the extent that it draws attention to the favored health status of White women relative to Black women or other women of color.
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At issue, then, is how to increase awareness of the special health concerns of minority women within the women's health movement and to ensure that the concerns of minority women are incorporated as integral components of the larger women's health agenda. Although some authorities now argue that the minority health perspective must be included in any discussion of the health of women in the United States,4-6 the dilemmas that minority women confront in embracing "women's" health may not be generally recognized.7,8 In this commentary, we describe these dilemmas. Our objective is to help advocates for both minority health and women's health to serve their constituents.
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EMANCIPATION AS AN UNDERLYING THEME |
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TOPABSTRACTINTRODUCTIONEMANCIPATION AS AN UNDERLYING...DIFFERING EVOLUTION OF HEALTH...WHITE VS MINORITY WOMEN:...ADDRESSING MINORITY WOMEN'S...TOWARD A UNIFIED PERSPECTIVEReferences |
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There are profound differences in the outlook and relative political strength of the women's health and minority health movements, but, as with many social movements,9 both center around a theme of emancipation. With respect to gender, emancipation issues center around the effect of discrimination against women in patriarchal societies, regardless of class, caste, or other such considerations10—namely, "glass ceilings," voting rights, and pay equity in comparison with males, as well as reproductive rights, research equity, and access to and equity in health care.11 These gender issues are a rallying point for social or political action among minority women, but minority women also have issues related to race or ethnicity.12 White women have the luxury of being able to ignore racial biases13 and are free to focus exclusively (or almost so) on gender problems. In contrast, minority women experience and must simultaneously guard against both racism and sexism.14 These 2 forces, although similar in some respects, operate independently.8,15,16
White women have the advantage of understanding the dominant culture as well as sharing the obligations associated with participation in it.13 In this sense, the discussion of gender equity among White men and women is a negotiation among cultural equals—people who share a common language, norms, and values.16 Minority women—who have been distanced from the majority culture by history, language, religion, and other factors related to race and ethnicity—do not have the same stake in the majority culture12,17,18; they enter discussions of equity with an entirely different set of premises. For example, many minority women may perceive White women as having exploited the civil rights movement to achieve their own goals.14,19 In addition, middle-class minority women may experience pressure to become assimilated into the dominant culture while also continuing to face reminders of their exclusion from it,20,21 which hinders their sense of commonality with White women.
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DIFFERING EVOLUTION OF HEALTH ADVOCACY |
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TOPABSTRACTINTRODUCTIONEMANCIPATION AS AN UNDERLYING...DIFFERING EVOLUTION OF HEALTH...WHITE VS MINORITY WOMEN:...ADDRESSING MINORITY WOMEN'S...TOWARD A UNIFIED PERSPECTIVEReferences |
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The evolution of the women's health and minority health movements is depicted schematically in Figure 1
as variations on a general advocacy model. Inequalities or other flaws in health and social systems create specific problems and issues that become focal targets of social movements22 and that generate advocacy for special funding, special programs, new regulations, or new methods for accomplishing goals. Successful health movements decrease disparities in health status or health services and increase equality of attention to health concerns. However, there are fundamental differences in the character of the women's health and minority health movements.
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As shown in Figure 1
, the women's health movement evolved as an offshoot of the modern women's rights movement that encompassed the activism in the 1960s, the development of the National Organization for Women, the consciousness-raising groups of the 1970s, and the introduction of academic departments of women's studies into universities. An important milestone was the Roe v Wade decision of 1973, with ensuing legislative struggles over reproductive rights. Such concerns led to increased advocacy for control of more general health matters and to greater attention to women's issues in mainstream medical research.7,19 Today, the women's health agenda includes conditions that occur throughout the entire life cycle and all types of diseases, as well as more general problems such as depression, lack of health care, and domestic violence.4,6 Efforts are made to link this US agenda to global women's health issues.23 The desired outcomes of successful advocacy for women's health include improvements in medical treatment and decreases in the incidence and prevalence of disease conditions specific to women. An additional goal is to clarify the role of social factors24 as determinants of women's health and to avoid the reductionist view that health differences between men and women are entirely biological in origin.25 In contrast, the minority health movement evolved as an offshoot of the civil rights struggle that is unique to the sociopolitical history of the United States, and it is equally relevant to both sexes. Current advocacy for minority health is anchored in a 1985 federal task force report documenting "excess deaths" among minority groups compared with the White population.26 For example, the task force found that among Native Americans and African Americans younger than 45 years, death rates were 47% and 42% higher, respectively, than would be expected on the basis of death rates for Whites. For persons 70 years and younger in these 2 groups, 22% and 42% of deaths, respectively, were "excess deaths." Disparities in some areas were seen to have persisted or worsened even in the presence of societal changes intended to improve the condition of minority groups.
The minority health movement is linked to the history of adversarial relations between the White American majority and people of color. Without regard to gender, these adversarial relations include stigmatization of people with dark skin,12 legal and de facto segregation and discrimination, and a host of painful historical associations with slavery, the Tuskegee study, involuntary sterilization, and internment in wartime relocation camps.27–29 At the extreme, the historic events and patterns of discrimination have led some minority observers to charge that the present situation in health care resembles earlier efforts to achieve the genocide—systematic annihilation—of the African American population; they argue that the poor health care in minority communities is a deliberate effort to encourage the gradual disappearance of an unwanted group.7,29 This deep, historically based distrust of the medical establishment and the mainstream society affects both women and men in minority populations.
Recent scientific and policy shifts may further marginalize minority group members from mainstream health advocacy. For example, the genomic revolution has created a climate that appears to favor biological explanations over social explanations for diseases.30 Although minority group categorizations are not biological designations,31 research on ethnic differences has a high potential for being misunderstood in such a climate32 and could well stimulate a new "eugenics" debate in which racial and ethnic health disparities are attributed to biological inferiority rather than to environmentally determined conditions such as poverty. The fear of such a scenario would tend to create closer allegiances within minority groups across gender lines but provoke tension within gender groups across ethnicity lines.
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WHITE VS MINORITY WOMEN: THE NUMBERS GAME |
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TOPABSTRACTINTRODUCTIONEMANCIPATION AS AN UNDERLYING...DIFFERING EVOLUTION OF HEALTH...WHITE VS MINORITY WOMEN:...ADDRESSING MINORITY WOMEN'S...TOWARD A UNIFIED PERSPECTIVEReferences |
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Minority women are no less in the minority—numerically, regarding political power, and with respect to the risk of being stereotyped or misunderstood—when the topic is limited to females. The women's health movement draws on half the US population for its constituency, but minorities—men and women—make up only about one fourth of the US population. The "minority population," however, comprises several subpopulations whose only common characteristic is being "non-White,"31 and women in a specific minority population may constitute as few as 1% (American Indian) or no more than 10% to 12% (Hispanic or African American) of the female population. In contrast, half the constituents of the minority health movement or any subset of it would be expected to be women.
Thus, in terms of numbers of constituents and relationship to the White majority, the women's health movement is more powerful than the minority health movement, even when the diverse minority populations speak as one voice. For numerical reasons alone, minority women might view the women's health movement as dominated by White women and feel "more equal" when pursuing health advocacy from a minority health perspective. Nonminority women who fail to understand these proportionalities may view minority women who give priority to minority issues (and advocate for both minority men's and women's health) as insufficiently informed about or loyal to women's rights issues.7 In addition, in the constant competition for funding and access to the national political agenda, attention to women's health issues may appear to dilute the resources that might be available for minority issues. This scenario would be less adversarial if the health issues for all women were the same, but, as we explain, they differ in several important respects. 4,6
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ADDRESSING MINORITY WOMEN'S HEALTH |
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TOPABSTRACTINTRODUCTIONEMANCIPATION AS AN UNDERLYING...DIFFERING EVOLUTION OF HEALTH...WHITE VS MINORITY WOMEN:...ADDRESSING MINORITY WOMEN'S...TOWARD A UNIFIED PERSPECTIVEReferences |
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Considerations of minority women's health are fraught with vestiges of the historical relations noted earlier, but also with additional issues related to social class. For both minority and majority women, feelings of mutual support may be inhibited by recollections of domestic servitude that reinforce the higher social class basis of the women's health movement as opposed to the minority women's health movement. In addition, stereotypical views about Black women and sexuality29 may inhibit open discussion of reproductive health issues in interracial advocacy forums. Underlying views of abortion diverge between Black and White women; for example, White women generally perceive abortion as an issue of the right of control over their bodies, whereas many African American women view abortion through the prism of "this country's shameful history of sterilization abuse."7
Within women's health, views of minority women's health issues may also be distorted by spurious theories about race-based disease "immunity" and related biases in medical thinking.29 Clinicians or researchers may deny or understate the potential relevance to minorities of conditions such as coronary heart disease that at one time had lower prevalences among minorities than among Whites. Although myths and misperceptions may be refuted by hard data—for example, those showing disease rates in minority populations that surpass those in the White population33—the availability of data does not immediately erase biases from clinical practice and teaching. Even when discussions are relatively free of stereotypes, biases, and competition between causes, health issues for minority women do not always fit well into the generalities applied to women's health overall.
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TOWARD A UNIFIED PERSPECTIVE |
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TOPABSTRACTINTRODUCTIONEMANCIPATION AS AN UNDERLYING...DIFFERING EVOLUTION OF HEALTH...WHITE VS MINORITY WOMEN:...ADDRESSING MINORITY WOMEN'S...TOWARD A UNIFIED PERSPECTIVEReferences |
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On February 21, 1998, President Clinton announced an initiative committing the nation to the goal of eliminating by 2010 long-standing disparities in health status that affect racial and ethnic minority groups.34,35 In light of this initiative, the dilemmas for minority women become even more profound. For women of color, working toward common goals for the benefit of all women, majority as well as minority, requires a suspension of attention to overriding issues of racial bias. This suspension, however, carries a price; it may separate minority women from the support systems that minority communities offer to men and women alike. A focus on gender issues independent of race, therefore, requires minority women to choose between racial issues and women's issues and therefore polarizes the debate. For reasons of community support alone, most, if not all, minority women must give priority to struggles against racial and ethnic discrimination. Thus, minority women tend to view women's issues from a perspective that is not shared with any other group—White women, White men, or minority men. This isolation may act as a barrier to social action, professional accomplishment, or health behaviors considered appropriate and desirable by majority women.
Can common ground be found on which to forge alliances to integrate gender- and ethnicity-based health advocacy? Could, for example, the women's health movement (re)frame HIV/AIDS, with its potential for vertical transmission to offspring and its higher burden in Black and Hispanic women,5,6 as a mainstream women's health issue, even though it might draw resources from health issues more salient for White women? Is it acceptable for policymakers to claim as a breakthrough in women's health a pathway first elucidated in minority women? For example, systemic lupus erythematosus affects more women than men, but it affects more Black than White women and has a poorer outcome in Black women.36,37 Should studies of Black women with lupus take priority in this field? In contrast, osteoporosis affects proportionately more White than minority women, although all women are at higher risk than men. A consideration of both lupus and osteoporosis as agenda items for the women's health movement could easily be embraced by a broad coalition of women, but the battle for priorities is likely to prove uneven if resources are limited.
A key question for researchers is how the women's health movement can exploit, in a positive way, the element of diversity as a means to better understand disease causation and progression.38 That is, ethnic differences in disease occurrence or prognosis may be caused by risk factors with different distributions and different time trends by ethnicity—for example, socioeconomic status variables, reproductive patterns, dietary and physical activity practices, alcohol consumption, occupational exposures to carcinogens, area of residence and migration, and certain gene frequencies. The identification of variables that mediate ethnic differences in disease patterns may lead to new etiologic hypotheses for closer study. Lin and Kelsey38 give examples of how the study of variation within and across diverse ethnic groups has been applied to the study of breast cancer, osteoporotic fractures, and several other health outcomes and discuss the methodological challenges inherent in this approach.
Minority health and women's health constitute different movements and different venues for action. However, many minority women's issues are also, in some form, issues for women in general. Thus, the goals of action for women's health can be mutually supportive even when the perspectives and strategies of participants vary by race and ethnicity. Health aspects on which minority women diverge from White women should not prevent the development of a shared women's health agenda. Recognition and acceptance of differing agendas among women will go much further in facilitating cooperation than will forcing alliances in which gender is the only permissible variable.
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Footnotes |
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Peer Reviewed
S. K. Kumanyika authored an original draft of this commentary. C. B. Morssink revised the initial article, expanding several themes. M. Nestle added arguments based on her reading of the issues. All authors participated in revisions leading to the final version.
Accepted for publication May 1, 2001.
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References |
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TOPABSTRACTINTRODUCTIONEMANCIPATION AS AN UNDERLYING...DIFFERING EVOLUTION OF HEALTH...WHITE VS MINORITY WOMEN:...ADDRESSING MINORITY WOMEN'S...TOWARD A UNIFIED PERSPECTIVEReferences |
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1. Health, United States, 2000 With Adolescent Health Chartbook. Hyattsville, Md: National Center for Health Statistics; 2000. Available at: http://www.cdc.gov/nchs/products/pubs/pubd/hus/00husdes.htm. Accessed November 3, 2000.
2. Third Report on Nutrition Monitoring in the United States. Vol 1. Washington, DC: Federation of American Societies for Experimental Biology, Life Sciences Research Office; 1995.
3. Hoyert DL, Kochanek KD, Murphy SL. Deaths: final data for 1997. Natl Vital Stat Rep. 1999;47(19). Available at: http://www.cdc.gov/nchs/releases/99facts/99sheets/97mortal.htm. Accessed November 3, 2000.
4. Office of Research on Women's Health. Agenda for Research on Women's Health for the 21st Century. A Report of the Task Force on the NIH Women's Health Research Agenda for the 21st Century. Executive Summary. Bethesda, Md: National Institutes of Health, Office of the Director; 1999. NIH Publication 99-4385.
5. Leigh WA, Lindquist MA. Women of Color Health Data Book. Bethesda, Md: National Institutes of Health, Office of the Director; 1998. NIH publication 98-4247.
6. Making the Grade on Women's Health: A National and State-by-State Report Card. Washington, DC: National Women's Law Center; 2000.
7. Wilson M, Russell K. Divided Sisters: Bridging the Gap Between Black Women and White Women. New York, NY: Anchor Books Doubleday; 1996.
8. Krieger N. Embodying inequality: a review of concepts, measures, and methods for studying health consequences of discrimination. Int J Health Serv.1999;29:295–352.[Medline]
9. Morris AD, Mueller CM, eds. Frontiers in Social Movement Theory. New Haven, Conn: Yale University Press; 1992.
10. Krieger N, Fee E. Man-made medicine and women's health: the biopolitics of sex/gender and race/ethnicity. Int J Health Serv.1994;24:265–283.[Medline]
11. Pirie M. Women and the illness role: rethinking feminist theory. Can Rev Sociol Anthropol.1988;25:628–648.
12. Essed P. Understanding Everyday Racism: An Interdisciplinary Theory. New York, NY: Sage Publications; 1991.
13. Lipsitz G. The Possessive Investment in Whiteness: How White People Profit From Identity Politics. Philadelphia, Pa: Temple University Press; 1998.
14. Hooks B. Feminist Theory: From Margin to Center. 2nd ed. Cambridge, Mass: South End Press; 2000.
15. Farley JE. Majority-Minority Relations. 4th ed. Englewood Cliffs, NJ: Prentice-Hall; 2000.
16. Doane AW Jr. Dominant group ethnic identity in the United States: the role of "hidden" ethnicity in intergroup relations. Sociol Q.1997;38:375–397.
17. Bray RL. Taking sides against ourselves. New York Times Magazine. November 17, 1991:56, 94, 95, 104.
18. Hacker A. Two Nations: Black and White, Separate, Hostile, Unequal. New York, NY: Ballantine Books; 1992.
19. Rosen R. The World Split Open: How the Modern Women's Movement Changed America. New York, NY: Viking; 2000.
20. Rowe MP. Barriers to equality; the power of subtle discrimination to maintain unequal opportunity. Employee Responsibilities Rights J.1990;3:153–163.
21. Lorde A. Sister Outsider. Trumansburg, NJ: Crossing Press; 1984.
22. Larana E, Johnston H, Gusfield JR, eds. New Social Movements: From Ideology to Identity. Philadelphia, Pa: Temple University Press; 1994.
23. Riley NE. Gender, power and population change. Popul Bull.1997;52:1–46.[Medline]
24. Link BG, Phelan JC. Social conditions as fundamental causes of disease. J Health Soc Behav. 1995;(extra issue):80-94.
25. Loue S. Gender, Ethnicity, and Health Research. New York, NY: Kluwer Academic/Plenum Publishers; 1999.
26. Report of the Secretary's Task Force on Black and Minority Health. Washington, DC: US Dept of Health and Human Services; 1985.
27. Gamble VN, Blustein BE. Racial differentials in medical care: implications for research on women. In: Mastroianni AC, Faden R, Federman D, eds. Women and Health Research; Ethical and Legal Issues of Including Women in Clinical Studies. Vol 2. Washington, DC: National Academy Press; 1994: 174–191.
28. Yu ESH. Ethical and legal issues relating to the inclusion of Asian/Pacific Islanders in clinical studies. In: Mastroianni AC, Faden R, Federman D, eds. Women and Health Research; Ethical and Legal Issues of Including Women in Clinical Studies. Vol 2. Washington, DC: National Academy Press; 1994: 216–231.
29. Gamble VN. Under the shadow of Tuskegee: African Americans and health care. Am J Public Health.1997;87:1773–1778.
30. Holtzman NA, Marteau TM. Will genetics revolutionize medicine? N Engl J Med.2000;343:141–144.
31. Pollard KM, O'Hare WP. America's racial and ethnic minorities. Popul Bull. 1999;53. Available at: http://www.prb.org/pubs/population_bulletin/bu54-3/54_3_intro.htm. Accessed November 3, 2000.
32. LaVeist TA. Why we should continue to study raceæbut do a better job: an essay on race, racism and health. Ethn Dis.1996;6:21–29.[Medline]
33. Kumanyika SK, Golden PM. Cross-sectional differences in health status in US racial/ethnic minority groups: potential influence of temporal changes, disease, and life-style transitions. Ethn Dis.1991;1:50–59.[Medline]
34. Call to action; eliminating racial and ethnic disparities in health. In: Proceedings of the National Leadership Conference; September 11, 1998; Potomac, Md. Available at: http://raceandhealth.hhs.gov/sidebars/report.htm. Accessed June 13, 2001.
35. Council on Economic Advisers for the President's Initiative on Race. Changing America. Indicators of social and economic well-being by race and Hispanic origin. 1998. Available at: http://www.access.gpo.gov/eop/ca/index.html. Accessed November 3, 2000.
36. Walsh SJ, Algert C, Gregorio DI, Reisine ST, Rothfield NF. Divergent racial trends in mortality from systemic lupus erythematosus. J Rheumatol.1995;22:1663–1668.[Medline]
37. McAlindon T. Update on the epidemiology of systemic lupus erythematosus: new spins on old ideas. Curr Opinion Rheumatol.2000;12:104–112.[Medline]
38. Lin SS, Kelsey JL. Use of race and ethnicity in epidemiologic research. Concepts, methodological issues and suggestions for research. Epidemiol Rev. 2000;22:187–202.
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