Traditional Chinese Medicine in Health Care in Macao

Home , Government of Macau, Macau Peninsula

ISSNe: 2182.2883 | ISSNp: 0874.0283 Available: https://doi.org/10.12707/RIV17007 THEORETICAL PAPER/ESSAY ARTIGO TEÓRICO/ENSAIO Traditional chinese medicine in health care in Macao A medicina tradicional chinesa nos cuidados de saúde em Macau Cuidado de la salud de la medicina china tradicional en Macao

Lam Nogueira Oi Ching Bernice* Abstract

Background: Traditional Chinese medicine (TCM) has been founded for more than 2,500 years of Chinese medical practice and also been practiced in Macau since the 19th century. Recently the Macau Special Administrative Region (MSAR) Government has established the World Health Organization (WHO) Collaboration Centre for Traditional Chinese Medicine (Macau) and has focused to the investment of TCM. Education for TCM is offered in higher education institutions in MSAR, however, nursing in TCM is not yet offered as a degree program. Objectives: Describe the healthcare system and the evolution of the western and eastern medicine in Macau; iden- tify the quality assurance and future development of TCM; and the future challenges and implications for science and education in Macau. Main topics under analysis: Descriptive analyses by reviewing statistical data, historical and literature review are applied in this article. Conclusion: Macau’s characteristic eastern and western culture is reflected in the expansion of TCM. With collaboration from WHO, this will benefits the Macau’s bridging and linking role with Portuguese-speaking countries.

Keywords: medicine, Chinese traditional; Macau

Resumo Resumen

Enquadramento: A medicina tradicional chinesa Marco contextual: La Medicina Tradicional China (MTC) teve origem há mais de 2.500 anos, sendo pra- (MTC) ha sido fundada por más de 2.500 años de prác- ticada em Macau desde o século XIX. Recentemente, o tica médica china y también se ha practicado en Macao Governo da Região Administrativa Especial de Macau desde el siglo XIX. Recientemente, el Gobierno de la (RAEM) criou o Centro Colaborador da Organização Região Administrativa de Especial de Macau (RAEM) Mundial da Saúde (OMS) para a Medicina Tradicional estableció el Centro Colaborador de la OMS para la Chinesa (Macau) e reforçou o investimento na MTC. Medicina China Tradicional (Macao) y se centró en la O ensino de MTC é oferecido em instituições de ensino inversión de la MTC. Educación para el MTC se ofrece superior da RAEM. Contudo, ainda não existe um pro- en las instituciones de educación superior en Macao, grama de graduação em enfermagem associada à MTC. sin embargo, la enfermería MTC no se ofrece como un Objetivos: Descrever o sistema de saúde e a evolução programa de grado. da medicina ocidental e oriental em Macau; identificar Objetivos: Describir el sistema de salud y la evolución a garantia de qualidade e o desenvolvimento futuro da de la medicina occidental y oriental en Macao; identi- MTC bem como os futuros desafios e implicações para ficar la garantía de calidad y el desarrollo futuro de la a ciência e o ensino em Macau. medicina tradicional china, así como los desafíos y las Principais tópicos em análise: Neste artigo são apre- implicaciones para la ciencia y la educación en Macao sentadas análises descritivas com base na revisão de da- futuras. dos estatísticos, revisão histórica e da literatura. Temas de análisis principales: Análisis descriptivo a Conclusão: A cultura oriental e ocidental que caracte- través de la revisión de los datos estadísticos, revisión riza Macau reflete-se na expansão da MTC, o que, com histórica y bibliográfica se aplican en este artículo. a colaboração da OMS, permitirá estabelecer a ponte Conclusión: El oriental y la cultura occidental función entre Macau e os países de língua portuguesa. de Macao se refleja en la expansión de la MTC. Con la colaboración de la OMS, esto beneficiará el papel de Palavras-chave: medicina tradicional chinesa; Macau puente de Macao y enlazar con los países de habla portuguesa.

Palabras clave: medicina china tradicional; Macau

*PhD, Coordinator, Associate Professor, School of Health Science, Macao Poly- Received for publication: 24.01.17 technic Institute, Macao [[email protected]]. Accepted for publication: 29.04.17

Revista de Enfermagem Referência Série IV - n.º 13 - ABR./MAI./JUN. 2017 pp. 157-164 Introduction Portuguese-speaking countries (Serviços de Saúde de Macau [SSM], 2016a).This article Macau is a Special Administrative Region describes the healthcare system in Macau, the (SAR) of the People’s Republic of China, sit- evolution of western and eastern medicine in uated at the Pearl River Delta on the south- Macau, and the quality assurance and future east coast of Mainland China, 60 km south- development of TCM in Macau. Addition- west of Hong Kong. Macau comprises the ally it sets out future challenges and implica- Macau peninsula, Taipa and Coloane Island. tions for science and education to further the With an estimated population of around considerable prominence that Macau gives to 647,700 living in an area of 30.4 km², pop- TCM as part of its declared policy of, and ulation density 21.1(’000/km2), (Direcção strategy for, economic diversification. dos Serviços de Estatística e Censos [DSEC], 2016), it is one of the most densely populat- ed region in the world. Development Macau Special Administrative Region (MSAR) had been a Portuguese colony since The healthcare system in Macau 1557, and was handed over to China on 20 “A sound healthcare system, putting preven- December, 1999 under the policy of one tion first” (GCS, 2016, p. 1) is the policy of country, two systems (Gabinete de Comuni- MSAR Government, with a commitment to cação Social, [GCS], 2016). With the past improve medical and healthcare quality, as historical background of almost 500 years well as the health of the population in Ma- of Portuguese governance, Macau possesses cau (SSM, 2016b). Macau’s Healthcare Sys- characteristics of eastern and western culture, tem is one the most well developed in Asia, and this extends to health care, in which there and the life expectancy of its people is also is combination of Western Medicine and Tra- one of the longest, with an average of 79.9 ditional Chinese Medicine (TCM). years for men and 86.3 years for women TCM has been founded for more than 2,500 (DSEC, 2016). years in Chinese medical practice, and it Macau has five hospitals and 708 primary includes various forms of herbal medicine, health care establishments, among which are acupuncture, massage, exercise and dietary 194 TCM clinics. In 2015 there were 1,674 therapy. TCM is widely used in China and doctors and 2,279 nurses, with ratios of 2.6 is becoming increasingly prevalent in Eu- per thousand residents and 3.5 per thousand rope and North America (National Center residents respectively (DSEC, 2016). for Complementary and Integrative Health Macau’s healthcare services are provided by [NCCIH], 2016). governmental and non-governmental insti- TCM has also been practiced in Macau since tutions. The governmental institutions in- the 19th century mainly by non-governmen- clude Conde São Januário Hospital (CHCSJ) tal parties and later with support by gov- which provides specialist medical services; ernment. Recently the MSAR Government, and seven health centers and three health with support from the mainland Beijing stations for primary healthcare; and the Pub- government, has focused to the development lic Health Clinical Center in Coloane. The of TCM and established the World Health primary healthcare system was established Organization (WHO) Collaboration Centre in 1985 by the Macau Health Bureau under for Traditional Medicine (Macau) in August the Portuguese Administration, to realize the 2015 (WHO, 2015). The Guangdong-Ma- objective of Health for all 2000 advocated by cau Traditional Chinese Medicine Indus- WHO. The health centers and health stations trial Technology Park is a new investment are located in the different districts of Macau located on Hengqin Island in the Zhuhai and offer easy access and free primary health Prefecture adjoining Macau, and, as men- care services for Macau residents in their own tioned by Chief Executive of the MSAR, this neighborhoods. Among them, the Health will benefit the steps taken to enable Macau Center of Macau Norte (Bairro Fai Chi Kei), to further its role as a bridge and link with Health Center of Areia Preta (Hac Sa Wan)

Traditional chinese medicine in health Revista de Enfermagem Referência - IV - n.º 13 -2017 care in Macao 158 and Health Center of Nossa Senhora do Car- times be a strong, unpleasant or bitter taste of mo-Lago are equipped with TCM Clinics. some TCM medication. The primary healthcare network based on The herbal combinations used in TCM are Government Health Centers is considered a prepared for, and tailored to, each individ- model of good practice by the WHO (GCS, ual (maybe 8-15 herbs in any preparation), 2016). and they change over time in response to The non-governmental health institutions in- the whole person’s condition and health sta- clude Kiang Wu Hospital, Macau University tus (Flower et al., 2012). Some of them are of Science and Technology Hospital (UH), designed for therapeutic action (Emperor Malo Clinic Day Hospital, Macau Yin Kui herbs), some support the therapy and oth- Hospital, Tung Sin Tong Clinic, the Work- er co-existing factors (Minister herbs), some ers’ Clinic, and various private clinics offer- support the main therapy whilst reducing ad- ing a range of medical services. Among these verse effects Assistant( herbs), and some focus non-governmental institutions, Kiang Wu on a particular part of the body (Envoy herbs; Hospital, the University Hospital, the Work- Flower et al., 2012). ers’ Clinic and Tung Sin Tong Clinic provide Some TCM medication acts more slowly that consultation for, and treatment with, TCM. some western medicines, as it focuses on re- The Macau Health Bureau is responsible for storing the whole body and bringing it into coordinating the activities between the public overall balance rather than focusing on symp- and private organizations in the area of pub- toms or isolated parts of the body. Hence the lic health, and for assuring the health of citi- duration of a course of TCM is often longer zens through specialized and primary health than for western medicine. care services, as well as disease prevention and In terms of health diagnosis and treatment, health promotion. TCM focuses on the whole person, including hot, cold, wet and dry classifications of patients Introducing TCM and their presenting symptoms (Liu, Leung, Going into a TCM department or pharma- & Tian, 2011). Patients visiting a TCM doc- cy of a hospital or health center in Macau, is tor may have up to 29 different pulses taken, interesting to westerners and to those unfa- their tongue examined, with data gathered miliar with TCM, as it is unlike going into from observation, testing, smelling, listening, a western medical center in some respects. palpation and questioning (van der Greef, Typically, upon entry to the TCM pharmacy, 2011), that is, a whole person approach. This the TCM patient is faced with many rows of differs from some patient treatments in the small brown drawers, often numbering over West, which focus only on the specific disease one hundred, each of which is labeled, and rather than the whole person, and often only in which the dried herbs and TCM ingredi- on one disease at a time. ents for medical preparations are kept. The In research terms, TCM often focuses on layout is similar to going into what would the therapeutic effect of TCM on specific be an ‘apothecary’s’ shop in times past. The ailments and functions of the body and ran- dry ingredients are selected and weighed out domized controlled trials (RCTs) are widely by hand, following the prescription from the used in testing TCM. Van der Greef (2011), TCM doctor, on a simple hand-held two-pan Liu et al. (2011) and Flower et al. (2012) re- balance, and assembled and wrapped by the port that RCTs are used for identifying the TCM pharmacist. Patients can collect these biochemical elements of herbs and their ef- and boil them themselves at home, to make ficacy, and Flower et al. (2012) report that the medicinal liquid, or the TCM establish- there are 17,000 such RCTs in TCM. ment itself can prepare and boil the ingredi- Alongside RCTs for testing the efficacy of ents and pass them to the patient in sealed TCM, other research on TCM in Macau is watertight packets, for the patient to heat up of a more fundamental ‘blue skies’ nature, in- and drink at home. Sometimes the medical vestigating the effects of identified herbs on establishment will also offer a traditional can- particular aspects of diseases and their cure, dy to conceal the aftertaste of what can some- that is, pre-clinical trial research.

LAM NOGUEIRA OI CHING BERNICE et al. Revista de Enfermagem Referência - IV - n.º 13 -2017 159 Much contemporary medical research focus- TCM expanding worldwide, it resumed its es on personalized medicine and attention to: TCM services. The service did not last for the real world; the whole person; the personal long and only parts of the service remain characteristics of participants. In personal- such as: acupuncture, massage and limited ized medicine the doctor faces a person, not TCM services. From March 1998, the TCM simply a disease (Leon, 2012). TCM, focus- restarted and continues to the present. The ing on the whole person, recognizes that the TCM services offered in Kiang Wu Hospi- whole person is a system and TCM works on tal include: consultation for TCM; TCM in the whole person, not only a specific ailment. males, gynecology, pediatrics, orthopedics In TCM the whole person is regarded as a and trauma, acupuncture and massage; and system (van der Greef, 2011; Flower et al., delivering and packaging herbal medicine 2012), involving, for example, ‘nutritional, (Kiang Wu Hospital, 2013). psychological, and lifestyle factors when de- Tung Sin Tong Clinic, the first TCM clinic, ciding the best course of treatment’ (van der was established at 1892 and offers free con- Greef, 2011). Like western medicine, TCM sultation and herbal medicine for the sick in focuses not only on treatment but on disease Macau, regardless of their nationality, race or prevention, health promotion and other pos- social status. From 1989 it started to receive itive benefits of herbs. subsidy from Macau government, and Tung Sin Tong Clinic is currently expanding and Evolution of western and eastern medicine establishing more clinics in several districts in in Macau Macau. Macau is enjoying not only a revival of TCM The development of TCM was initiated by but its expansion and development, not only non-governmental efforts, and later gained in provision but in research, development additional support from the Macau govern- and industrialization. It is becoming an im- ment. In 1999, the first TCM services started portant and targeted element of its econom- to be provided in the Government Health ic development and the Macau government Center (the Fai Chi Kei Health Center), is providing much support for this devel- serving the increasing Chinese population opment, capitalizing on the long history of located in the Northern District of Macau TCM in Macau. Alongside this there is in- City. Since then the services have expanded creasing regulation, licensing, professionali- into two more Health Centers: Hac Sa Wan zation, standards and quality control of TCM Health Center in Macau and Nossa Senho- and its practitioners and trainees. ra do Carmo-Lago Health Center in Taipa. In the 16th century, the first European Hos- Together these three Government Health pital (São Rafael Hospital) was built to care Centers provide free TCM services for Macau for poor, sick people. Until the middle of the residents, including consultation, acupunc- 19th century, Macau had three Portuguese ture, and herbal medicine. The characteris- hospitals providing western medicine (San- tics of these governmental health care insti- ta Casa da Misericórdia Hospital/São Rafael tutions, then, are that they combine eastern Hospital, São Lázaro Hospital and the Mil- and western medicine. itary Hospital), mainly serving Portuguese The number of private TCM clinics and missionaries and soldiers. Of these, only the herbal medicine shops is increasing in Macau. Military Hospital still remains today and the In 2015, there were in total 194 registered Government Hospital that practices west- private TCM clinics with nearly 1,135,908 ern medicine is now renamed Conde São consultations recorded. The ratio of doctors Januário Hospital (SSM, 2016b). practicing TCM/Chinese Herbalists, approx- Kiang Wu Hospital, the first Chinese Hospi- imately one per thousand of the population, tal providing TCM services for the Chinese has remained steady since 2011(DSEC, population, was established at 1871. It grad- 2016). ually turned to western medicine and stopped The government of Macau values the devel- its TCM services in 1944. However, in the opment and application of TCM. With the middle of the 1980s, with the influence of approval of the government of Macau, the

Traditional chinese medicine in health Revista de Enfermagem Referência - IV - n.º 13 -2017 care in Macao 160 Faculty of Traditional Chinese Medicine at nary fields of biomedical and pharmaceutical Macau University of Science and Technolo- sciences. ICMS/SKL started offering Master gy (M.U.S.T.) was established in 2000 and of Science degree programmes in Chinese its Bachelor’s degree programme in TCM Medicinal Science and Medicinal Adminis- was offered at the same time. In early 2011, tration from 2002, and it currently also pro- the university became the support institu- vides the PhD degree programme in Biomed- tion of the State Key Laboratory of Quality ical Sciences, and Bachelor of Science degree Research in Traditional Chinese Medicine programme in Biomedical Sciences (Table (SKL-QRCM). In 2003, in order to meet the 1). The Expert Committee of the Ministry of increasing medical needs of the local popu- Science and Technology in Beijing appraised lation, MUST. established a TCM with the highly the achievements of the SKL (at the approval of the Macau Health Bureau. This University of Macau and Macau University clinic also provided opportunity for clinical of Science and Technology) and successfully practice for MUST medical students and passed the mid-stage assessment of the SKL staff. Recently, the Faculty of Traditional in 2013 (University of Macau, 2016a) Chinese Medicine of MUST offers Bachelor, A characteristic of research in TCM in Ma- Master and Doctor of Philosophy Programs cau is that it seeks to investigate the effects in TCM. (Table 1: Macau University of Sci- of TCM and herbal medication on ailments ence and Technology, 2016a). The University that can also be treated with western med- of Macau established the Institute of Chi- icine. This rapprochement, or fusion, be- nese Medical Sciences (ICMS) and the SKL- tween eastern and western medicine is not QRCM in 2002. The ICMS/SKL has devoted only unusual but embodies the fusion of itself to promoting research in TCM and the eastern and western cultures that is a charac- nurturing of local talents in the interdiscipli- teristic of Macau. Table 1 Traditional chinese medicine program in higher education in Macau

University Program Degree

Chinese medicine Doctor of Philos- Traditional Chinese medicines ophy Integrated Chinese and Western medicine

Traditional Chinese medicine Macau University of Sci- Pharmacology in Traditional Chinese medicine ence and Technology Integrated Chinese and Western medicine Master (The Faculty of Chinese Management in production and Sales of Traditional Medicine) Chinese medicine

Traditional Chinese medicine Bachelor Pharmacology in traditional Chinese Medicine Biomedicine

Doctor of Philos- Biomedical sciences University of Macau ophy (Institute of Chinese Medi- Chinese medicinal science & medicinal administration Master cal Sciences) Biomedical sciences Bachelor

LAM NOGUEIRA OI CHING BERNICE et al. Revista de Enfermagem Referência - IV - n.º 13 -2017 161 Quality assurance of TCM in Macau traditional Chinese patent medicines; (3) to In past times a few TCM practitioners were review the technical qualifications of pharma- graduates of formal institutions of TCM, and cists and pharmacies in the profession. the majority of TCM practitioners in Macau In line with the new regulations, the Macao were scattered among the grass-roots health government approved 456 kinds of tradition- care services. Most of their training came al Chinese herbal medicines for pharmacy from ancestral sources or was under the tui- sales. The list includes two categories: one list tion of a teacher, or from study or training in of toxic traditional Chinese herbal medicines, Mainland China’s Chinese Medicine colleges and another of commonly used herbal treat- and universities (Zeng, 2003). ments. The pharmacies must have a technical- In 1990, the Macau Health Bureau, through ly responsible person with one of the follow- its 84/90/M decree (Governo de Macau, ing qualifications: (1) pharmacist; (2) Chinese 1990), established the criteria for eligibility or TCM practitioner; (3) staff member with and recognition of health professionals, in- 5 years of experience in the preparation and cluding doctors of TCM/Chinese Herbalists. adjustment of TCMs, who must be certified From this ordinance, doctors of TCM must by their own statements together with those obtain a certificate of Higher Education in from the pharmacies or TCM associations in TCM from a recognized education institu- which they obtained their experience (De- tion in Macau, Portugal or Mainland China, creto-Lei n.º 53/94/M of 14/11/1994). The and Chinese Herbalists must obtain recogni- Consumer Council of Macao also has the tion of relevant knowledge from the Chinese power to investigate the quality of TCMs, Medical Association. and it periodically conducts checks of these In addition, the Macao Health and the Ma- and, where necessary, alerts the public to dan- cao Traditional Chinese Medicine Associ- gerous or unauthorized products. ation also actively strengthens cooperation In addition, the Center for Safety and Qual- with the Mainland. In 1996 and 1997, there ity Assurance of Traditional Chinese Medi- was a twosemester Macao TCM training cines and Foods in MUST provides standard course for Macao civil servants and practi- analytical tests to evaluate the level of harmful tioners of TCM, running over one year with pollutants, such as heavy metals and pesticide 10 subjects, including TCM, TCM surgery, residues in Chinese medicinal herbs and prod- acupuncture, and massage. Well-known pro- ucts, by mass spectrometry analysis. Further, fessors from Mainland China were invited it provides quality assurance tests for medic- to teach, greatly improving the profession- inal products, dietary supplements, food or al quality and ability of TCM practitioners other products that contain Chinese medic- (Zeng, 2003) inal components, from the University’s Hos- More recently, Chinese Herbalists must also pital or Macao’s Chinese pharmaceutical obtain a certificate equal to, or more than, 3 industry, to improve the quality of clinical years of study on a TCM day program, and services in Macau. This Center was award- doctors of TCM must have 5 years or more of ed the ISO/IEC17025 laboratory accredita- study for a Bachelor in TCM, on a day pro- tion by the National Association of Testing gram (SSM, 2015). Authorities, Australia (NATA) in 2008, and In order to maintain the public health of Ma- continues to expand international accredited cao and improve the quality, effectiveness and testing and food commercial certification li- safety of TCM, the Macao Health Bureau censes, such as the China CNAS certification. posted new drug regulations on November The SKL-QRCM also keeps detailed records 14, 1994. Its purpose was, and remains, to of the sourcing and quality of herbs used in strengthen the management of TCM: (1) to TCM. ensure the use of safe, effective and high-quality TCM for the people of Macao in order to Future developments in TCM in Macau improve the rational and careful use of TCM; The Macau government expressly values the (2) to regulate the import, export, whole- development of TCM and has announced its sale, distribution and pharmacy business of commitment to the industrialization of TCM

Traditional chinese medicine in health Revista de Enfermagem Referência - IV - n.º 13 -2017 care in Macao 162 in Macau, emphasizing how the development for minimising and treating Parkinson’s dis- of the TCM sector is one of the major ele- ease complications; Pharmacological Study of ments in the diversification of Macau’s econ- the Chinese Herb Pair Radix Puerariae-Sal- omy. via miltiorrhiza Bunge in Ameliorating Insu- The WHO Collaborating Centre for Tradi- lin Resistance and Endothelial Dysfunction tional Chinese Medicine (Macau) was estab- (University of Macau, 2016c). lished in August 2015, with help from the The training of professionals and the scien- global health body and the Chinese central tific evidence from research studies are essen- government. Several agreements in relation tial features here, and the Macau and Beijing to the development of TCM have also been governments have provided generous grants signed between the Macau government and for research in TCM in Macau. The degree the State Administration of Traditional Chi- programs in TCM have been well developed nese Medicine. These processes evidence the for some time, however, though at the time of international recognition of Macao’s effort to writing this subject has not yet been offered as promote TCM and have created the expecta- part of, or the whole of, a degree program in tion of further development of the sector in nursing. The TCM degree program in Nurs- Macau. ing has been already for many years in Main- Development of TCM is not limited to land China and the Hong Kong SAR. With MSAR, but in its worldwide expansion and the characteristics of health care in Macau, a links. Macao’s Health Bureau plays an im- combination of Western Medicine and Tradi- portant role in the future development of tional Chinese Medicine, it is important for TCM, for the control of quality of both the nurses to learn more about TCM to provide human resources and related products, and health education and promotion for the pop- for research and development of TCM. ulation. In terms of research, Macau University of Science and Technology has set key directions in TCM. (Macau University of Science and Conclusion Technology, 2016b). The study of immo- bilized anti-respiratory virus component in Macau is poised to become a leading center TCM by the viral receptor on the respiratory for TCM research, development, industrial- cells and it’s mechanism; A study of the active ization, pharmacology and practice, and this ingredients of Lei Gong Teng(Tripterygium has already commenced and is thriving. In Wilfordii Hookf) and their nano-particle this, sponsorship from the governments in drug carrier for treating chronic nephritis; Beijing and the Macao SAR has been exten- Identification of the molecular mechanisms sive and provided a major source of support. and drug action targets of Rh2E2, a new As the Macao government , in its 5-year stra- derivative of ginsenoside, on anti-cancer by tegic plan, has placed economic diversifica- using proteomics technology; Establishment tion as a strategic initiative for the develop- of LC-MS and LC-NMR-based Novel Lip- ment of Macao, it has accompanied this with idomic Platform and Its Application in Tra- a strong emphasis placed on all aspects of ditional Chinese Medicine Research. (Ma- TCM and the developments of networks of cau University of Science and Technology, researchers and practitioners across the world. 2016b). The University of Macau has received Macau’s characteristic eastern and western funding for several research projects in TCM culture is reflected in the expansion of TCM, (University of Macau, 2016b), for example: including the steps taken to integrate eastern Chemical and Pharmacological Study on a and western medicine. The successful collab- Novel Fungus from Natural Cordyceps Sin- oration between governmental and non-gov- ensis; Key Technologies of Innovative TCM ernment institutions in promoting TCM is based on Network Pharmacology and Molec- clearly in evidence in Macau. The govern- ular Pharmaceutics; Characterization, struc- ment’s future efforts will include ensuring tural optimization and mechanistic study of that Macau is positioned as an international the neuroprotective components from TCM base for quality control and quality develop-

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