A 32-page
Private Eye
special report, 'MMR: the story so far' by Heather Mills,
offers 'a comprehensive review of the MMR vaccination/autism
controversy' - from the perspective of Dr Andrew Wakefield,
the gastroenterologist at the centre of the controversy (1).
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Dr Wakefield's choice of a popular
satirical magazine and a journalist with no background in
science to present his case in a major scientific
controversy may seem curious. It confirms his maverick
status, but it also undermines his claim to be taken
seriously - even as a maverick. It also raises questions
about the roles of the medical establishment and the media
in the continuing MMR-autism panic.
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The history of science and medicine
provides many examples of dissidents and heretics,
individuals who challenged conventional wisdom, suffered
condemnation and rejection - or worse - only to be
ultimately vindicated.
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The gastroenterologist Barry Marshall is a
recent example. When he first suggested in 1983 that the
underlying cause of the excessive acid secretion that causes
peptic ulcers was a chronic infection with the bacterium
Helicobacter pylori, he was met with derision. He was, after
all, an Australian junior hospital doctor and his hypothesis
flew in the face of conventional wisdom.
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Yet, within two years he had confirmed it,
in part by staging a dramatic demonstration of drinking a
solution of the bacterium, producing inflammation of his own
stomach - confirmed by gastroscopy - and subsequently
treating this (2). Marshall showed that Helicobacter was at
the root of a range of diseases, including gastric and
duodenal ulcers and stomach cancer, and he showed that its
eradication (by a simple drug regime) produced dramatic
results.
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Mavericks who prevail against orthodoxy
have to pass two tests. They have to substantiate their own
hypotheses; and they have to convince their peers that they
are right. Whereas Marshall spectacularly passed both tests
between 1983 and 1985, since 1998, when Dr Wakefield first
published his hypothesis that MMR may cause inflammatory
bowel disease, which in turn may cause autism, Dr Wakefield
has singularly failed to pass either test.
Where's the evidence?
The core of Dr Wakefield's case is that, in some children,
the MMR immunisation provokes inflammation of the small and
large bowel - enterocolitis - and that this causes toxins to
leak into the blood stream. These toxins then pass into the
brain, producing damage that is manifested as the clinical
picture of autism (3).
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Dr Wakefield has failed to
persuade his medical colleagues of his case against MMR |
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Though Dr Wakefield has published several
papers since 1998, none provides significant evidence for
his central hypothesis. For example, a widely publicised
paper produced jointly with the Dublin-based virologist John
O'Leary claims that measles virus particles have been
discovered in the bowels of children with autism (4).
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This paper does not indicate whether the
children studied had received the MMR vaccine or whether the
virus particles were the same as those in the MMR. Even the
authors admitted that it shed no light on the question of a
link between MMR, bowel disease and autism.
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Far from working exhaustively on his core
thesis, Dr Wakefield seems to have concentrated his energies
on secondary issues, such as the surveillance for adverse
effects following the introduction of MMR in Britain, and
the controversy over the increased prevalence of autism (5).
Studies in these areas have taken Dr Wakefield beyond his
own sphere of professional competence - gastroenterology -
into epidemiology, public health and autism in which he has
no particular experience or expertise. These studies have
failed to provide support for the MMR-bowel disease-autism
link.
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Dr Wakefield has conspicuously failed to
persuade his medical colleagues of his case against MMR. A
number of expert review groups have analysed the published
work and some have received oral presentations from Dr
Wakefield and his colleagues. The UK Medical Research
Council (MRC) has produced three separate reports, in March
1998, April 2000 and December 2001. Other studies have been
conducted by the American Medical Association, the Institute
of Medicine (USA), the World Health Organisation, the
American Academy of Paediatrics, the Canadian Public Health
Body and the Irish Department of Child Health.
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According to the survey published by the
MRC in December 2001, these reviews were 'unanimous in their
conclusions that a causal link between the MMR vaccine and
"autistic colitis" and autistic spectrum disorders was not
proven and that current epidemiological evidence did not
support this proposed link' (6).
Ducking the debate
The recent MRC autism review assembled many of the leading
authorities in the field in Britain, as well as involving
people with autism and advocacy groups, and produced a
comprehensive report on the current state of medical science
on the subject. For any scientist confident in an
alternative theory of autism, this inquiry offered an ideal
forum in which to present his research and make his
reputation. Yet Dr Wakefield turned down an invitation to
submit his case to the MRC.
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According to the
Private Eye
report, this was because some members of the review had
agreed to advise the vaccine manufacturers in litigation
brought by groups of parents who believe that the MMR
vaccine caused their children's autism. These include
Professor Michael Rutter, arguably Britain's leading child
psychiatrist over the past 20 years, and Dr Eric Fombonne,
an internationally respected clinician and epidemiologist in
autism.
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A journalist is incapable
of evaluating Dr Wakefield's scientific work |
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The MMR court cases are largely the result
of the efforts of lawyers advised by Dr Wakefield (and
parents encouraged by his claims). Once these actions were
underway, it was inevitable that the vaccine manufacturers
would seek advice from leading authorities in the field -
such as Rutter, Fombonne and the others. These have only
become advisors to the drug companies because of the
allegations against MMR. Dr Wakefield's explanation for his
refusal to make a submission to the MRC seems more like a
pretext to avoid an open debate with his peers.
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The
Private Eye report repeatedly refers to leading autism
specialists as 'advisors to the drug companies', as though
this impugns their professional integrity. However, it
neglects to inform readers that the epidemiologist Professor
Walter Spitzer, who provides
pro bono advice
to the litigants, is also a shareholder in Glaxo and Merck -
as he informed the MRC review. Indeed, given the fact -
included in the
Private Eye report - that some 90 percent of authors in
leading medical journals receive some funding from drug
companies, refusing to discuss with anybody receiving such
funding would drastically curtail medical debate.
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No doubt there are problems arising from
the role of the drug companies in medical research, but
these are not peculiar to vaccines. Indeed, they have little
impact on the world of autism, where drug treatment is very
limited.
Playing to the
gallery
Though he has yet to substantiate his own hypothesis or
convince his peers that the link between MMR and autism is
anything more than speculation, Dr Wakefield has, in a
series of newspaper and TV interviews, taken his case to the
general public.
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Dr Wakefield has a history of courting the
press. As early as 1995 his photograph appears in a lengthy
anti-MMR feature in the
Sunday Times
(London) magazine, in which his earlier (and subsequently
discredited) thesis of a link between MMR and Crohn's
disease is quoted. It seems that parents of autistic
children first began to make the link with MMR in response
to this and similar articles in the mid-1990s, and brought
their children to Dr Wakefield's clinic at the Royal Free
Hospital in North London.
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Following the press conference to launch
the February 1998 paper, all the headlines went to Dr
Wakefield's call for giving the MMR as separate vaccines -
an issue not raised in the paper itself and not supported by
any of his co-authors. In April 2000 he attracted attention
by presenting unpublished data to a congressional inquiry in
Washington, DC. The launch of Dr Wakefield's paper
criticising the introduction of MMR in Britain in January
2001 (in a journal with a circulation of 350) was staged by
the medical research charity Visceral, of which Dr Wakefield
was then a trustee and is now an employee. It became a media
circus (7).
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Dr Wakefield has received sympathetic
coverage in most of the broadsheet newspapers and on several
TV programmes. A special edition of the BBC's flagship
current affairs programme
Panorama in
February 2002 provided a major boost to the controversy, by
reporting details of Dr Wakefield's then unpublished
Molecular Pathology
paper, which claimed the presence of measles virus in the
bowels of autistic children.
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Of all prejudices, the most
ancient is commonsense |
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And now we have the
Private Eye
special, in which Dr Wakefield's case is presented through
the medium of a journalist who, we are told, has been 'specialising
in home and social affairs' for more than 20 years. Heather
Mills provides a hagiography of Dr Wakefield as a pioneering
researcher who, having discovered the cause of Crohn's
disease (this will be big news in the world of
gastroenterology), is now making major strides towards
revealing the cause of autism (strides unrecognised in the
world of autism). Mills offers a detailed account of Dr
Wakefield's case against MMR, even doughtily settling a few
scores on his behalf against his detractors.
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The problem here is that, whatever her
journalistic skills, Ms Mills is incapable of evaluating Dr
Wakefield's scientific work. Take, for example, his most
recent paper, entitled 'Small intestinal enteropathy with
epithelial IgG and complement deposition in children with
regressive autism' (8). No, I don't know what this means
either, and I have studied immunology.
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This article is published in the journal
Molecular Psychiatry,
whose readers are 'researchers and clinicians involved in
neuroscience, psychiatry and areas allied to psychiatry
including neurology, neurosurgery imaging and psychology'.
This certainly excludes me and Ms Mills: in fact, there are
probably only a few hundred people in the country capable of
making an informed judgement on the significance of Dr
Wakefield's findings.
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(Though I could make little headway with
Dr Wakefield's article, I was struck by the accompanying
editorial comment that 'there have been suggestions of
autoimmune involvement in essentially all psychiatric
disorders, including schizophrenia, depression and obsessive
compulsive disorder, but the data do not yet support final
conclusions. The field of psychiatry is plagued with the
issue of non-replication'.) (9)
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The selective presentation of findings
from research of this sort, according to the requirements of
an established line of argument, reduces science to
propaganda.
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Lacking scientific knowledge in any of the
spheres involved in the MMR/autism controversy, Ms Mills has
evidently put her trust in Dr Wakefield and her own
prejudices on the subject. Of all prejudices, the most
ancient is commonsense, which inevitably makes its
appearance: 'Commonsense suggests introducing one live
vaccine with the potential to suppress the immune system
must be safer than injecting three.' (10)
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Was it legitimate for the
Lancet to
publish Wakefield's 1998 paper? |
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To Pope Urban VIII in the seventeenth
century, it was both commonsense and a matter of faith that
the sun revolved around the earth. Galileo's scientific
discovery challenged both popular prejudice and divine
authority. Similarly, medical science defies the intuition
that a triple vaccine suppresses the immune system and
confirms that it is indeed safer than single vaccines (see
Myths of immunity, by Dr Michael Fitzpatrick).
Who's to blame?
Though Dr Wakefield has made negligible headway in
convincing the worlds of science and medicine of his
theories, he has had a major impact on public opinion. In
response to health panics such as that over MMR and autism,
the media are often blamed for scare-mongering. But as the
MMR/autism story illustrates, such scares often begin within
the medical-scientific establishment.
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The origins of this scare lie in Dr
Wakefield's decision to go public with his hypothesis of a
link between MMR and autism before he had either produced
evidence in support of it, or succeeded in persuading any
significant section of scientific or medical opinion of the
validity of his theory.
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A lesser, but not insignificant, factor
was the failure of the process of peer review to protect the
public from the adverse consequences of junk science. Was it
legitimate for the
Lancet to publish Wakefield's 1998 paper? Even though it
appeared accompanied by a critical commentary, the prestige
of the Lancet
gave the paper a legitimacy it would have been denied if it
had appeared in a specialist journal. Furthermore, the
recent trend for controversial articles in leading medical
journals to make headlines in the mainstream press, and to
circulate on the internet, guaranteed a major public impact.
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The paper's methodological flaws were
readily apparent: the selection bias resulting from the
subjects' attendance at the clinic of a well-known anti-MMR
campaigner; the recall bias arising from the parents'
recollection of the relationship between immunisation and
the onset of symptoms; the small number and heterogeneous
character of the cases; the lack of precision in the
diagnosis of autism. These errors, and the highly
speculative character of the paper's conclusions, made it
unsuitable for publication in a journal such as the
Lancet.
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Dr Richard Horton, the
Lancet's editor,
justified his decision to publish the article on the grounds
that, in the spirit of openness proclaimed in the Phillips
Report on the BSE/CJD debacle, 'full disclosure of new data
- subject to external peer review - is preferable to
well-meaning censorship' (11). But this was not an issue of
censorship, or of disclosure of data, though the fact that
the peer review process missed the manifest deficiencies of
the Wakefield paper is a cause for concern.
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The key question is whether an
authoritative medical journal should publish a paper that is
likely to undermine public confidence in the national
immunisation programme without substantiating a single link
in the proposed chain of causality between MMR and autism.
This paper caused great public anxiety and a fall in the
uptake of MMR - without advancing the scientific
understanding of autism one iota.
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It was nearly four years
before any member of the team broke the silence |
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It is also regrettable that Dr Wakefield's
immediate colleagues were so reticent in making their own
positions clear. Though, as it was widely pointed out, there
were more signatories to the February 1998 paper (thirteen)
than the number of children on whom it was based (twelve),
Dr Wakefield's co-authors remained aloof from the
controversy. While three paediatricians involved in the
study distanced themselves from the call for single
vaccines, it was left to another Royal Free paediatrician -
Professor Brent Taylor - to provide a comprehensive exposure
of Dr Wakefield's case.
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Apart from muted endorsements of the
national immunisation programme, it was nearly four years
before any member of the team broke the collective silence
(four years in which Dr Wakefield was highly vocal).
Finally, in February 2002, the most senior member of the
team, the eminent paediatric gastroenterologist Professor
John Walker-Smith, wrote to the
Lancet declaring
his personal confidence in MMR (12).
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In an attempt at even-handedness,
Professor Walker-Smith condemned the 'adversarial approach'
of the legal action against the vaccine manufacturers and of
some Department of Health officials towards Dr Wakefield.
(It would surely be considered reprehensible if such
officials failed to take an adversarial approach to
unsubstantiated claims that the national vaccination policy
was responsible for causing a devastating condition like
autism among thousands of children.) Professor
Walker-Smith's main point was the need for further research
to identify whether 'there are factors that may place a very
small but important group of children at risk' of autism.
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The notion of a subgroup of children
vulnerable to MMR is not advanced in the February 1998 paper
- it represents a fallback position adopted by Wakefield in
response to the weight of epidemiological evidence that MMR
could not be a factor in the vast majority of cases of
autism. But there is no better evidence for a vulnerable
subgroup than there is for total population vulnerability to
MMR (and if this subgroup corresponds to the number of cases
now pursuing litigation, it cannot be regarded as 'very
small').
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One might have expected the senior
clinician involved in the 1998 study to acknowledge that,
after four years, the further investigations called for in
the final paragraph of that paper had failed to confirm its
speculations about a 'chronic enterocolitis in children that
may be related to neuropsychiatric dysfunction', and the
link between the onset of these symptoms and the MMR
immunisation. While more research is always desirable,
further explorations of this hypothesis seem like throwing
good money after bad.
How the press
swallowed the maverick myth
The role of the media in health scares is generally
secondary to that of medical authorities (13). However, at a
time when there is a high level of popular anxiety about
health issues, the media plays an important role in
amplifying public concerns and reinforcing anxieties.
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In the current MMR-autism panic the way
the media has helped to politicise the controversy has
ensured that it has had a wider impact. This was most
apparent in the furore over whether the UK prime minister's
infant son Leo had been immunised, in which newspapers and
politicians tended to line up according to party loyalties.
The media has also encouraged the campaign for single
vaccines, which has been presented as an issue of choice and
rights - and was taken up in these terms by opposition
politicians.
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The press generally takes
Dr Wakefield at his own estimation |
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It says much about the degradation of the
concept of rights in contemporary society that some parents
are now demanding that the state subsidises their choice to
expose their children - and other people's children
irrespective of their parents' choices - to an increased
risk of infectious diseases. The major beneficiaries of this
scare have been private doctors who have skilfully exploited
public fears to boost their income.
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For all its sanctimonious posturing about
doctors who act as paid advisors to drug companies,
Private Eye
appears oblivious to the commercial interests of the private
GPs who have emerged as some of Dr Wakefield's staunchest
supporters. It is similarly indulgent of the lawyers who are
also great champions of Dr Wakefield's cause, and have
already earned more than £1million in legal aid funding.
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Perhaps the most striking feature of the
MMR-autism scare - well illustrated by the
Private Eye
special - is the media's uncritical acceptance of the myth
of Dr Wakefield as a maverick. Though this myth has been
assiduously promoted by Dr Wakefield, who appears to relish
his role as martyr to the medical establishment, his record
in defying scientific and medical orthodoxy is unimpressive.
Indeed his appeal to the public reflects his failure to win
over his peers. Yet Dr Wakefield is generally taken at his
own estimation, as a David ranged against the Goliath of the
medical establishment, who has suffered personal and
professional persecution as a result.
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It is true that Dr Wakefield's work has
been criticised by a number of medical authorities, and his
campaign against MMR has been vigorously repudiated by
various professional bodies that are concerned with
implementing the vaccination programme. But, given the
seriousness of Dr Wakefield's allegations, the absence of
scientific evidence for them, and the potentially dangerous
consequences for public health, the official response to him
has been remarkable for its restraint.
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In the past, health correspondents have
been criticised for simply parroting Department of Health
press releases and recycling articles from the medical
journals. Yet they now seem to have extended this uncritical
approach to a self-proclaimed maverick. A few awkward
questions to Dr Wakefield might shed more light on his
position than the sycophantic demeanour adopted by Heather
Mills and several earlier interviewers.
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If Dr Wakefield has made such dramatic
breakthroughs in his research into Crohn's disease, then why
is it that these are not generally recognised? Indeed why
has he now apparently abandoned that field entirely? If his
work on the MMR-autism link is a genuine scientific advance,
then why has this not been acknowledged by experts in this
field? If he believes he has made a significant
breakthrough, then why is he so reluctant to argue his case
with the experts? Why is it that other researchers have
failed to replicate his findings - in relation to both
Crohn's and autism?
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There has been much discussion of the
dangers of the anti-MMR campaign to public health. There is
little doubt that the publicity Dr Wakefield's work has
received has contributed to a decline in the uptake of MMR
over the past four years, with the consequence that
outbreaks of measles, mumps and rubella are now more likely.
Yet, perhaps because of Dr Wakefield's presentation of
himself as a champion of the families of children with
autism, there has been less attention to the problems that
this furore has caused to these families.
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In my surgery the mother of a boy recently
diagnosed as autistic told me how guilty she felt about
having allowed him to have the MMR. While self-deluded
scientists, lazy journalists, unscrupulous lawyers and
private GPs are ready to exploit her grief and anger, she is
not a step nearer understanding her son's condition, and
several steps further away from coping with it.
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Dr
Michael Fitzpatrick is author of
The Tyranny of
Health: doctors and the regulation of lifestyle. He is
speaking at the
spiked conference
After 11 September: Fear and Loathing in the West, on
Sunday 26 May at the Bishopsgate Institute in London. See
here for full details.
Buy The Tyranny of
Health (Routledge, 2000) from
Amazon (UK) or
Amazon (USA).
Read on:
spiked-issue: MMR
Myths of immunity, by Dr Michael Fitzpatrick
(1) 'MMR: The story so far',
Private Eye Special
Report, May 2002
(2) See James LeFanu,
The Rise and Fall of Modern Medicine, 1999, p177-186
(3) Wakefield AJ et
al (1998) 'Ileal-lymphoid-nodular hyperplasia,
non-specific colitis, and pervasive developmental disorder
in children', The
Lancet 351: 637-41
(4) Wakefield, AJ et
al, 'Potential viral pathogenic mechanism for new
variant inflammatory bowel disease',
Molecular Pathology,
2002, 55: 0-6
(5) Wakefield AJ and Montgomery SM, 'MMR vaccine: through a
glass darkly',
Adverse Drug Reactions and Toxicological Reviews, 2000:
19: 265-83
(6) MRC,
Review of Autism Research: Epidemiology and Causes,
December 2001, p28
(7) See Kamran Abbasi, 'Man, mission, rumpus',
British Medical
Journal, 3 February 2001
(8) Molecular
Psychiatry, 2002, 7: 375-382
(9) Licinio, J et al,
'Autoimmunity in autism',
Molecular Psychiatry
2002, 7: 329
(10) 'MMR: The story so far',
Private Eye Special
Report, May 2002, p31
(11) 'Nothing to Fear',
BMA News Review,
16 May 1998
(12) Lancet, 23
February 2002; 359: 637
(13) The Tyranny of
Health, Dr Michael Fitzpatrick, Routledge, 2000, p30.
Buy this book from
Amazon (UK) or
Amazon (USA)
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