maryannewaweru

A Kenyan Journalist Writing About Health

Archive for the month “March, 2014”

Kenya on Awareness Campaign to Increase Uptake of Iron and Folic Acid in Pregnant Women

When Scholastica Kasyoka conceived her first child six years ago, she was elated at the thought of becoming a new mother. To ensure that all would be well with her pregnancy, she immediately started her antenatal clinics at a health facility near her home in Kayole, Nairobi.

During her initial ANC visits, she was given iron and folic acid tablets and was told to take one tablet each day. These tablets, she was told, would help her have a healthy pregnancy and healthy baby. And indeed, Scholastica took one tablet daily -as instructed. But just for a while, for a few days later, she stopped.

“I would feel very sick every time I swallowed them. I would feel nauseated, weak, and would many times vomit. Hard as I tried to keep up with the tablets, I just could not. So I stashed them away and carried on with the pregnancy,” she remembers.

Nine months later, Scholastica gave birth to a baby girl. But something was wrong. The nurses told her that her newborn had a problem.

“They said my daughter’s spinal cord was not well formed,” she recalls of the disheartening news that cut short her celebrations as a new mum.

Scholastica Kasyoka. Her daughter was born with spina bifida --a neural tube defect.

Scholastica Kasyoka. Her daughter was born with spina bifida –a neural tube defect.

Scholastica was later to leant that her daughter had spina bifida. She had never heard of spina bifida; she had no idea what it was.

“The nurses told me that my baby was born with a deformed spine because I had stopped taking the iron and folic acid tablets I had been given,” she remembers.

Spina bifida is a neural tube defect characterized by the incomplete development of the brain, spinal cord, or the protective covering around the brain and spinal cord.

Anne Mulwa, a clinician at Bethany Kids Hospital –hosted by the AIC Kijabe Hospital in Central Kenya, says that in some cases of children with spina bifida, part of the contents of the spinal canal protrude through the spinal column. Spina bifida may lead to disability.

“Spina bifida may cause difficulties with bladder control, and can lead to paralysis at the point where the bifida is highest. Depending on the severity of the deformity, people with spina bifida may be paralyzed or may have challenged mobility,” she says.

Bethany Kids Hospital is one of the largest referral hospitals in Kenya for children with disabilities and who need surgical intervention. The highest numbers of referrals are those of neural tube defects. From its inception in 2004 to the year 2012, Bethany Kids conducted a total of 14,333 surgical procedures. Operations on children with neural tube defects accounted for more than half (51%) of the total surgeries. Scholastica’s daughter Grace, is among these statistics.

Bethany pie 2_img_0

Though the exact cause of spina bifida is not known, research suggests that lack of enough folic acid in the pregnant woman’s diet, more so during the first trimester when the spinal cord is being formed as a key factor in causing spina bifida and other neural tube defects. Folic acid is particularly essential before the woman gets pregnant –and within 28 days after conception.

Esther Kariuki, a nutritionist with the Micronutrient Initiative says that women, especially those in the childbearing age should make it a habit to eat foods rich in iron and folic acid, and where necessary, boost this with recommended supplements. Some of the foods that contain high amounts of these essential nutrients, Ms. Kariuki says, include; liver, meat, green leafy vegetables and fruits rich in citric acid.

“Neural tube defects happen in the first few weeks of pregnancy; usually before a woman even knows she is pregnant. It doesn’t help matters that many pregnancies are unplanned, so by the time she realizes she’s pregnant, it could be too late to prevent these birth defects.” she says.

Women who have had prior pregnancies that resulted in babies with spina bifida or other neural tube defects are also at a high risk of having a subsequent similar pregnancy. Ms. Mulwa adds that such women are advised to take folic acid even when they are not pregnant.

It is for this reason that Scholastica was put on folic acid supplements after she delivered her daughter, even though she was not sure she wanted to have a baby again –not with the problems she was facing with her daughter -a child who would need lifelong care because of her disability.

Various fruits and vegetables are rich in iron and folic acid.

Various fruits and vegetables are rich in iron and folic acid.

The World Health Organization (WHO) recommends daily iron and folic acid supplementation for pregnant women. The recommended daily dose is 60mg of iron, and 0.4 mg of folic acid. Doing so reduces the risk of having a pregnancy affected with spina bifida or other neural tube defects, reduces the risk of having babies with low birth weight and iron defects. The supplements also reduce the risk of maternal anaemia.

Kenya’s Ministry of Health has been implementing the WHO recommendation of daily supplements for pregnant women through its antenatal care strategies. However, the current uptake and adherence rates of iron and  folic acid supplements among pregnant women has been low, according to Ms. Evelyn Kikechi, a nutritionist at the Department of Nutrition. This could be due to a combination of many factors.

One of them is pregnant women’s failure to follow the instructions given to them about taking the tablets.

“When the women are given the supplements during their ANC, many of them stop taking them once they start experiencing side effects. The side effects include nausea, vomiting, a general feeling of weakness as well as a taste of ‘metal’ in the mouth”.

Ms. Kikechi aptly describes some of the side effects that Scholastica experienced, which made her stop taking the supplements. Many women, Kikechi says, do not understand the importance of these supplements. It also doesn’t help that women delay their first ANC visit, thereby missing out on the opportunity to be given the supplements in their first trimester.

A mother and her child at Bethany Kids Hospital. The child has spina bifida.

A mother and her child at Bethany Kids Hospital.

Some religions don’t allow visits to hospitals or taking of ‘Western’ medicine, thus women don’t visit ANC clinics –missing out on opportunities for the needed supplements. Pregnant women are also reluctant to vist ANC because they fear they will get tested for HIV. Others are not able to attend ANC clinics because the health facilities are far off, and they may not have money for transport. Getting to the health facility is therefore not a priority –over tilling the land and preparing meals for their families.

According to the 2008-09 KDHS, less than half (47%) of pregnant women make four or more ANC visits and only 15% access antenatal care while in the first trimester of their pregnancy. The report adds that about half (52%) receive care before the 6th month of pregnancy. The median number of months of pregnancy at first visit is above the first trimester –at 5.6 months.

Some cultural practices also stand in the way of women accessing iron and folic acid supplements. Some communities prescribe certain herbs and specific soils and stones to the pregnant women, claiming these are sufficient enough to enable them have healthy babies. But this is not always the case, where infact, eating the soils and stones could lead to even bigger health problems for the woman.

Another reason for the low uptake of iron and folic acid supplements by pregnant women is some health provider’s limited understanding on the reason for giving their clients the supplements.

Kenyatta National Hospital. The government is sensitizing all health workers on iron and folic acid supplements for pregnant women.

Kenyatta National Hospital. The government is sensitizing all health workers on iron and folic acid supplements for pregnant women.

“Because some health providers in the ANC clinics do not have a clear understanding of the importance of these supplements, they fail to give the pregnant women sufficient information on the same. They do not stress on the need for these women to take these tablets, so the women do not take it seriously either,” Ms. Kikechi says.

According to her, all staff at public health hospitals are currently being sensitized on the need to inform women on the importance of iron and folic acid supplements, and give them to every pregnant woman who visits an antenatal clinic. The government, in collaboration with other partners and stakeholders is also engaged in various awareness campaigns, including the use of mass media to pass on messages of the importance of iron and folic acid supplements.

But the government too has its contributory role in the low uptake of these iron and folic acid supplements among pregnant women.  A Kenya Service Provision Assessment (KSPA) survey done in 2010 showed that not all government facilities were stocked with these supplements. Only 2 out of every 5 health facilities had iron tablets, while 74% had folic acid tablets.

In addition, for facilities that stocked the supplements, there were frequent stock-outs, caused by among others: communication breakdown between facilities and depots, low prioritization of IFA supplements by government, differences in forecasting by different MOH units, and inadequate budget allocation.

Even further, the current country policy on iron and folic acid supplementation requires that all pregnant women be given these supplements whether they have been screened for anaemia or not. However, current practice at the facility level is that health workers insist on screening pregnant women for anaemia before prescribing the tablets. This is despite statistics from the 2010 Kenya Service Provision Assessment (KSPA) showing that just about 36% of ANC facilities have the capacity to test for anaemia –thereby denying supplements to the ‘eligible’ target group.

A happy mother with her healthy child.

A happy mother with her healthy child.

To reduce the health burden of the country, stringent efforts to educate the public, especially women, on the essentials of good maternal and child health is of utmost importance. If Kenya is to achieve MDGs 4 and 5, then it needs to seriously pull up its socks. Creating awareness on the importance of iron and folic acid supplements to childbearing women and health workers, as well as policy makers will go a long way in reducing the number of children born with birth defects.

How Can I Prepare for a Healthy Pregnancy?

Are you planning on becoming pregnant? Do you know what measures you should be taking to ensure that you have a healthy pregnancy and a healthy baby?  Our guest writer today tells us more on this.

By Dr. Stephen Mutiso, Consultant Obstetrician/Gynaecologist

A healthy pregnancy culminating into birth of a healthy baby is the ultimate desire of any mother. The outcome of any pregnancy is determined long before conception. To optimize pregnancy outcomes, it is important to have good health prior to conceiving.

Achieving good health before pregnancy includes adopting a healthy lifestyle. A healthy eating habit ensures you have adequate nutrients such as folic acid –which are important for baby’s good growth.

Diet rich in fruits and green vegetables provide high levels of micronutrients, hence should be encouraged to be taken by women contemplating getting pregnant. Weight reduction for those who are obese is important as obesity is associated with bad pregnancy outcomes. Ceasation of smoking and alcohol and other substance abuse is critical as these substances are harmful to the growing baby.

In addition to lifestyle changes, it is important to have a health check up by your gynaecologist before getting pregnant. This health checkup usually 3 months before conception, and is called preconception care. The goal of preconception care is to provide the woman with the best chance of a having a healthy pregnancy and a healthy baby. Preconception care involves review current and past medical and pregnancy history, physical assessment and laboratory testing to screen and detect any new and pre-existing diseases. If you have any chronic disease, it is important to inform your doctor. Any new or preexisting diseases must be treated or controlled well before pregnancy.

Education and counseling are important services offered during preconception care. Key topics usually covered include diet, HIV and other STDs, smoking and alcohol cessation. Folic acid supplementation is also provided during preconception care.

Chronic medical diseases which may affect pregnancy include: diabetes, hypertension, asthma, heart diseases, obesity, hypothyroidism, sickle cell anemia, HIV, Hepatitis, Venous thrombosis, kidney disease and epilepsy. Chronic medical diseases should be put under control before becoming pregnant. In some cases, a change in treatment may be needed because some medications are harmful to the baby.

Preconception care therefore is not a luxury but a very key intervention to improve pregnancy outcome. It’s very necessary for every woman regardless of age and number of previous births. If you’re planning to get pregnant its important you adopt a healthy lifestyle as well as schedule an appointment you’re your gynaecologist.

Dr Stephen Mutiso is based in Nairobi, and he provides a wide range of gynecological services, including; antenatal services, delivery, Vaginal Birth after Caesarean (VBAC), Obstetric Fistula, Infertility issues and Fibroids among others. He has admission rights in various private hospitals.

He is based at Kenyatta National Hospital Doctors plaza, Suite 26/27

Telephone: 0722 678 002 or 0788 306 674

Email: mutisoh@yahoo.com   —    Website: www.drmutiso.com

What Happens to a Kenyan Woman’s Family After She Dies While Giving Birth?

Every two hours in Kenya, a woman dies during pregnancy or childbirth. Quite unfortunate.

A new report on maternal health in Kenya has further amplified the devastating impact of a mother’s death on her family and in her community. The study, titled: ‘Price Too High to Bear’, reveals that that the unfortunate deaths of these women (mostly preventable), gravely affect her immediate family, the survival of her newborn, the health and opportunities of her surviving children, as well as the economic productivity of her family and her community.

The report by Family Care International (FCI), the International Center for Research on Women (ICRW), and the KEMRI/CDC Research and Public Health Collaboration in cooperation with Kenya’s Ministry of Health highlights the financial costs of the deaths of mothers in poor remote communities on their households, as well as the impact of these costs on family well-being.

The study was done in three sub-counties in Western Kenya (Rarieda, Gem and Siaya town -all in Siaya County) between 2011 and 2013. These were the following key findings:

The loss of a mother harms her surviving family members, her children’s health, education, and future opportunities.

The report states that of the 59 maternal deaths in the study, 14 women died during the last three months of pregnancy, one died during labour, and 44 died post-delivery. It is also important to note that over 70% of the maternal deaths occurred in the course of a normal delivery, while the remaining ones who died had experienced a caesarean section, use of forceps, or other intervention during delivery.

The link between maternal death and high neonatal mortality was also demonstrated:

Of the 59 women who died, 31 infants survived delivery. Of these, 8 died in the first week of life, with another 8 dying in the next several weeks. This left a total of only 15 surviving babies from 59 pregnancies.

In most of the households, the women who died used to carry out various tasks in their homes. These women used to contribute an average of 61 hours of household work each week, with tasks including; childcare, cooking, laundry, and fetching water and firewood. Following their deaths, the women’s husbands, mothers-in-law, older children, or other surviving family members had to pick up the slack, with 88% of families reporting that this had reduced these members’ ability to contribute earnings to household income.

Some of the deceased women were also involved in farming. For these, their deaths in some cases forced the household to allow land to lie fallow, or to cultivate fewer crops. Some families indicated that they had lost crops after the death of the woman, because surviving household members were not able to allocate to farming the time they had when the woman was alive.

A mother carries her son on a farm in rural Kenya.

For the surviving school-going children, they were in some cases withdrawn from or forced to miss school, because economic disruptions made it difficult to afford school fees. The household could no longer afford to pay the school fees, because the mother’s income was not available any more. Even when there was some money, it was used to hire casual farm labour.

Where children continued their schooling, often their grief and new household responsibilities negatively affected their schoolwork. In a number of cases, families reported that children withdrew from school altogether. Others who remained in school often had less time for schoolwork — and less time to actually attend school due to the additional household chores and because they had to take care of their younger siblings.

Social, emotional and other non-­economic consequences

In many parts of Western Kenya –where the study took place, a ‘household’ is made up of all those who eat under the same roof. Before the mother’s death, majority of individuals in the household ate in the woman’s home. But after she died, only about a quarter of individuals from her household continued eating in her house. Of those who changed where they had their meals (most of them children aged below 18 years), they said they did so because of the death of the mother. In most cases, children began taking meals in the home of their grandmother. Other children were removed from household and given out to relatives for foster care.

When a woman dies, her funeral costs are a crippling hardship for her family.

Funerals are a big deal in Africa, and Kenya is no exception. Many communities strive to give their departed relatives a ‘grand, respectable’ send off which could see them spend huge amounts of money. Across all wealth levels of households interviewed, families’ funeral costs exceeded their total annual expenditure on food, housing, and all other household consumption. On average, economically active members took a month off from work during the funeral period. Given the already high costs of the funeral, this lack of economic activity is an additional burden for the household.

A mother selling potatoes by the roadside in rural Kenya.

Those are just some of the key findings of the study. Indeed, it only goes to show that Kenya continues to have a high maternal mortality rate, despite commitment from the government to address the issue. It only means that the country needs to pull up its socks in reducing maternal mortality rates. Meanwhile, 2015 is just around the corner, and I wonder if my country will be able to achieve MDG5, that of reducing maternal mortality.

I can only hope for the best.

A Difficult Pregnancy and Premature Twins Inspired A New Venture

Her twins were due on 20th July 2013, but they came early -on 29 April 2013. It had been a difficult pregnancy right from the beginning, as she experienced heavy bleeding, severe cramps, had an open cervix…until doctors recommended that she undertakes a cervical stitch if she wanted to save her babies. She is Maryanne Kariuki, and it is this experience that led her to begin her own personal initiative, the A & J Initiative. Read more….

Maryanne_Kariuki with her twins Avie and Jamie.

Maryanne_Kariuki with her twins Avie and Jamie.

The Condom Message in Kenya’s Safe Sex Campaigns: Has it Reached Female Sex Workers?

Due to the nature of their work, the risk of female sex workers acquiring or transmitting HIV to their clients is quite high. The Kenyan government, together with other stakeholders have over the years been engaged in safe sex campaigns targeting these women. The promotion of consistent condom use is one of the messages passed on. Have these messages reached and possibly influenced female sex workers? Here are some details of a conversation I had with one such sex worker in Nairobi. 

By Maryanne Waweru-Wanyama

Every evening, 35 year-old Susan Wangui welcomes home her four children from school. An industrious mother, she ensures they take their bath, supervises them as they do their homework and have their dinner. When they are well settled for the night, she bids them goodbye and leaves for work. Her children –three girls and a boy, are aged between three and eleven years. While away at work, the eldest child, a girl, watches over her siblings. They live in the slums of Huruma in Nairobi.

In the early morning, just before sunrise, Susan returns home to her children. She makes their breakfast and prepares them for school. Once all the children leave, she cleans the house and does their laundry before heading to the market to buy food for their dinner. In the evening, the routine is repeated.

Susan’s children believe she works in a bar in Nairobi’s central business district. But the truth is she is a commercial sex worker. Her base is in one of the streets in downtown Nairobi, around the Muthurwa area. Unlike many other sex workers, Susan does not roam the streets looking for clients. Her ‘office’ is in one of the bars in a dingy street, where she strategically positions herself as she slowly sips a drink. Clients know how to spot her kind, and she too knows how to spot those who need her services.

It is a job she has been doing for the last 10 years, one that she is proud of.

“I enjoy this job as it is what enables me to put food on the table for my children,” says the single mother. She makes about 8,000 shillings a month, which she says is sufficient enough to put a roof over her children’s head, feed and clothe them.

Female sex worker Susan Wangui during the interview.

Female sex worker Susan Wangui during the interview.

Susan’s entry into the flesh trade business was as a result of desperation.

“I had searched for a job for a very long time, without any success. I found myself always borrowing money from my friends to feed my children. One day, my neighbour asked me:

“Why are you always asking us for money, yet you are a woman like us? Come I show you how to make easy money.”

Susan, a class 8 drop-out then accompanied her friend to town and was immediately introduced to a client, whom she ‘serviced’. And that marked her debut into the flesh trade. A decade later, she has no regrets.

Each night, Susan attends to between three to seven clients, charging between 200 – 300 shillings for each. On very few lucky occasions, she gets a client who pays 1,000 shillings. Each day, she is assured that she will have money to buy food for her children. Food is cheap in the slums, and with 100 shillings, one can comfortably feed a family of six. It does not matter if the meal is a balanced one.

Despite Susan’s love for her job, she is aware of the risks she faces as a sex worker.

“There is the scare of violence – from clients who want to rape you, as well as harassment from police and City Council officers.”

Susan and other sex workers also face the risk for HIV, Sexually Transmitted Infections, unwanted pregnancies and a myriad of other health problems such as pneumonia.

A fact acknowledged by Dr. George Githuka, Programme Manager for key populations at the National AIDS and STI Control Programme (NASCOP).

“Female sex workers are what we call a high risk group due to their behaviour. What I mean is that if she has several clients in a day, she can easily acquire or transmit HIV. If she is HIV negative, she runs the risk of acquiring HIV. If she is HIV positive, she runs the risk of transmitting HIV to her clients.”

Dr. George Githuka of NASCOP talking about the  interventions the government is undertaking with regard to key populations such as female sex workers in Kenya.

Dr. George Githuka of NASCOP talking about the interventions the government is undertaking with regard to key populations such as female sex workers in Kenya.

Even more vulnerable is the contribution of social laws and legislations that make it harder for them to do their work.

“The stigma and discrimination that female sex workers face makes them hide the true nature of their work. Most of their activities are also criminalized, making it difficult for them to access health services, and also making it difficult for health workers to access them. This means services that would help reduce their vulnerability to HIV infection do not effectively reach them,” he adds.

Behaviour Change Programs

According to UNAIDS, review of data in 50 countries showed that 3 out of every 25 female sex workers were HIV positive. Further, the chance of women who engage in sex work being infected with HIV is 13.5 times higher than others.

A 2009 Modes of Transmission study found that in Kenya, sex workers contribute to 14.1% of all new infections at a national level.

It is such figures that the Kenyan government, in recent years, has embarked on programmes that target this population. The Ministry of Health, through NASCOP has initiated various interventions.

“In the past, health services were not tailored to be responsive to the health needs of sex workers. NASCOP’s Most at Risk Populations (MARPS) program is aimed at addressing this gap. We offer targeted interventions that are in tune with their needs, such as advocating for their free access to condoms, as well as advocating for their free HIV testing every three months. We also emphasize on STI screening each time a sex worker visits a hospital, and subsequent treatment offered where necessary,” says Dr. Githuka.

Other players complementing and collaborating with the government in these efforts are those in the private sector.

One such programme is the Sex Workers Outreach Programme (SWOP). Run by Kenya’s University of Nairobi and Canada’s University of Manitoba, SWOP is a sex workers’ health project that promotes the health and safety of female sex workers. It does so by providing them with comprehensive reproductive health services, including HIV/AIDS services. It also educates them on the benefits of consistent and correct use of condoms.

Susan is a regular client at SWOP’s Nairobi clinic. She has attended a number of workshops and she has accessed various reproductive health services at SWOP.

“When I started sex work 10 years ago, I was not keen on condom use. I did not know much about condoms, and did not insist much about using them with my clients. But over the years, I have come to realize their value. This was after my friends and I were introduced to SWOP four years ago by a community health worker in my Huruma neighbourhood,” she says.

More Money for Unprotected Sex

Today, Susan does not compromise on condom use.

“My clients must use a condom. I don’t know them or where they come from, so I cannot accept that we have sex without protection,” she says.

According to the World Health Organization (WHO), male latex condoms have an 85% or greater protective effect against the sexual transmission of HIV and other sexually transmitted infections (STIs).

Susan often comes across clients who refuse to use a condom, and instead offer her a handsome amount of money.

“For me, a condom is a must. When someone offers me double or triple the amount, I always ask myself why. What is his motive for doing so?”

She says despite the enticing offer, she never gives in.

“I would rather get paid 200 shillings for using a condom, than 2,000 shillings for not using one. What will happen to me tomorrow if I take that 2,000? I may not live to see my children go to secondary school. No, that I cannot accept,” she says.

Regular Clients

Susan has no regrets about losing a client who refuses to use a condom.

“There is no day I can miss a client. God always has good plans for me because he knows I need to feed my children, so I don’t pine over losing such a client,” she says.

With a career spanning over ten years, Susan has formed a clientele base of regular customers, some of whom she has offered her services for many years. Among them are married men, who often call her when in need. But despite the good ‘business relations’ she has with them, Susan insists on using condoms with these clients too.

“This is a business, this is not love. He is not my husband, so we must use protection,” she says.

A condom dispenser in a health facility, where those who need condoms can get them for free.

A condom dispenser in a health facility, where those who need condoms can get them for free.

Challenges Accessing Condoms

Susan gets her condoms from SWOP, some health facilities, or at the numerous toilets around town that stock condoms in the condom dispensers. She picks as many as she can, sometimes even boxes at a go. While Susan may not have problems accessing condoms, NASCOP acknowledges the difficulties some sex workers get while trying to get them.

“Condoms are available from public hospitals. While it is normal for someone to pick two or three condoms, a sex worker may need to pick a whole box of them. However, when they attempt to do so, they face questioning from the hospital staff, with some being told to return the box and instead ‘just pick a few’,” says Dr. Githuka. 

Susan however says that sometimes there are no condoms in public health facilities, which inconveniences her when she really needs them. During the world condom day on 13 February 2014, NASCOP assured all Kenyans of enough condom stock for anyone who needs them.

“We have about 100 million condoms in stock right now. Kenyans consume about 150 – 200 million condoms annually. This means that we are fully covered for the next 6 – 8 months,” said Dr. Martin Sirengo, Head of NASCOP.

Alcohol and Sex Work

As one who says that she insists on condoms, how does Susan introduce the issue to her clients?

“In this job, you have to drink alcohol. It is not possible to do this job while fully sober. That is why I must take a little alcohol to boost my confidence, but careful not to make me drunk. That way, my shyness evaporates and I am able to undress and have sex with a stranger. But I make sure I’m not drunk enough to forget to ask my client to use a condom.”

In an assessment of alcohol use among female sex workers in Western Kenya, researchers, led by L. C. Langat found that excessive alcohol intake was prevalent in the sex workers who were interviewed, with majority of them presenting indications of alcohol dependence. The researchers established that female sex workers consume alcohol as a coping mechanism in their work, and in response to stigma associated with the business.

A UNAIDS 2012 report showed that more than 60% of female sex workers interviewed had used condoms in the last 30 days with a paying customer. Preliminary results of the latest Kenya AIDS Indicator Survey shows a decline in Kenya’s HIV prevalence rate over the last five years. According to this report, the prevalence rate had dropped from 7.2 percent in 2007 to 5.6 percent in 2012. This achievement can be partly attributed to an increase in education and awareness campaigns –both by the government and the private sector. It appears that Susan is one such beneficiary of these stringent efforts.

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