This policy statement provides evidence that children are uniquely vulnerable to harm from exposures to environmental agents where they live, learn, and play. Children’s physical, physiological, and behavioral traits can lead to increased exposures to toxic chemicals or pathogens. In addition, their bodies are in dynamic stages of development, making them more susceptible to harm from these exposures. Cumulative risks, even at low doses, from other sources can compound the adverse effects of exposure to harmful chemicals or biological agents and necessitate concerted, intentional efforts to protect the youngest and most vulnerable. Moreover, the social determinants of health interact with these exposures to create increasing risk for further disparities among children. This policy statement calls for coordinated and comprehensive efforts to prevent environmental risks to all children to protect their health and well-being and urges agencies, public health practitioners, policymakers, community-based and environmental justice organizations, health economists, communication leaders, and researchers to advance policy and planning activities to address this need.
Relationship to Existing APHA Policy Statements
- Policy Statement LB-15-01: Opportunities for Health Collaboration: Leveraging Community Development Investments to Improve Health in Low-Income Neighborhoods
- Policy Statement 20157: Public Health Opportunities to Address the Health Effects of Climate Change
- Policy Statement 200011: The Precautionary Principle and Children’s Health
- Policy Statement 20137: Improving Health and Wellness through Access to Nature
- Policy Statement 20119: Reducing PVC in Facilities with Vulnerable Populations
- Policy Statement 201011: Reforming Primary Health Care: Support for the Health Care Home Model
- Policy Statement 20108: Requiring Clinical Diagnostic Tools and Biomonitoring of Exposures to Pesticides
- Policy Statement 201013: American Public Health Association Child Health Policy for the United States
- Policy Statement 20094: Ensuring the Achievement of the Millennium Development Goals: Strengthening US Efforts to Reduce Global Poverty and Promote Public Health
- Policy Statement 200914: Building Public Health Infrastructure for Youth Violence Prevention
- Policy Statement 20084: Calling for a Global Ban on Lead Use in Residential Indoor and Outdoor Paints, Children’s Products, and All Nonessential Uses in Consumer Products
This policy statement addresses children’s distinct relationship with their environment in order to convey the vulnerability of children’s health in response to toxic chemical, biological agent, and built environment exposures.
Children’s environmental health, which includes exposures and outcomes across the prenatal, infant, toddler, adolescent, and young adult life stages, has been identified by APHA, the National Institute of Environmental Health Sciences, the U.S. Environmental Protection Agency (EPA), and the World Health Organization as a critical focus area for the study of environmental health. As a result, APHA has led various projects on this issue. For example, recently APHA launched the “Environmental Public Health Systems: Protecting the Health of Our Children” project to study the current state of child health services available across the United States. APHA is conducting a 50-state scan and case studies to understand how the environmental public health system responds to the needs of young children and will use the results to highlight best practices and recommend improvements. However, until now no APHA policy statement has specifically described children’s health in relation to their environment. This statement demonstrates that children are uniquely vulnerable to environmentally mediated adverse health outcomes as a result of their developmental status, unique behaviors and traits, and immediate surroundings. Limited access to social and economic opportunities and lack of quality resources can increase a child’s vulnerability to toxicants and pathogens present in the environment. These vulnerabilities are heightened by the myriad health effects associated with climate change, a global phenomenon that disproportionately threatens the youngest and poorest.
Children disproportionately suffer adverse health and developmental outcomes resulting from unique relationships with their environments during development, a time when children differ markedly from adults in behavior and biology.[2–5] Extensive evidence shows how and why environmental stressors, toxicant exposures, and certain settings specifically affect children and how early-life exposures can affect the health and development of an individual throughout the life span.[2–5]
The prevalence of certain chronic diseases and developmental disorders in childhood has risen dramatically. More than 10 million children younger than 18 years are estimated to be diagnosed with asthma, about 14% of the population. An estimated one in six children had a developmental disability between 2006 and 2008; these conditions ranged from mild disabilities, such as speech and language impairments, to serious developmental disabilities, such as intellectual disabilities, cerebral palsy, and autism. Autism affects approximately one in 68 children, or 1.5% of the childhood population, and rates have been increasing according to assessments made between 2002 and 2010.[6,7] Attention-deficit/hyperactivity disorder (ADHD) has rapidly become one of the most prevalent neurodevelopmental childhood disorders. As of 2011, approximately 6.4 million children 4 to 17 years of age (11% of children in this age group) had been diagnosed with ADHD. Also, the Centers for Disease Control and Prevention notes the rapid increase in the prevalence of obesity: “The percentage of children aged 6–11 years in the U.S. who were obese increased from 7% in 1980 to nearly 18% in 2012. Similarly, the percentage of adolescents aged 12–19 years who were obese increased from 5% to nearly 21% over the same period.” Concurrently, we are witnessing rising trends in comorbidities such as type 2 diabetes, which increased approximately 21% from 2001 to 2009 in children between 10 and 19 years of age. Rates of cancer have remained relatively stable, yet trends show that the demographics of childhood cancer have been shifting to people of color, especially the African American population. Moreover, the types of cancer affecting children are shifting, with a higher prevalence of renal and thyroid cancer among children. Often, children who develop severe health effects from environmental exposures—such as worsening asthma symptoms exacerbated by poor air quality—miss more school days, which could result in diminished academic performance.
Chief among the environmental chemicals or substances that contribute to these conditions are lead, mercury, pesticides, combustion-related air pollutants, bisphenol A, phthalates, and polybrominated diphenyl ethers. For example, ADHD has been associated with exposures to lead, manganese, organophosphates, and phthalates[13–17]; lead and inorganic mercury are linked to the complex etiology of autism; and criteria air pollutants are linked to the development and severity of asthma. Exposure to these and other hazards occurs by eating contaminated foods or nonfood items such as dust, soil, and flaking paint chips; drinking contaminated beverages, including breast milk, and liquids not intended for consumption; breathing in contaminated air; and absorbing toxicants through the skin. As noted by the Agency for Toxic Substances and Disease Registry, “Children are at increased risk because of their increased exposures and increased vulnerability.”
During development, children’s behaviors and traits differ greatly from those of a mature adult, leading to greater exposures to certain toxic chemicals.[2–5,20–23] Before a child can walk, crawling occurs on ground surfaces, which may increase exposures to harmful chemicals found in soils and dust on carpets and floors.[3,18] With their innate curiosity, children, especially toddlers, exhibit hand-mouth and hand-object behaviors throughout development.[3–5,20] Also, children’s height places their breathing zones at lower levels than those of adults, leading to a greater risk of exposure to harmful chemicals that are emitted lower to the ground, are high-density pollutants, or exist as low-lying vapors. In addition, childhood is marked by rapid growth and development, with increases in physical size; complex, dynamic development of organ systems; and changing metabolic capabilities and behaviors. The physiological, metabolic, and behavioral aspects of the development of a child lead to an increased need for food, water, and air. This increased intake (per kilogram of body weight in comparison with adults) results in increased exposures to certain toxic chemicals. Finally, young children usually are unaware of environmental hazards and also lack control over their environments. They are powerless to reduce a harmful exposure or to remove themselves from a hazardous setting, and they are dependent on adults for protection.
Other physiological factors related to development increase children’s vulnerability to harm from these exposures. The EPA identifies these factors as a more permeable blood-brain barrier, less effective filtration in nasal passages, highly permeable skin, lower levels of circulation of plasma proteins, and the continuous development of the digestive system, metabolic pathways, renal clearances, and vital organs. The timing and dose of environmental exposures are critical in determining health outcomes, especially during the development of an organ or organ system, pathway, or behavior. “Windows of susceptibility” or “critical windows of exposure” define the period of time during which a child is most susceptible to a dose of an environmental agent.[3,5] Each identified developmental stage—prenatal, newborn, infant, toddler, prekindergarten, adolescence, and young adulthood—makes a child vulnerable to different environmental exposures. Prenatal care and, increasingly, preconception care are especially viewed as critical to risk reduction and healthy child development; the latter is of particular interest with respect to the developmental origins of health and disease paradigm.
In addition, the need for safe and healthy places for children to spend their time is of great importance for their physical and mental well-being. Urbanization has changed how children interact with the outside environment; children who live near high-density roads and polluting industries and who spend time outdoors may be exposed to elevated levels of harmful air pollutants. According to the American Lung Association’s State of the Air report, more than half of U.S. residents live in counties where the levels of ozone or particulate matter exceed national standards. In addition to air pollution, areas with an insufficiently built environment—including a lack of playground equipment, green space, or safe walking and biking paths—can limit children’s time spent outdoors. Moreover, the exercise or athletics available to a child or the time a child can dedicate to an activity may be further restricted due to water pollution affecting swimming, increased heat exposure affecting team sports, or neighborhood crime that discourages parents and caregivers from allowing their children to play outside. Children may be unable to commit to the recommended hour of physical activity per day as a result of these constraints. Indeed, there is a trend of decreasing physical activity among children—especially adolescents and teens—in the United States. Physical inactivity is the fourth-leading cause of global mortality.
Children living in rural, agricultural areas may be exposed to pesticide drift or to elevated levels of contaminants in unmonitored private drinking-water wells. Children living in sprawling suburbs of poor design may lack access to safe routes that facilitate walking and biking, encouraging indoor sedentary behavior and motor vehicle dependency, with their resultant health effects.
In addition, U.S. children spend most of their time indoors, in residences, schools, and child-care centers, where exposure to multiple environmental contaminants from various sources could produce acute or chronic health effects. Furthermore, indoor air quality in non-occupational settings is not regulated, so monitoring data on air pollutants in settings where children spend most of their time are scarce, and there are no enforceable standards to protect children. Pollutants may originate from an indoor source, such as environmental tobacco smoke, carbon monoxide from gas appliances or wood-burning stoves, indoor use of pesticides, poorly maintained interior lead paint, or volatile organic compounds emitted from resins in household furnishings or from cleaning products. In addition, outdoor pollutants may infiltrate the indoor environment: contaminants from workplaces, lawns, or streets carried inside on shoes and clothing; pollutants in pipes contaminating a building’s water supply; gases such as radon found in soil leaching through a building’s foundation; and motor vehicle exhaust being pulled inside through an air conditioner unit. Indoor pollutants can also be biological and include pet dander, mold, and pest excrement.
Children are exposed to an array of toxic chemicals from everyday consumer products, including antimicrobials such as triclosan, bisphenol A, flame retardants, heavy metals such as lead and cadmium, per- and polyfluoroalkyls, phthalates, and solvents. These chemicals are variously linked to increased risks of cancer, diabetes, obesity, and other chronic health conditions, and they can have adverse effects on development, reproduction, learning, and behavior. While everyone is exposed to these chemicals, the Centers for Disease Control and Prevention has detected higher levels of certain chemicals in children than in adults. For example, urinary levels of arsenic, chlorinated phenols, certain phthalates, and flame retardants and serum levels of triclosan, parabens, and the sunscreen chemical benzophenone-3 are higher in children than adults.
Significant evidence indicates that environmental conditions and social determinants of health play important roles in producing and maintaining health disparities.[4,26,27] Disadvantaged and minority communities face a greater likelihood of exposure to ambient hazards.[26–28] For example, African American communities are often located in areas zoned for mixed residential, industrial, or commercial use—areas at increased risk of toxic exposures—whereas predominantly White communities tend to be zoned strictly for residential use.[26,28–32] The Columbia Center for Children’s Environmental Health notes that “[l]ow-income neighborhoods bear a disproportionate share of pollution sources such as diesel bus depots, major commercial roadways, and deteriorated public housing.” Poorly maintained public housing can produce lead exposures, dampness and mold, and pest infestations.[26,28,31–36] Concurrently, minority neighborhoods tend to have higher rates of mortality, morbidity, and other health risk factors than White neighborhoods, even after economic status and other characteristics have been taken into account.[25,26,29] Children are especially vulnerable to the cumulative effects of toxic exposures to chemicals, stress, nutritional deficiencies, limited health care, substandard housing, and other factors associated with social or economic disparity. Those with multiple risk factors experience higher rates of illness and disability, particularly with respect to asthma, learning disorders, and ADHD.[6,32]
One effort to build awareness and action is the Coordinated Federal Action Plan to Reduce Racial and Ethnic Asthma Disparities. The plan, developed by the President’s Task Force on Environmental Health Risks and Safety Risks to Children, outlines problems created by disparities associated with social determinants of health. Aside from experiencing higher prevalence rates of disease resulting from environmental exposures, children facing disparities have increased environmental health burdens such as limited access to quality health care, low levels of health literacy, lack of family resources and community support, low food and housing security, and lack of coordination across service delivery agents.[26,28,29,37] We must identify priority issues related to environmental health and safety risks in order to effectively address environmental health disparities among children.
In recent decades, federal strategies to eliminate childhood lead poisoning have focused primarily on expanding efforts to correct lead paint hazards, which are still a major source of lead exposures among children. However, following the events in Flint, Michigan, in 2016, U.S. efforts must consider other sources of lead exposure, such as drinking water, soil, and consumer products. The President’s Task Force on Environmental Health Risks and Safety Risks recently published a report titled Key Federal Programs to Reduce Childhood Lead Exposure and Eliminate Associated Health Impacts and is working on a new federal strategy to eliminate lead in children’s environments.
Health disparities already experienced by the most underserved children are exacerbated by the myriad health effects associated with climate change, which causes more stress for developing children while creating additional environmental factors children must confront. The burdens of climate change are borne disproportionately by vulnerable populations including children, indigenous groups, people of color, the elderly, low-income communities, immigrants, and people who are not fluent in English.[39– 44] Direct health effects include trauma caused by severe weather and natural disasters, resource scarcity, and increased morbidity and mortality due to disease exacerbated by extreme heat events. Indirect effects include the spread of infectious diseases and increases in certain environmental allergens and air pollutants, which exacerbate illness. Increased rainfall, expansion of disease-vector breeding grounds, and breakdowns in water supply or sanitation networks contribute to the changing patterns of infectious and parasitological disease. Increased environmental allergens attributed to the lengthening ragweed pollen seasons and elevated levels of particulate matter, pollutants, dust, and smoke resulting from increased forest fires contribute to higher rates of morbidity and mortality associated with respiratory and cardiopulmonary health problems. The dependence of children on the care of adults places them at a higher risk of climate-related health burdens.[39,44] Vulnerabilities among children, especially those younger than 5 years, are attributable primarily to their development status, dependence on adults, and unique behaviors and traits. Climate change threatens many of the achievements in public health—clean water, clean air, and adequate food—made over the last century.
The costs of environmentally mediated disease and disability affect the afflicted individual and his or her family, businesses, and the social and economic fabric of society. Children who miss many school days and whose academic performance is impacted by illness or disabilities associated with environmental exposures can experience diminished lifetime earnings, and missed school days affect the productivity of both parent and child. The cost of environmentally mediated disease or developmental disability in children was estimated, conservatively, at more than $76 billion in 2008. Some costs are inevitably missed in economic models, such as medical costs for children whose families are unable or unwilling to pay for treatment. Another reason the true economic costs to individuals, families, businesses, and society are often underestimated is that certain values, such as psychosocial values, are difficult to calculate. These values include a parent’s lost productivity due to exhaustion, distraction, and anxiety in the workplace. Other considerations include wage penalties for a work hiatus to care for a sick child, the costs of comorbid conditions, and quality-of-life impacts on children and their families as a result of living with or caring for illness, even on symptom-free days. It has been estimated that families would be willing to pay, on average, between $56.48 and $64.84 per month for a 50% reduction in childhood asthma symptoms and the associated familial stress.
A significant portion of the cost associated with environmental disease is related to health disparities. One analysis of the economic burden of overall health disparities estimated that elimination of racial and ethnic minority group disparities would have saved $230 billion in direct medical care expenditures and more than $1 trillion in indirect costs associated with illness and early death over a 3-year period. A study of the economic aftermath of the 2014 decision by officials in Flint, Michigan, a community of predominantly low-income African Americans, to switch the city’s drinking water source to save $5 million revealed that the resulting lead contamination and elevated blood lead levels among children cost the city $400 million and resulted in 1,760 quality-adjusted life-years lost. Numerous studies have shown that the return on investment in preventive environmental health programs and services is significant. For example, data from the National Asthma Control Program indicate that each $1 investment in national and state-level programs leads to a savings of $71 in asthma-related costs. 
Embracing a robust and comprehensively preventive environmental health framework requires commitment and actions across multiple sectors and at all levels of government. Identified areas in need of attention and improvement include the following: moving clear, available, and accessible science into action; implementing a connected public health approach; better tracking and reporting children at risk; instituting chemical policy reforms that reduce children’s exposures to chemicals; and engaging in cross-sector collaboration to complex societal problems.
Only within the past few decades has there been sufficient proof that children experience a burden of environmental health outcomes. Conducting epidemiological research on children—especially children encumbered by social determinants of health—makes producing viable, ethical, and sufficient data extremely difficult. Furthermore, environmental health research requires a multifactorial approach. In 2005, a number of public health institutions, including the Johns Hopkins University School of Medicine and the University of California, Berkeley, School of Public Health, began to study community-based participation with regard to environmental health research. The study researchers found that “most organizations supporting health research, especially basic research (e.g., epidemiologic, genetic), do not require researchers to work with communities in the identification, design, implementation, analysis, and dissemination of research.” Although community-based participatory research is not always an appropriate method for investigations focusing on children’s environmental health, the researchers concluded that incorporating community involvement—especially among marginalized communities—into research methods and designs would be beneficial in conducting the most effective children’s environmental health studies.
Globalization further complicates exposures to environmental hazards. Scientists estimate that, by 2030, two thirds of the global population will live in an urban environment. Beyond traditional risks for the “urban poor” such as influenza outbreaks, respiratory infections, and diarrheal disease, city environments introduce various physicochemical hazards such as lead, air pollution, traffic hazards, mercury, phthalates, mold, pesticides, polybrominated diphenyl ethers, secondhand smoke, and “urban heat island” amplification of heat waves.[2–5,26,31–35,41,50,52–56] The dense populations and ubiquitous pollutants of urban environments complicate environmental health interventions. Globalization has motivated many people to relocate to more populous city centers, which also offer more in terms of culture, community, and technology than rural areas. Yet the shift of populations to more crowded, urban areas has compromised traditional public health measures used to combat environmental risks. An argument against mitigating environmental health risks is the potential to intervene within a market built on an industrialized society. For example, globalization has increased the number of personal cars owned and used each day; the purchase of these cars provides jobs to those who work assembling them. However, most of the pollution produced by transport emissions affects city dwellers in low-income areas. Furthermore, environmental health interventions are costly and often radical. Solutions to reducing environmental health disparities are often complex and require redistributing wealth and redesigning urban environments to make an impact.
While there is overwhelming scientific agreement that climate change is occurring, the few studies opposing the established scientific consensus have been used by well-funded campaigns to promote skepticism or denial about whether climate change is happening and whether it is human caused, contributing to a political climate in which passage of policies to address climate change is extremely difficult. This poses particular danger to children, because the impact of current climate emissions will increasingly be felt for decades into the future, threatening current and future children’s health as temperatures rise, air quality and food quality decline, food and water become scarcer, and patterns of climate-sensitive infections change and extreme weather events lead to physical and psychological injury. Moreover, the success of these campaigns in undermining evidence-based policy-making has serious implications for protecting children’s health from other environmental hazards.
Evidence-Based Interventions and Strategies
This policy statement advocates for preventive environmental public health services to reduce or eliminate environmental risks to children’s health where they live, learn, and play. In 1997, Executive Order 13045 established the Task Force on Environmental Health Risks and Safety Risks to Children. This task force remains in effect today, to accomplish the same goals outlined in the original executive order. Its goals include federal strategies for children’s environmental health and safety, targeted annual priorities to guide the federal approach, and recommendations for appropriate partnerships among federal, state, local, and tribal governments and the private, academic, and nonprofit sectors. Under these goals, government agencies were encouraged to participate in and comply with the implementation of the order. Many research agencies, committees, and organizations were born out of the premise of Executive Order 13045 to mitigate environmental health risks to children. Specifically, the EPA established the Children’s Health Protection Advisory Committee in 1997 to advise the agency on regulations, research, and communications related to children’s health; the National Institute of Environmental Health Sciences, along with the EPA, established the Children’s Environmental Health and Disease Prevention Research Centers in 1998; and the Pediatric Environmental Health Specialty Units were created to provide consultation to public agencies and educate health professionals on protecting children from environmental exposures.
Federal agencies, academic research centers, and nonprofit organizations often take the lead on preventive research for children’s environmental health. Evidence points to multidisciplinary, comprehensive, cross-cutting approaches such as health impact assessments (HIAs), especially those addressing the unique vulnerabilities of children and other vulnerable groups, as the best means of mitigating environmental health exposures. This policy statement advocates for the enactment of policies requiring state and local government agencies to consider environmental impact assessments and HIAs equally with social and economic factors during discretionary decision making. Furthermore, collaboration among government agencies at the state, federal, and local levels; research institutions; communities; and public health experts is imperative to create effective, feasible, and cost-efficient methods to protect children against environmental hazards.
The Children’s Environmental Health Network’s Blueprint for Protecting Children’s Environmental Health: An Urgent Call to Action is a resource that can be used to frame many of the action steps listed below and to guide priority setting. The blueprint was developed with a broad base of input and consensus from key federal offices; pediatric and public health professionals; leaders in sustainable business, agriculture, transportation, and urban planning; child health and environmental justice advocates; and other traditional and nontraditional partners.
Coordinated, comprehensive, and intentional efforts to reduce or eliminate environmental risks to children are a valuable investment in children’s health and long-term development and in the well-being of future generations. Therefore, APHA urges agencies, public health practitioners, policymakers, community-based and environmental justice organizations, health economists, communication leaders, business leaders, and researchers to advance policy and planning activities that incorporate or address the following objectives in relevant legislation or public health priority-setting regulations. Specifically, APHA:
- Calls on public health agencies, national and community organizations, and research and science institutions to create clear and accessible information to support effective action on children’s environmental health. These groups should also identify gaps in research or information, strengthen the understanding between children and their environment, create a credible source of information, and develop a research agenda to build on existing research efforts.
- Calls on local, state, and national health agencies and organizations; communities; and American society as a whole to prioritize children and families and develop an action plan to focus health mitigation strategies on preventing children’s environmental health risks and limiting their exposures to such risks. Public health offices and officers should formulate intervention strategies. Policymakers and public officials and administrators should actively include community members when developing children’s environmental health strategies and policies given that health risks can vary from neighborhood to neighborhood within one community.
- Urges collaboration among health departments and health care providers/payers to develop a supportive system to ensure lead-safe housing, reduce asthma triggers in children’s environments, and reduce return visits to emergency rooms or other health care centers, as well as to create an evaluation system to monitor at-risk children for environmental hazards.
- Encourages state and local officials to engage with public health professionals, drinking water suppliers, and local stakeholders to accelerate full lead service line replacement, with a particular focus on burdened communities.
- Calls for those in the housing industry to adopt the evidence-based Healthy Housing Standard, a tool developed by APHA and the National Center for Healthy Homes, for property owners, advocates, elected officials, code agency staff, public health leaders, and all who recognize the impact housing has on community health. Also, public housing agencies and private management companies should ensure compliance.
- Urges those who create and maintain the built environment, such as design professionals, transportation officials, and urban planners, to create and maintain buildings, streets, neighborhoods, parks, and other elements of the built environment in ways that prioritize children’s health and well-being.
- Calls for federal, state, and private funding to support local health departments and community partners in promoting healthy neighborhoods, activities, and play environments for children, including access to parks and green spaces, safe routes for biking and walking, public transportation, and access to universal playgrounds designed to be accessible to all children (with and without disabilities).
- Urges educators and educational affiliates, such as boards of education, school administrators, teachers, and parent-teacher associations, to recognize the environmental hazards that may be present in schools, to monitor schools for the presence of these hazards, and to remediate them when they are present.
- Urges state agencies that administer quality ratings, improvement systems or programs, or other nonregulatory systems for child-care programs to include environmental health criteria in rating requirements.
- Urges state and local child-care licensing officials to adopt all environmental health standards included in the third edition of Caring for Our Children as required regulations for licensing.
- Supports the existing effort to develop a chemical prioritization process and implement chemical policy reforms that will enhance the regulation of and reduce children’s exposure to toxic chemicals found in many consumer products.
- Urges the development of new integrated state, county, and city systems that can respond to, evaluate on site, and track and report children at risk for suspected exposures. Each system should include an increased presence for pediatric environmental health experts, new health care provider protocols for uncovering or assessing environmental exposures and potential health risks, and specialized services for families with at-risk children.
- Calls for federal, nonprofit, and private-sector leaders to use the National Radon Action Plan to expand efforts to reduce radon risks.
- Encourages institutes of higher learning to incorporate the basic principles of children’s environmental health and strategies and approaches to reduce risk into the teaching and training curricula of professional programs across sectors, especially those geared toward the care of children, such as the teaching, child-care, and health care professions.
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