Featured, Features, frontpage, Online — January 11, 2018 at 11:42 am

The Ebola Fighters: Uncharted Territory, or a Repeat of Past Shortcomings?

Major Richard J. Hossfeld*

Brooke Hossfeld MPH, MLS(ASCP)CM**

Major David R. Dixon***

Disclaimer: The opinions and views expressed in this paper are those of the authors alone and do not represent the views of the DoD or U.S. Government.

I. How did we get here?

“The World Health Organization is the guardian of global public health. It’s the one international authority that can enact quarantines, declare pandemics, and coordinate disease responses.”[1]

-Julia Belluz, Senior Health Correspondent, Vox.com; Steven Hoffman, Associate Professor of Law and Director of the Global Strategy Lab at the University of Ottawa

 

“Ebola was the Hurricane Katrina for the World Health Organization—its moment of failure. The organization’s missteps in the early days of the outbreak are now legendary.”[2]

-Jason Beaubien, NPR News

 

In 2014, the deadly and contagious Ebola virus blazed a trail through West Africa.[3] On December 26, 2013, a young boy fell ill with fever and diarrhea in a remote village in Guinea.[4] By the time the boy died, his sister, mother, and grandmother had all fallen ill.[5] By March, 2014, the Guinean Ministry of Health called the World Health Organization (WHO) for support to isolate and contain this outbreak to a single country.[6] The WHO director-general at the time, Dr. Margaret Chan, who had received criticism in the past for the level of alarm raised for the relatively innocuous “swine flu” pandemic, waited until August 8, 2014, to declare the Ebola epidemic a Public Health Emergency of International Concern.[7] By the time alarm was raised on an international level, the Ebola virus had spread to several neighboring countries.[8]

The global health security strategy gives the WHO the central global leadership role in addressing serious disease threats. The Ebola outbreak revealed that the WHO was neither willing nor able to play this role.[9] After initially being criticized for being overly cautious, President Obama sent over 3,000 military personnel to Liberia, mostly medics and engineers.[10] This was the United States’ largest ever intervention in a global health crisis.[11] According to President Obama, the United States had “a security interest in controlling the epidemic in Africa so that it did not spread to the U.S. and other countries.”[12] And “only the American military had the resources, hierarchical structure, and discipline to carry out such a largescale effort.”[13] This concern regarding the safety and security of our own borders raises questions of our ability to quickly initiate an outbreak response team to mitigate disease spread, both internationally and domestically. Outbreaks of infectious diseases such as Ebola require prompt response for containment. But bureaucracy wastes precious time and human lives. This raises the question of when is the correct time for the U.S. government (USG) to become involved in international public health incidents?

The WHO repeatedly exhibits incompetent responses towards global epidemic disease outbreaks, with the 2014 Ebola outbreak serving as the most recent and egregious example. The lack of timely emergency declarations from the WHO necessitates that the USG must act as the global first responder towards future outbreaks. The USG must do this through its governmental, intergovernmental (IGO), and non-governmental (NGO) diplomatic and interagency organizations, funding, and accompanying tactical capabilities. Radical reform of the WHO’s funding and member-nation authority is necessary to empower the body to properly execute its mission. Both the current funding and organization of the WHO are fundamentally flawed and inhibit its ability to mobilize globally to fight disease outbreak. It is incumbent upon the United States to act as the leading authority to set the stage for future pandemic mitigation by spearheading organizational, financial, and bureaucratic transformation of the WHO.

Instead of waiting passively for effective WHO reform, the USG—which currently provides more funding to the WHO than any other member[14]—should act as the authority to influence disease response coordination and declare epidemic and/or pandemic outbreak on behalf of the world. It is also in the national security interests of the USG to task its appropriate agencies to allocate portions of their budgets to pandemic planning and response. Agencies that could be deployed to this mission include the Centers for Disease Control and Prevention (CDC), U.S. Agency for International Development (USAID), and the U.S. Department of Defense (DoD). This proposal is not intended to be a long-term solution, but rather a temporary triage in order to prevent unnecessary loss of life and human suffering until the WHO is properly organized and funded to execute its mission as a shepherd of international health interests. Once the WHO proves that it is a competent global health body, the USG would revert to its traditional member-nation status.

The WHO’s primary objective is “to build a better, healthier future for people all over the world. Working through offices in more than 150 countries, WHO staff work side by side with governments and other partners to ensure the highest attainable level of health for all people.”[15] The decision-making body of the WHO is the World Health Assembly, which is led by an appointed director-general.[16] 194 Member States make up the assembly.[17]

The United States has previously taken military action without a UN Security Council resolution.[18] As with national security, in the critical area of world health the USG may be morally obliged to act unilaterally—although it may currently be legally limited from doing so. It is in the interests of U.S. national security to be able to lead and mobilize an international health response if the bureaucracy of the WHO suffers from paralysis such as it did during the 2014 Ebola crisis.[19] Furthermore, similar systemic WHO shortcomings are root causes for historically delayed and lackluster response efforts, and unnecessary loss of life—such as with the responses to HIV and malaria.[20] Director-general Chan admitted that her agency was unprepared for the Ebola epidemic: “It overwhelmed the capacity of WHO, and it is a crisis that cannot be solved by a single agency or single country.”[21]

Despite such clear indications of under-performance, the level of member nation non-interest in adequately funding WHO emergency responses is suggested by the restrictions that they place on funds that they donate:

At present only 25% of WHO’s biennial programme budget comes from assessed contributions. The remainder comes from voluntary funds that are largely restricted for purposes specified by donors. There are no core funds for emergency response as such, although every year a considerable amount of money is spent as donor contributions for emergencies. WHO is put at a severe disadvantage by the fact that the core funds are so limited and do not allow an appropriate base for response.[22]

This is a problem that will likely lead to future ill-fated operations if not addressed properly.

II. Well, what does our doctrine say?

“The reason the U.S. Navy does so well in wartime is that war is chaos, and the U.S. Navy practices chaos on a daily basis.”

– German officer from World War II (apocryphal)[23]

 

“A serious problem in planning against American doctrine is that the Americans do not read their manuals, nor do they feel any obligation to follow their doctrine.”

– Soviet author of Cold War vintage (apocryphal)[24]

 

This section addresses how military doctrine might be applied specifically in world health situations calling for governmental leadership. As one may suspect, limited doctrine exists for multi-national government responses in the area of world health. Joint Publication-5 illustrates how a Joint Force Commander (JFC)[25] should be prepared to independently fill gaps and functions when NGO/IGOs are not present:

JFCs and staffs should consider how to involve interagency and multinational partners and relevant [IGOs] and [NGOs] in the planning process; how to coordinate and synchronize joint force actions with the operations of these organizations; and the military actions and resources required to fulfill their functions when they are unavailable, consistent with existing legal authorities. Regardless of the level of involvement during the planning process, commanders and staffs must consider their impact on joint operations.[26]

By this same rationale, the United States cannot count on an international union to make the declaration required to mobilize a pandemic response.[27] Achieving unity of effort requires the application of a comprehensive approach that includes coordination, consensus-building, and deconfliction among all the stakeholders toward an objective. Until the WHO can do this, the USG must fill the void.

A JFC can use U.S. military doctrine to assist planning and execution in matters relating to organization, Command and Control (C2), unity of effort, unity of command, and unified action. In doing so:

[U]nity of effort is ensured by establishing unity of command. Unity of command is based on the designation of a single commander with the authority to direct and coordinate the efforts of all assigned forces in pursuit of a common objective. Commanders exercise military [C2] to ensure that military operations are planned and conducted in accordance with the guidance and direction received from the President and [Secretary of Defense] in coordination with other authorities (i.e., alliance or multinational leadership). In operations involving interagency partners and other stakeholders, where the commander may not control all elements, he seeks cooperation and builds consensus to achieve unity of effort.[28]

If the USG leverages and appropriately influences decisions within the WHO, a trickle-down influence from its success would create larger international buy-in and increase the size and capacity of a Combined Joint Task Force (CJTF) responding to an outbreak crisis.

Mission accomplishment is highly dependent upon a commander’s timely guidance. “Unified action begins with national strategic direction from the President and includes a wide scope of actions including interorganizational coordination techniques, information sharing, collaborative planning, and the synchronization of military operations with the activities of all the civilian stakeholders. Interorganizational coordination depends on a spirit of cooperation.”[29]

Because the WHO, not the President of the United States (POTUS), declares an international pandemic disaster under current organization, the USG cannot effectively mobilize international authority and response.[30] This results in dilution of the commander’s guidance. The CDC can make suggestions and recommendations to the WHO, but the discretion remains with the WHO. “Unified action is promoted through close, continuous coordination and cooperation, which are necessary to overcome confusion over objectives, inadequate structure or procedures, and bureaucratic and personnel limitations.”[31] While unified action is present with the modern WHO, its speed is inadequate for time-sensitive responses.[32]

III. Response to the Ebola Outbreak

“This is the first country I’ve been in 14 years where they’ve been happy to see me everywhere I’ve been. Everywhere I go in the country, without exception, and I’ve been to all corners of the compass, everyone is happy to see us. What the Department of Defense brings to the fight is speed, flexibility, and confidence. The military brought with it some unique capabilities to fill gaps USAID and the government of Liberia didn’t have.”[33]

– MajGen Gary Volesky, Commander Joint Task Force-United Assistance

 

Once the WHO declared an epidemic in August 2014, the USG quickly leapt into action in Operation United Assistance.[34] As shown in Figure 1, this was approximately six months after the outbreak first occurred. The WHO’s failure to declare an epidemic sooner is the main reason why a large response was dramatically delayed.[35]

Figure 1

POTUS determined that Ebola was a national security priority and directed a comprehensive U.S. response with the following goals: (1) control the epidemic at its source in West Africa; (2) mitigate second-order impacts, including blunting the economic, social, and political tolls in the region; (3) engage with and coordinate a broad global audience; and (4) fortify global health security infrastructure in the region and beyond.[36] USAID, working with CDC personnel, established Disaster Assistance Response Teams (DART) in West Africa. The 28-member DART played a central coordinating role for the U.S. response, marshaling resources across federal departments and agencies such as the CDC, National Institutes of Health, Public Health Service, and DoD.[37]

Hospitals in Guinea, Sierra Leone, and Liberia were overwhelmed with patients and could not keep up with demand, so the opening stages of the response addressed constructing adequate medical facilities, treatment centers, and triage networks.[38] Joint Task Force-Port Opening (PO) at Léopold Sédar Senghor International Airport in Dakar, Senegal, focused humanitarian supplies and military support into West Africa as part of Operation United Assistance. General David Rodriguez, Commander United States Africa Command (USAFRICOM), noted that the Operation constructed a twenty-five-person field hospital, created multiple mobile medical labs, worked with partners to establish Ebola Treatment Units, and created and staffed multiple mobile medical labs with twenty-four-hour turnaround and the capability of processing hundreds of samples per day.[39]

Throughout the response, the USG employed strategic communication (“Stratcomms”) to maximize the informational lever of national power. Stratcomms are “focused [USG] efforts to understand and engage key audiences to create, strengthen, or preserve conditions favorable for the advancement of [USG] interests, policies, and objectives through the use of coordinated programs, plans, themes, messages, and products synchronized with the actions of all instruments of national power.”[40] These Stratcomms aimed to educate West Africans on proper behaviors and prevention methods in order to help mitigate further disease spread.[41] Stratcomms also addressed the rampant fear and misinformation that was sweeping the region regarding Ebola and the associated intervention.[42]

The success of U.S. Stratcomms efforts did not occur in isolation. Rather, the USG’s efforts in communications were bolstered by international cooperation across West Africa to achieve a multifaceted response:

We are working . . . with both the French and the U.K. who are also doing some things, like putting the hospital up, like our 25-person hospital. [M]ost of those efforts are being run and controlled by the United Nations and international community, so we . . . coordinate with them and communicate with them.[43]

IV. Conclusion / Recommendations

“The Ebola outbreak shook this organization to its core.”[44]

– Dr. Margaret Chan, former WHO Director-General

“It is the world’s first Ebola epidemic, and it’s spiraling out of control. It’s bad now, and it’s going to get worse in the very near future. There is still a window of opportunity to tamp it down, but that window is closing. We really have to act now.”[45]

– Dr. Tom Frieden, CDC Director

 

USAFRICOM and USAID, under strategic guidance from POTUS, executed Operation United Assistance with great precision and professionalism. Many analysts describe this outbreak as the “Katrina” on the world stage,[46] and it is evident that the USG bridged international gaps in the WHO’s delayed Ebola response. The impact of a timely response cannot be overstated: Delay in this case was the catalyst for increased infection rates and casualties.[47]

For this reason the USG should apply 2014’s lessons to influence WHO reform. “The organization was set up in 1948 with the ambitious mission of rallying countries around health problems. It’s supposed to be the key player for health around the world. But the organization has been struggling of late as it loses funding and influence relative to other disease-focused groups.”[48] Funding for Ebola in 2015 was $3.7 bilion internationally and $1.7 billion domestically.[49] U.S. global health funding by sector for FY 2015 gave 55% of funds to HIV/AIDS, while allocating only 1% for pandemic preparedness.[50]

There already have been positive organizational outcomes following the outbreak, but improvement should be continued: around twelve West African countries and the United States are participating in the African Partner Outbreak Response Alliance, which “provides a forum for discussion on the ways for partners to best prepare for a variety of future infectious disease epidemics in the region.”[51] Additionally, USAFRICOM’s Disaster Preparedness Program “has engaged more than 16 African nations, and produced 26 national and military contingency response plans, and four disaster-management strategic work plans.”[52]

Recommendations

  1. The CDC must increasingly use its voice on the global stage to lead global response efforts and fill the gaps left by the WHO. As the United States and the CDC cannot forcibly enter a country and conduct health operations unless invited, this should be a temporary solution until the WHO develops into a capable body that can act without the kinds of problems that hampered its effectiveness in addressing the Ebola outbreak.
  2. The U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID) provides many of the DoD’s core competencies for outbreak prevention and mitigation. These capabilities go hand-in-hand with CDC, Doctors Without Borders, and USAID civilian skills. USAFRICOM, along with the other Combatant Commands (CCMD), should heavily lean on these organizations in their planning efforts before executing a response. Furthermore, it is imperative that CCMDs and USAMRIID can operate as the first “boots on the ground” at first indication of an outbreak, and then reach back to other non-militry organizations for surge capabilites based on conditions. These actions should happen prior to an epidemic or pandemic declaration by the WHO in order to save lives and mitigate disease spread in the early stages of infection.
  3. The WHO’s plans, responses, capabilities, and notional budgets should be developed with contributors that share responsibility for outbreak response. The WHO should be held accountable for exercising its response to large-scale pandemics, much like the DoD and CCMDs exercise operations plans. These exercises should include as participants DoD, CDC, USAID, Doctors Without Borders, and (to an extent) the UN. The annual results and lessons learned from these exercises should be transparent and shared with all member-nations of the WHO.
  4. The current structure of the Commissioned Corps of the U.S. Public Health, Department of Health and Human Services should be expanded so that it may surge to meet demands outside of U.S. borders. The Corps typically executes operations only on U.S. soil.[53] A reserve force could be employed to backfill current structure, or it could be used as an expeditionary medical force to augment other emergency response organizations.

In summary, in order to help the WHO meet its crisis response duty, the CDC should increase its global presence to fill current gaps in the WHO. The U.S. military, specifically USAMRIID, should take the initiative to establish a presence as hotspots develop. The WHO should participate in multiagency exercises and publish its lessons learned. And finally, the US Public Health Commissioned Corps should develop a reserve capacity that can surge to meet high threat demands. Taking these steps will help to protect the “security interest” that President Obama identified in the Ebola crisis and which the WHO has fallen short of protecting.[54]


* United States Marine Corps Reserve; Joint Forces Staff College; National Defense University – Norfolk, VA; richard.hossfeld@usmc.mil

** Tulane University School of Public Health and Tropical Medicine – New Orleans, LA; bbailey4@tulane.edu

*** United States Marine Corps Reserve; Marine Corps University – Quantico, VA; david.dixon@usmc.mil

 

[1] Julia Belluz & Steven Hoffman, Why we fail at stopping outbreaks like Ebola, Vox (Oct. 1, 2014), https://www.vox.com/2014/9/30/6843117/slow-ebola-virus-epidemic-response-WHO-after-brantly-Americans-infected.

[2] Jason Beaubien, Critics Say Ebola Crisis Was WHO’s Big Failure. Will Reform Follow?, NPR (Feb. 6, 2015), https://www.npr.org/sections/goatsandsoda/2015/02/06/384223023/critics-says-ebola-crisis-was-whos-big-failure-will-reform-follow.

[3] Alexander S. Kekulé, Learning from Ebola Virus: How to Prevent Future Epidemics, Viruses (July 9, 2015).

[4] Id.

[5] Id.

[6] Id.

[7] Id.

[8] Id.

[9] See generally David P. Fidler, Epic Failure of Ebola and Global Health Sec., 21 Brown J. of World Aff. 179, 180 (Spring/Summer 2015).

[10] Robert Moser & Patrick McDonald, Ebola & American Intervention, Ethics Unwrapped, https://ethicsunwrapped.utexas.edu/case-study/ebola-american-intervention (last visited Dec. 14, 2017).

[11] Id.

[12] Id.

[13] Id.

[14] See World Health Org., Assessed contributions payable by Member States and Associate Members 2018–2019 (2017), http://www.who.int/about/finances-accountability/funding/2018-19_AC_Summary.pdf?ua=1.

[15] About WHO, World Health Org., http://www.who.int/about/en/ (last visited Dec. 14, 2017).

[16] Media Centre: World Health Assembly, World Health Org., http://www.who.int/mediacentre/events/governance/wha/en/ (last visited Dec. 14, 2017).

[17] Governance, World Health Org., http://www.who.int/governance/en/ (last visited Dec. 14, 2017).

[18] See Ewen MacAskill & Julian Borger, Iraq was was illegal and breached UN charter, says Annan, Guardian (Sept. 15, 2004), https://www.theguardian.com/world/2004/sep/16/iraq.iraq.

[19] Rob Yates, Ranu S. Dhillon & Ravi P. Rannan-Eliya, Universal health coverage and global health security, 385 Lancet 1897, 1897–98 (May 9, 2015).

[20] See World Health Org., World malaria report 2017 (Nov. 29, 2017), http://apps.who.int/iris/bitstream/10665/259492/1/9789241565523-eng.pdf; Deborah Anderson, Hard Lessons: How the WHO failed to address Ebola and HIV, The European (Jan. 13, 2015), http://www.theeuropean-magazine.com/deborah-anderson/9390-how-the-who-failed-to-address-ebola-and-hiv.

[21] Beaubien, supra note 2.

[22] World Health Org., Rep. of the Ebola Interim Assessment Panel to the Sixty-Eighth World Health Assembly, U.N. Doc. A68/25 (2015), http://apps.who.int/gb/ebwha/pdf_files/WHA68/A68_25-en.pdf.

[23] See James R. Holmes, Unorthodox and Chaotic: How America Should Fight Wars, The Diplomat (Sept. 27, 2013), https://thediplomat.com/2013/09/unorthodox-and-chaotic-how-america-should-fight-wars/.

[24] Id.

[25] “A general term applied to a combatant commander, subunified commander, or joint task force commander authorized to exercise combatant command (command authority) or operational control over a joint force.” Joint Force Commander, U.S. Dep’t of Def., Joint Pub. 1-02, Dictionary of Military and Associated Terms 125 (as amended through 2016), https://fas.org/irp/doddir/dod/jp1_02.pdf.

[26] U.S. Dep’t of Def., Joint Publication 5-0, Joint Operation Planning II-1 (2011), http://www.dtic.mil/doctrine/new_pubs/jp5_0.pdf.

[27] See Lincoln Chen & Keizo Takemi, Ebola: lessons in human security, 385 Lancet 1887, 1887–88 (May 9, 2015).

[28] U.S. Dep’t of Def., Joint Publication 3-08, Interorganizational Coordination During Joint Operations I-5 (June 24, 2011), https://web.archive.org/web/20121106121321/https://fas.org/irp/doddir/dod/jp3_08.pdf.

[29] Id.

[30] See Heath Kelly, The classical definition of pandemic is not elusive, Bull. of the World Health Org. (2011), http://www.who.int/bulletin/volumes/89/7/11-088815/en/; Regulations and Laws That May Apply During a Pandemic, Ctrs for Disease Control and Prevention, https://www.cdc.gov/flu/pandemic-resources/planning-preparedness/regulations-laws-during-pandemic.htm (last updated Nov. 9, 2016) (describing President’s limited domestic role in declaring emergencies during a pandemic).

[31] Id.

[32] Jim Yong Kim, We Need A New Global Response to Pandemics, World Bank: Voices (Jan. 21, 2015), https://blogs.worldbank.org/voices/we-need-new-global-response-pandemics (“The global response to Ebola was late, inadequate, and slow.”).

[33] Michelle Tan, 2-star: Ebola cases decreasing in Liberia, Army Times (Dec. 4, 2014).

[34] Lena Sun et al, Out of Control: How the world’s health organizations failed to stop the Ebola disaster, Wash. Post (Oct. 4, 2014), http://www.washingtonpost.com/sf/national/2014/10/04/how-ebola-sped-out-of-control/.

[35] Belluz & Hoffman, supra note 1.

[36] Press Release, White House, Press Briefing on Government Response to the Ebola Epidemic in West Africa (Oct. 3, 2014), https://www.whitehouse.gov/the-press-office/2014/10/03/press-briefing-government-response-ebola-epidemic-west-africa-1032014.

[37] John Kerry, U.S. Sec’y of State, & Chuck Hagel, U.S. Sec’y of Def., Remarks at Munich Security Conference (Feb. 1, 2014), https://2009-2017.state.gov/secretary/remarks/2014/02/221134.htm.

[38] Betsy McKay, Ebola’s Long Shadow: West Africa Struggles to Rebuild Its Health-care System, Wall St. J. (June 4, 2015), https://www.wsj.com/articles/africa-struggles-to-rebuild-its-ravaged-health-care-system-1433457230.

[39] United States Africa Command, TRANSCRIPT: Pentagon Briefing on DoD Response to Ebola with GEN Rodriguez (Oct. 8, 2014), http://www.africom.mil/media-room/article/23695/transcript-pentagon-briefing-on-dod-response-to-ebola-with-gen-rodriguez.

[40] U.S. Dep’t of Def., Strategic Communication Joint Integrating Concept 2 (Oct. 7, 2009) (quoting U.S. Dep’t of Def., Joint Publication 1-02 Dictionary of Military and Associated Terms (May 30, 2008)), http://www.dtic.mil/doctrine/concepts/joint_concepts/jic_strategiccommunications.pdf.

[41] See, e.g., Erika Check Hayden, Spread of Ebola ends: 7 lessons from a devastating epidemic, Nature: News (Jan. 14, 2016), https://www.nature.com/news/spread-of-ebola-ends-7-lessons-from-a-devastating-epidemic-1.19138.

[42] See Ruth Kutalek et al, Letter to the Editor, Ebola interventions: listen to communities, TheLancet.com (Mar. 2015), http://www.thelancet.com/pdfs/journals/langlo/PIIS2214-109X(15)70010-0.pdf.

[43] United States Africa Command, supra note 39.

[44] Dr. Margaret Chan, Director-General, World Health Org., et al, WHO Leadership statement on the Ebola response and WHO reforms (Apr. 16, 2015), http://www.who.int/csr/disease/ebola/joint-statement-ebola/en/.

[45] Abby Haglage, CDC: ‘Window Is Closing’ on Containing Ebola, Daily Beast (Sep. 2, 2014), http://www.thedailybeast.com/cdc-window-is-closing-on-containing-ebola.

[46] See, e.g., Beaubien, supra note 2.

[47] See Kim, supra note 32.

[48] Belluz & Hoffman. supra note 1

[49] Adam Wexler & Jennifer Kates, Issue Brief, The U.S. Global Health Budget: Analysis of Appropriations for Fiscal Year 2015, Henry J. Kaiser Fam. Found. (Dec. 22, 2014), http://files.kff.org/attachment/issue-brief-the-u-s-global-health-budget-analysis-of-appropriations-for-fiscal-year-2015.

[50] Id.

[51] Nathan Herring, APORA Supports Fight Against Infectious Diseases in Africa, United States Africa Command (Aug. 17, 2015), http://www.africom.mil/media-room/article/26527/apora-supports-fight-against-infectious-diseases-in-africa.

[52] Adeyemi Okunogbe, What the Ebola Crisis Taught us About Emergency Preparedness in Africa, The Rand Blog (June 4, 2015), https://www.rand.org/blog/2015/06/what-the-ebola-crisis-taught-us-about-emergency-preparedness.html.

[53] See Commissioned Corps of the U.S. Public Health Service, History (Sept. 5, 2014), https://usphs.gov/aboutus/history.aspx.

[54] Moser & McDonald, supra note 10.

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