Transforming Lives: Dr. Indira Narayanan Reflects on Her Dedication to Public Health & Wellbeing

I have always felt research is important. It has been a part of my life. You, of course, have to do it with ethical practices.
Consultant in Global Maternal and Newborn Health and Adjunct Professor, Neonatology, Georgetown University, DC.
Consultant in Global Maternal and Newborn Health and Adjunct Professor, Neonatology, Georgetown University, DC.

Dr. Indira Narayanan is an adjunct professor of Neonatology and a consultant in Global Maternal and Newborn Health at Georgetown University in Washington, DC. She is an experienced & independent medical doctor with a track record of working in hospitals and in the field of global maternal and newborn health. Dr. Narayanan is a highly skilled professional in health and nutrition. She is widely known and respected globally for her groundbreaking research on the therapeutic implications of anti-infective elements in human milk. Her research was originally published as a leading article in The Lancet, a prestigious medical journal. Dr. Narayanan was one of the pioneers in emphasizing the importance of mothers in newborn facilities, particularly in low- and middle-income nations.

In this conversation between Dr. Darshit Patel, representing MedBound, and esteemed guest Dr. Indira Narayanan, we gain valuable insights into the multifaceted professional journey of Dr. Narayanan. Delving into her vast expertise in the field of neonatology, we explore her experiences working with newborns and uncover her invaluable advice for aspiring medical professionals. Stay tuned to gain profound insights from this insightful discussion

Dr. Darshit Patel: Welcome to this Docscopy session, an initiative by MedBound Times, an initiative by MedBound. I am Dr. Darshit, and it is my honor to engage in an insightful interview with you today, ma'am. To begin, would you kindly provide us with your professional introduction?

Dr. Indira Narayanan: Yes, thank you for interviewing me. That's very kind of you. I'm currently working as a consultant in global health, where I focus on global newborn health, and I'm also an adjunct professor in the Department of Pediatrics-Neonatology at Georgetown University Medical Center, Washington, DC.

Dr. Darshit Patel: Can you please share some insights into your life and professional journey, including the driving factors behind your decision to specialize in pediatrics? Additionally, we are keen to learn about the factors that motivated you to pursue a career in the noble profession of teaching.

Dr. Narayanan: As you are aware, I was born in India, but I'm currently an American citizen by naturalization. However, I really feel like a global citizen. I don't feel like I belong to any country or a single country anymore. My global journey began as a child. My father, too, was a doctor. He was an orthopaedic surgeon who was also internationally known and had travelled to different countries. He later became the director general of health services. So I think some of the public health components have probably gotten into my blood. As a child, I studied in three countries as my father travelled. It was actually on three separate continents. I first studied in Chennai, India, then in the UK and the USA, and finally came back to Delhi. And I think this is because my father always had the feeling that you should serve your own country. I don't feel guilty for having shifted from India because I gave the very best years of my younger life to India. And now, as I said, I feel like a global citizen, and therefore, I love serving the whole world. Actually, when I went back to Delhi, I did the pre-medical course, joined the medical college at Lady Hardinge Medical College, and then did MD pediatrics at the Safdarjung Hospital. At that time, I decided to specialize in neonatology. I've served newborns in various capacities in India as a Neonatologist, working in several large NICUs. And then, I will tell you later where I think you are asking some questions about how I came to America and how I joined the global health arena. My service in newborn health has expanded to over 50 years. And I'm very grateful to God, destiny, or whatever you want to call it, that it has allowed me to remain in the newborn arena.

Dr. Patel: Certainly. It is indeed fascinating to note that while medical practitioners traditionally concentrate on individual patient care, professionals engaged in Public health, Health policies, and Global health address the health concerns of larger populations. Could you highlight the major differences that you have experienced while working in different domains of Healthcare?

Dr. Narayanan: Indeed, the approach to global newborn health has been a focal point of my work at Georgetown University. I have been privileged to teach a separate course on this topic for international health students. This emphasis on newborn health is vital. And as I often teach the students, when you're a clinician, you have a very narrow-minded view. I don't mean narrow-minded in a bad way but with a narrow vision. And it's right because that's the way clinicians have to act. They have to focus on the baby and the immediate environment, the parents, and the families. But when you're in global newborn care, you're not addressing the clinical components, but you're looking into what is needed to support that clinical component. And this would be like, right from the competence of the staff dealing with it, what is required for their training? What policies are required that extend beyond the hospital or the facility? Where is the link with the community? and goes up even higher when you develop national policies. And that is what I have been thrilled about because I have helped countries develop national newborn health strategies and I think doing both, with the background of being a clinician and coming into global health, has given me a very holistic approach to newborn care. It's not just what I view as a clinician. Of course, as I get deeper and deeper into global health, my clinical skills become rusty. So, I no longer work in the newborn or NICU, as I used to do before. But I link with some very excellent colleagues in the level four NICU in Georgetown, and we work together for the global health components. It's been a very exciting journey.

Lady Hardinge Medical College, delhi, India
Lady Hardinge Medical College, delhi, IndiaImage: Wikimedia Commons

Dr. Patel: What are the most common or challenging situations in this field of work within the global health sector?

Dr. Narayanan: I think perhaps in one way I've been blessed because I came with a clinical background, so I sort of have some idea of how to work with the clinicians and also how to expand the view. One of the challenges is that in global health, you're dealing with a variety of countries, each with a different socioeconomic status, their advancement, and the resources they have. And truly speaking, although you call it "Global health," it isn't really global health. The focus is primarily on low- and middle-income countries. There's very little said about high-income countries. So, I'm often not clear why they call it global health because you focus so much on these countries, which in a way is correct. After all, they are the ones who need a lot of support. I think that is one of the challenges. And then another thing that I have noticed is that much of the support for it comes from high-income countries, and they are sometimes not quite familiar with all the challenges that exist in low- and middle-income countries. And that is another blessing I have because I come from a low- and middle-income country, and therefore I am not only familiar with the clinical situation but also familiar with the background of the country, the resources, the challenges, and their attitude. This is also what I teach to the students in Global Health: you have to deal with some humility because I sometimes see people come from very advanced centers thinking that they know everything. They do know a lot; there is no question about it. They are working in a much better setup, but I think you have to give credit to people who work in low- and middle-income countries who strive to use the best-given resources that they have, and you cannot transplant everything from an advanced country to a low- and middle-income country because you have to adapt to certain things. And this is why when I teach global health students, I say that besides going in with some humility, you also have to remember that learning is a two-way experience. It is not that people are going to learn from you when you are teaching or training them or you go to a country, you are also learning from them, and when you have that attitude, you will find that you will really have improvement at the global level.

The baby's progress was remarkable, and it quickly became the centre of attention in the neonatal unit.
The baby's progress was remarkable, and it quickly became the centre of attention in the neonatal unit.Image: Wikimedia Commons

Dr. Patel: Are there any interesting patient-related cases or experiences that you distinctly remember?

Dr. Narayanan: One significant experience that stands out in my memory occurred when I transitioned from public hospitals to private hospitals after many years. At the time, there was a notable difference in outcomes between public and private healthcare facilities. Despite limited resources, the hospital I joined achieved remarkable results. We successfully saved a 600-gram infant, which was a groundbreaking accomplishment in those days. I vividly recall an incident when I discovered a tiny baby on a tray in the labour room, and upon questioning why I wasn't informed, I was informed it was considered an abortion. Realizing the baby was alive and breathing, we immediately transferred the infant to the neonatal unit. The baby had likely been hypothermic for an extended period, but with careful monitoring and administering necessary treatments, the baby's condition improved, and we were able to initiate feeding after a few days.

The baby's progress was remarkable, and it quickly became the centre of attention in the neonatal unit. However, a sudden and alarming event occurred when the baby reached one month of age: the baby stopped breathing. The nurses were overcome with panic, and we immediately initiated resuscitation efforts. Since we didn't have a ventilator at the time, we manually ventilated the baby, taking turns to sustain their breathing. As time passed, I began expressing my concerns to the nurses, recognizing the potential harm we might be causing without the necessary equipment like oxygen blenders or pulse oximeters. I firmly believed that this approach was not appropriate.

Together with the nurses, we made collective decisions on when to discontinue resuscitation based on ethical considerations. We maintained constant communication with the parents, who were also hospital staff members, and they entrusted us with the decision-making process, having full faith in our abilities and the unit. I continued engaging in conversations with the nurses, urging them to be cautious yet persistent. Their attachment to the baby grew stronger with each passing moment. And then, miraculously, the baby started breathing again. It was truly unbelievable, but this baby not only survived but thrived. I apprehensively anticipated the follow-up, concerned about the possibility of developmental challenges. However, to my delight, the child grew up exceptionally well, even achieving second place in their class at school.

In the years that followed, I became a Rotarian and received generous donations and supplies for the hospital through the Rotary Foundation. When it came time to install these resources, I deliberately chose not to invite any VIPs. Instead, I invited the young girl, who had now grown up, to be the chief guest and inaugurate the new facilities. This particular event holds a special place in my memory.

Bottles of Pumped Human breast milk
Bottles of Pumped Human breast milkSource: Wikimedia Commons

The second thing in my life that brought me into the global arena before I even got into global health was a research idea. In all the medical colleges that I worked at, I was always teaching students, which is a big passion for me. I do that even here and also research which has also been with me for many years. We did a study to show this because most people said this again way back in the 80s when people thought that human milk had a lot of anti-infective factors but could protect against infection. After all, it got destroyed in the infant’s gut. They said if formulas were terrible it was because of poor hygiene and dirty bottles, and adding water that was not clean but we felt that babies who were on breastmilk did well. You cannot compare breastfeeding with bottle feeding, because with breastfeeding you hardly get any contamination, and exposure to organisms is very low as it contains naturally occurring antibodies as well.

In contrast with the bottle, where you are getting a whole lot of other types of contamination, we thought it was not sensible to compare breastfeeding with bottle feeding. What we did was compare it in a randomized controlled study, 'Breastmilk with the Formula'. So these were the babies who could not suck so breast milk was expressed and given to the babies even though in those days there were no milk banks in low and middle-income countries, it was just collected, and we educated the mothers to the best that we could because I worked in a place where there were very low socio-economic groups of mothers coming to the hospital and we found out that we do get contamination in breastmilk despite whatever degree of care you are asking them to take because we were not pasteurizing this milk. In contrast to the formula prepared by the nurses especially when the new research study was going on they were bent over backward on getting everything correct they hardly grew anything. Despite that, the breastmilk-fed babies did report remarkably well. It was like there was this little umbrella over the baby which protected the baby and then I had this most remarkable thing. I will never forget this. It's one of the incidents that changed my life, and whether you call it destiny or God, something comes into your life. When I did this research, I suddenly got a letter from a big international conference in Kuala Lumpur, and I don't know why I just sent them the abstract of my work.

This is pretty crazy because in those days, government hospital people were, you know, not paid that much, and there is no way I would have managed to go to another country to present my work, and you will not believe it. Just two weeks after that, I got a message. You know, you didn't apply for funding. We will fund you for this trip. And I said, "My God, this is remarkable." And when I went there, it was even more remarkable. It was not like a regular conference. From all across the world, top-notch immunologists, pediatricians, and neonatologists were invited, making the event feel like a plenary session. Everybody listens to everybody's presentation. So I was so lucky that when I presented this work, they said this is the first work of a randomized control study that has been shown to prove the clinical importance of the antique. The article got published in The Lancet. That's how my name got known outside, and I think that's why I got this offer for global health, and that was the third big thing that kicked off my life in global health. In 1999, I think it was somewhere in June, about 10:00 PM, I received a call from a company called PATH, which is programmed for suitable technologies and health. They asked me to come as the team leader for newborn care for a USAID project on newborn child health, and I immediately responded, "Of course, I will."

I thought it was a scam. I said, "Who on Earth will call me from America at 10:00 PM and offer me a job, you know?" And then I got frantic calls again and again. Then I realized, "This is not a scam, yes, and they are telling me the truth". And by that time, as you know, I had served for many years in India. Actually, I was in the US at that time, and I was studying there. Unfortunately, my husband had passed away, and I thought I had nothing to lose. I said, "Let me go and try it", because, as I said, you know, my father had been in the DGHS, and I did have that public health background. I used to also do some consultation and I've taught public health bosses in India and I said, "Let me try this, if I don't like it. I can always come back." You can always come back to your own country from wherever you go. But that set off my thing. I fell in love with global health, and I've stuck with it. So these have been fantastic, sort of. There were special events in my life that sort of shaped me the way I am today.

Georgetown University in Washington, DC.
Georgetown University in Washington, DC.Image: Wikimedia Commons

Dr. Patel: Ma'am, having had the privilege of working in both India and the United States, can you tell us what difference do you see in the pediatric healthcare system, in these two countries?

Dr. Narayanan: I will give you some points. I had not worked on the clinical side here, because I never came to do clinical work here. I've come as a visiting professor many times because that's the other thing, You know, I often joke that because of the research, many people invited me abroad, and they were all very high level, I was invited to posh hotels and fancy places to give lectures. And then when I came into global health care, I got into the poorest of countries, I went into those giggity rides on rough roads to the community, so I have a very balanced view of the world and it's been a wonderful, wonderful experience. So, I think some of the differences are that you have more resources in high-income countries even though they complain. Also, they are overworked and it's nothing compared to what the low- and middle-income countries do after work. In addition, perhaps because the workload may be less, they also have to do it much more intensively. So they're sitting around doing nothing the whole day with fewer patients. They have to do a lot of things for each patient. I think the quality of care is much better in many centers, not that it is not that good. In some of the centres in lower-middle-income countries, especially in India. India is home to some excellent hospitals. It is more challenging to practice quality of care, and quality of care is a very special focus for me in global health. I think those things are different in the two places. Maybe the type of patients you have to deal with is a little different because, in low- and middle-income countries, you also have extremely poor and far less educated people. So I think the approach may be different, not that your care has to be different because, for me, the top priority is not just good quality care, but compassionate quality healthcare. I spent a lot of time teaching students about that. Care must be provided in a compassionate manner, which is crucial.

Consultant in Global Maternal and Newborn Health and Adjunct Professor, Neonatology, Georgetown University, DC.
‘Lights out’ for Antibiotic-Resistant Superbugs

Dr. Patel: I have two specific questions related to awareness, especially in paediatrics and child health. Therefore, as you must be aware, we frequently report the rise in the number of cases of antibiotic resistance and of secondary infections. Incidences like these are increasing, so what would be your advice in the case of rational use of antibiotics, especially in children?

Dr. Narayanan: As I said, I have not practiced clinical work for a very long time, but a lot of this is common sense, and we're certainly doing a lot for antibiotic stewardship. Misuse of antibiotics is rampant, particularly in middle-income countries.

In some countries, purchasing antibiotics without a prescription is now illegal due to concerns surrounding their over-the-counter availability.

Naturally, this also means that the doctors have to be diligent. They cannot just prescribe antibiotics for safety. They do need some criteria. Advanced Countries have mobile apps which help you decide on antibiotics. I have discussed it with some of the people in India and they sometimes say some of the criteria used for that are difficult to apply in low- and middle-income countries, but I think they need to sort that out. But this is a very big issue and the other thing that worried me was even the WHO thing. You know, the management of possible sepsis, which is very important because they manage it better in the centers for babies and are not taken to the higher-level centers, and I think it's a great idea, but sometimes it worries me that somebody will overuse antibiotics in that type of situation. But that is difficult to decide because you have to sort of decide: To what extent do I have to go to save this baby who's not able to go to the facility or do I have to worry about the antibiotic, needless antibiotic resistance, and overuse of antibiotics? That's a difficult question to answer.

Dr. Patel: What guidance would you offer to parents who display hesitancy or reluctance in having their baby vaccinated?

Dr. Narayanan: This is also difficult, maybe less difficult in low- and middle-income countries because. I believe the advice I previously gave regarding vaccinations is still valid today. The established vaccinations have so far been effective, but I can't say the same about COVID because that vaccine is much more recent. I believe that many more randomized control studies need to be published on the complications associated with the vaccine, the complications associated with the disease, and the deaths associated with the disease before it can be decided whether or not the vaccine is safe. But the childhood vaccines that have been there for many, many years are well established. So, the things that I tell the mother are that we have to be honest with them because vaccines do have side effects also and unfortunately some of them can be pretty severe. So. Fortunately, they are much rarer complications. So, I usually used to tell them that there will be of course the local minor problems we say it's easy you can overcome them with analgesics or whatever you have. But any complications reported with a vaccine are never as high a percentage as it is in the disease, obviously, you're not going to give a vaccine where the complication rate is higher than it is with the disease, and it is not protective enough. So, I think it's common sense and most pediatricians would agree that except when you have some newer vaccines where you're not quite certain. We can't give a blanket thing. We can only say as we currently know it is still more effective at protecting and having fewer complications than the actual disease. But for the very new ones, you cannot give that guarantee, but certainly, for the old ones, I think there is enough evidence that we can make those statements.

Dr. Patel: So, we'll step into some lighter portions of this interview now. Ma'am, what are your plans for the coming few years?

Dr. Narayanan: Yeah, there are only a few years because I've been here for many more. Many people are shocked that I'm still working, but I just love it, because it's mine. Newborns have been my total life-long passion, and if you're interested, I've written a poem about it that I can share with you.

I think I will still work in global health. I'm in a very fine situation here at Georgetown University because, as I said, my clinical sense now is Rusty. After all, for over 23 years now, I've been in global health. So, I will work with what I have worked on.

One of my favourite countries is Ghana in Africa. They invited me to write up their national strategy for newborn health in 2014. They invited me again in 2018 to update it and I've been working with the hospitals there too. You know, to focus on the quality of care. It's all voluntary. Nobody gets paid for anything for that and we have been in the process of publishing it. We have improved one of the things: babies were coming very late for jaundice, especially newborn babies that got discharged very early. So they were doing a lot of needless exchange transfusions and by doing a quality improvement program we were able to decrease those incidents. We've got some very, very interesting results. These are getting ready for publication and Georgetown has been invited to be a part of another USAID project with Jordan, so we are working with them. This focuses on the 'Golden hour', the first hour of the life of newborns. It was only in 2022 that I was permitted to start a very short course in global health, just under global newborn health. Of course, it's a one-credit course, which is a tiny course, I do it like a workshop. It's a small step in global health, but a giant leap for the newborn because it came as an independent entity. I don't prescribe a vertical program for newborn health, it should always be linked with maternal and child health. But I think it needs attention to itself, because it sort of, that's one of the problems with newborn health. It has a degree of invisibility. It gets masked by the giants of maternal health on one side and child health on the other, because, after all, the newborn is only in the first four weeks of life. And unfortunately, that is your highest death period. We had the highest mortality rates in this period. And in fact, it was the high neonatal mortality that hindered some countries from getting the MPG4 goals, and if we don't take care, it'll also interfere with the SDG, and therefore I think this is something extremely important.

Dr. Patel: Ma'am, can you kindly tell us about your passions and what you like to do in your free time?

Dr. Narayanan: You know the crazy thing I did was planning my retirement. And then I felt like I had left some of my paintings behind, and I am also writing a poem. I wrote about one of my two great passions. One was on breast milk, which got published in a medical journal because the editor was there when I presented it at the meeting. He said to send it to him and he would publish it in the journal, which he did. And I've written one for the newborn which is my signature tune. I end all my lecture sessions with that. But somehow everything gets back to work. I used to read lots of storybooks, but I'm back to reading articles about the quality of newborn care and so on. So I'm one of those freaks who gets stuck in this. But I suppose when I'm unable to do this, I will probably try to do those other things I don't know yet. But it'll depend on my physical capabilities. I will stay as long as I can maybe a few years. I'm not clear about it. Whatever God has destined for me.

Dr. Patel: So, this brings me to the question: if your life was a movie, what would be the title for it?

Dr. Narayanan: I think I would say 'In the service of the family and newborns globally'. Family & Newborns are of course very important for me. I moved from DC to Boston now because most of my work is remote except for the course which I have to go back to DC. I can stay in Boston and add that to being closer to part of my family here. But at this stage, you know that even their grandchildren, when they're very young, have time. Now everyone is busy, so I also need something to do instead of running after them. So, I think in this way I have the best of both worlds.

Dr. Patel: Finally, what would be your message to young doctors like us?

Dr. Narayanan: I think if they're coming into medicine, they have to come with their eyes open. Things have changed significantly, and I think a lot has to do with the way the administration manages hospitals, especially in high-income countries. In the low & mid income countries the doctors handle patients, you know, and we naturally tend to provide compassionate care. We want to spend more time with them. Here, there's a lot of time spent just writing up everything because you want to avoid medico-legal problems. I agree that it's important to record it, but you also need time to talk to patients and spend time with them. So, I think you should first go with it, with your eyes open. In some of the low- and middle-income countries, I have heard of people joining it just because they feel they could make money. That's the wrong reason to get into this line but if you have a passion for it, the reason why I say passion is important, choose a line where you are passionate, because then it no longer becomes work, it becomes a way of life for you. And then it's more and more exciting because you have more ideas. Of course, you have to grab things like basic administration, management but that's with every job. But if you like the area that you're working in, I think it's wonderful it's a way of life. It is your passion, and you live it. Its no longer just work.

There is no way you should do research without really good ethical practice. However, there are two things, that require evaluation: research and quality of care.
There is no way you should do research without really good ethical practice. However, there are two things, that require evaluation: research and quality of care.Image: Wikimedia Commons

Dr. Patel: After talking to you, I have come to understand the true importance of research. Do you think more emphasis should be paid to the Research projects? Especially post COVID.

Dr. Narayanan: I have always felt research is important. It has been a part of my life. You, of course, have to do it with ethical practices. There is no way you should do research without really good ethical practice. However, there are two things, that require evaluation: research and quality of care. Research automatically has evaluation because if you're doing it correctly and especially if you do like randomized control studies, and even without that. You do have an evaluation that needs to be objective and correct. Even with quality care, you have to have data to monitor that whatever you're doing is getting the right result. That is very important because if you just keep doing things and training people, it doesn't necessarily show that you've got good results.

You might have increased somebody's knowledge and skills, but if the unit is not functioning in a manner that improves the outcome for the babies, the satisfaction of the patients, and the; satisfaction of the mothers and fathers of babies if you don't consider it as a family-centred approach. There are wonderful things that have happened to the newborns like Kangaroo Mothercare, and maternal involvement, and I started this way back in Delhi somewhere in the 80s when we had mothers as a part of the neonatal unit, which is now expanded much more. I think those components are extremely important and if we don't do that you will be practicing medicine which you think is alright, but it may not have an impact if you cannot document your fears. I have made this improvement. Not me, when I say I, it's always teamwork. No one works in isolation. So I strongly feel that whether you call it research or evaluation, even your quality of care is for every patient, whether you're doing research or not. So I think that those things are extremely important.

Consultant in Global Maternal and Newborn Health and Adjunct Professor, Neonatology, Georgetown University, DC.
Hypnophobia - The Fear that keeps you awake…

Dr. Patel: Thank you immensely, Ma'am, for your inspiring insights. It has been a pleasure engaging in this conversation with you. As we conclude, would you kindly honor us by sharing one of your poems?

Dr. Narayanan: So, I called it 'The newborn', and, as I said, I'm a humble admirer of the area.

"Many years ago, more than I care to remember,

I stepped as a young student into the sanctum sanctorum, the NICU,

Irresistibly, my finger slipped into the beautiful little hand.

I gazed in awe, the hand had grasped my finger and my heart too.

It mattered not when I later learned that the grasp was but a reflex,

By this time, the hand was tight around my heart,

To this very day, we have journeyed together all the way,

Making sure that over the years nothing could keep us apart

We stayed together even when came my darkest hour of need,

When my shattered heart cried, "Why me?"

The tiny grasp and the mystical smile sent a calming

"Take heart! Time will heal. Most surely!"

The newborn has always been a part of my work, my life,

As a doctor, a researcher, a teacher, and a counselor.

Pointing me in the direction of international health,

Taking me around the world to countries galore.

Through my numerous journeys around the world,

One fact was hard to understand but plain to see.

How could a mighty atom, with cries so loud,

Stay so many years cloaked in invisibility?

But now, my friends, these silenced cries of the innocent,

Only at our peril can we continue to ignore it.

Together, we must forge ahead, helping babies thrive.

Surviving the ordeals of birth and living among the rich and poor

Some time ago, I decided to cut back and pause.

It was time, I thought, to stop and smell the roses on the way.

But soon it dawned on me and I realized my loss.

It was now clear to me; the newborns are the roses on my way.

So it did not take me long to get back to the grind,

I am happy to have my dear newborns in my view.

A little nod, a gentle shove to support all levels

Precious bundles that add to this world a special hue.

And when one day I pass on, hopefully up above,

I'm afraid I have to admit it. I have to say,

I will not be able to resist giving even God a little nudge,

to ensure that he does his bit to get my newborns on their way!"

Consultant in Global Maternal and Newborn Health and Adjunct Professor, Neonatology, Georgetown University, DC.
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