History of Nursing in the USPHS
The Public Health Service originated in 1798 as the Marine Hospital Service through an Act of Congress signed by President John Adams on July 16, 1798. Congressman Edward Livingston from New York was a leader in attaining enactment of this bill. The concept of providing seamen with medical care originated in England. A hospital for English seamen began operating after King William III decreed it by law in 1696. The hospital funding was obtained through payroll deductions from the seaman’s monthly wages. By 1708, the American colonies began opening hospitals to provide medical care for seamen. Often ships would leave port abandoning ill seamen. There was no system in place to provide them with health care. The country was dependant at that time on the sea economically. Concerns about potential imported epidemics from diseased seamen and resulting national economic sequelae if ports were closed moved the notion to establish a national health care system for seamen modeled after the English system. In 1799, the first hospital opened as a component of the Treasury Department. Congress had mandated the Marine Hospital Service to provide “for the care of sick and disabled seamen”. A network of hospitals across the country developed over time to fulfill this responsibility. A payroll deduction of twenty cents from the seamen’s monthly wages funded the hospitals. Health care was also extended to the US Navy (from 1799 to 1817) and to the Revenue Marine Division of the Treasury Department (later it became the US Coast Guard.) The first facility opened at Castle Harbor, Boston in 1799. Hospitals were established in ports on all coasts, and major inland waterways. In 1870, the Service reorganized establishing national standards. Also in 1870 a headquarters in Washington, D.C. was established. Dr. John M. Woodworth was appointed as the first Supervising Surgeon (a position now known as the Surgeon General) in 1871. With the passage of the National Quarantine Act of 1878 following a yellow fever epidemic, responsibility for quarantine of infectious disease transferred from the states to the Service. The Commissioned Corps was established in 1889 to provide a uniformed, mobile, career corps of capable physicians known by the term surgeons. The Officers were assigned to the Service, not to a particular position, geographic location, or hospital.
Since the inception of the Marine Hospital System in 1798 nursing care was provided to the ill and disabled seamen. In the early days of the Marine Hospital System, former seaman identified as attendants, administered nursing care to patients. The attendants functioned under the direction of the surgeons. Nursing skills were learned through practice and observation of others.
A movement to open formal Schools of Nursing started in the 1890’s. The nurse training programs were apprenticeships. Educating nurses to become health leaders and health promoters came later. Nursing did not become a profession until the twentieth century.
Health inspection duties and care of immigrants were assumed by the Service with the passage of the 1891 Immigration Act. In 1892, a facility located at Ellis Island opened for the processing of arriving immigrants. At this facility thousands of immigrants received health inspections daily to determine if they met the health requirements for entry into the United States. The Service on Ellis Island occasionally hired trained nurses. The nurses worked under the direction of the surgeons. In 1903, Mary Daly was one of the trained nurses that assisted the surgeons in conducting health inspections at Ellis Island.
In 1902 the Service was renamed the Public Health and Marine Hospital Service. During 1912, the Service, known as the PHS, formally employed trained nurses. During that same year, the Service was granted legislative authority to study the diseases of man. The Children’s Bureau was established as mandated by Congress for monitoring issues related to children’s welfare. In 1913 trained nurses Ms. Edna B. Hill and Ms. W. S. Brasher were sent to rural Kentucky to work under the supervision and direction of the surgeons in the Trachoma Treatment and Prevention Program. The Trachoma Control Program Chief Nurse was Ms. Mae Hicks. Over the next eleven years, fourteen Trachoma Hospitals were opened. Each Trachoma Hospital had a bed capacity for twenty five to thirty five patients and a healthcare staff consisting of one doctor and two nurses. Travel was arduous and field clinics were established to bring treatment into the remote communities. The communities showed their support of the health program by providing facilities, such as schools or churches in which to locate the clinics. Local women’s groups provided meals to the patients. The Trachoma Program was a vehicle for expansion of the role of nurses. Field nurses assessed patients. Nurses of the Trachoma Program taught health education. Instructing mountain families on health promotion and prevention issues was both innovative and pioneering at the time. Basic principles of hygiene and infection control were among the topics that the nurses taught to prevent the spread of trachoma. The mountain families were taught not to share wash towels or sleep in the same bed with infected persons. The following year, in 1914 M. Maude Fauquier became the first nurse assigned to participate in field studies at the Public Health Service Hospital for Pellagra in Spartanburg, South Carolina. Dr. Joseph Goldberger, a PHS Officer had correlated diet with pellagra in 1914, paving the way for treatment and prevention.
The American Red Cross Department of Nursing was created to recruit nurses for assignment with the United States Public Health Service, the Army, and the Navy. During World War I Lucy Minnigerode, a Nursing leader and American Red Cross Official, was instrumental in nurse recruitment. Nurses were assigned to the cantonment area wards, US Base Hospitals overseas, with the National Guard, or at embarkation sites. The Public Health Service employed more than 120 nurses for disease prevention duties in the extra-cantonment zones established around military camps and in venereal disease clinics. Some nurses worked with local health departments in the extra-cantonment areas. Public Health Service nurses were charged with communicable disease investigation, health care instruction, disease prevention, sanitation, and assisting in the health inspection of school age children. The recognition of nursing as a discipline occurred with the appointment of Mary Lent as Supervising Nurse of the extra-cantonment nurses. Her leadership brought about a coordinated system of local public health nursing services. This coordinated system served as a catalyst for the formation of the field of Public Health Nursing at the state and county levels.
With the conclusion of World War 1 an Act of Congress awarded the responsibility for the care of sick and disabled veterans to the PHS. Lucy Minnigerode was appointed in 1919 as the first PHS Superintendent of Nursing for 23 Marine Hospitals and dispensaries. During the Spanish Influenza epidemic of 1918, Lucy Minnigerode developed partnerships between the PHS and the American Red Cross to open a hospital and clinic to care for victims.
Congress passed the Sheppard-Towner Act (Federal Maternity and Infancy Act) in 1921 allocating money to employ public health nurses through the Children’s Bureau for maternal and child health. From 1921 until 1929, PHS nurses worked with states participating in maternal and infant hygiene programs. The Sheppard-Towner Act led to the establishment of 2,978 Prenatal and Child Health Centers across the nation. Home Visits by nurses were made to instruct mothers on self and infant care. Nurses demonstrated through health promotion activities that they could improve the Nation’s health. In 1921 the PHS purchased the Louisiana Leprosy Hospital in Carville thus creating the National Leprosarium (Gillis W. Long National Hansen’s Disease Center.)
By 1922, through the leadership of Lucy Minnigerode the nursing staff expanded from 90 to 1,800 nurses working in hospitals with a bed capacity of 20,500. In 1922, the American Red Cross assigned 628 nurses to the PHS. In January 1922, the PHS opened a School of Nursing located at Fort McHenry, Maryland. In April of 1922, the responsibility for the care of veterans transferred from the PHS to the newly created Veteran’s Bureau. The Veterans Bureau accepted the transfers of 1,400 PHS nurses and the School of Nursing. The PHS was left with a staff of 350 nurses and 24 hospitals containing 3,000 patient beds. Federal nursing was recognized by the American Nurses Association by the naming Lucy Minnigerode as the first chairperson of the section for Nurses in Government.
In 1923, nursing was accepted into the Civil Service System as a sub-professional group. The scope and variety of nursing within the PHS in the 1920’s is documented in the 1923 Annual Report of the Surgeon General. The discussion of nursing services in the report indicated that positions filled by professional women (nurses, aides, and dieticians) in the PHS, with the exception of physicians were included in the nursing section. The report begins by stating that while the major operations of the nursing service are in the hospital division; the work of the service involves other divisions as well. These other activities are summarized as follows:
“Eleven nurses are employed in the division of domestic quarantine -chiefly, in trachoma investigations; nine are employed in the division of scientific research, the majority of these in industrial hygiene; one nurse is employed in the venereal disease division for special educational work; and 11 are employed in the division of foreign quarantine at New York, Boston, Gloucester, and San Francisco, respectively, where they are necessary for the delousing of female immigrants, care of the sick detained patients, and for general nursing work. A quarantine hospital is maintained at Hoffman’s Island, New York, with four nurses on permanent duty there. This number is necessary to meet emergencies arising suddenly from time to time…”
Toward the end of the decade, the PHS became involved with the health care of American Indians. In 1928, a PHS medical officer was assigned to serve as Director of Health for the Bureau of Indian Affairs within the Department of the Interior. Over the next several decades, various PHS staff, including nurses were assigned to provide health care to American Indians under the Bureau of Indian Affairs.
In 1929, the Division of Mental Hygiene was established. In 1930, nurses became involved in correctional nursing as the PHS assumed responsibility for federal prison health care. Nurses trained in psychiatric work were assigned to the narcotics hospitals for drug addicts opened by the PHS in Lexington, Kentucky and Fort Worth, Texas from 1935-1938.
A survey completed by Sophie Nelson in 1932 revealed the need for increased public health nursing services. The visionary report produced by Ms. Nelson covered areas such as minimum qualifications and levels of education relating to nursing skills. She raised concerns in the report that the civil service classification of nursing as a sub-professional group, and without qualification standards prohibited the potential growth of nursing as a field. The report further elaborates that nurses with educations from institutions of higher learning would possess the qualifications needed to meet the public health needs of the country. In 1933 Pearl McIver was employed by the PHS in the Division of Public Health as a public health nursing analyst to address the public health nursing needs of the country. In 1934, Ms. McIver continued her work within the Division of Domestic Quarantine, States Relations Division. The PHS scope expanded at this time with the establishment of the Maternal and Child Health Division and the Crippled Children’s Divisions.
The Social Security Act of 1935 was an important component of Franklin Roosevelt’s “New Deal”. The demands on the Service for public health nursing consultants increased greatly when the Social Security Act of 1935 assigned to the PHS the duties of assisting states and districts in establishing health organizations as well as facilitating the training of public health personnel. The Washington staff advised the regional staff on standards of nursing service. The creation of the Nursing Unit of the Children’s Bureau in 1936 was to provide public health nursing services. Pearl McIver was chief of the division responsible for training and assigning public health nurses to health departments. The PHS hired several additional public health nurses to assist Ms. McIver in providing consultation to the states regarding nursing issues. In 1936, the PHS presented the states with a review of projects submitted to the Works Project Administration (WPA.) This was the beginning of federal public health nursing consultation to state health departments. In 1939, the PHS moved during reorganization from the Treasury Department to the Federal Security Agency along with other social service agencies. From 1940 to 1945 the PHS employed 16,000 people.
With the entrance of the United States into World War II in 1941, an already existing shortage of nurses was exacerbated. The Office of Civilian Defense requested the Red Cross to train 100,000 nurse aides yearly to perform non-skilled nursing care. To alleviate the nursing shortage on July 1, 1942 Congress appropriated funds for nurse education in the form of refresher classes, postgraduate courses in specialty areas, and to increase nursing program enrollment for students with financial need. The Surgeon General requested the Office of Defense Health and Welfare Services, the Health and Medical Committee, and three-nursing education consultants to form an advisory group for preparing regulations for the allotment of these funds and to guide the administration of these funds. In 1942, 73 schools of nursing provided 2,300 inactive graduate nurse’s with refresher courses at no charge in return for their agreement to return to the work force. By 1943 48 institutions of higher learning had given postgraduate instruction in various specialties to 2,885 graduate nurses. Twenty-four colleges and universities provided 813 public health nurses with advanced public health training. A national census of nurses was completed. In an effort to recruit more nurses for essential civilian and military duty on June 15, 1943, Congress passed the Nurse Training Act (often called the Bolton Act after Representative Frances Payne Bolton, who introduced the bill.) The bill, Public Law No. 74 of the 78th Congress contained a provision prohibiting discrimination
based on race, creed, or color. This Act created the Cadet Nurse Corps of the Public Health Service. The Corps provided scholarships and stipends to all students enrolled in accredited schools of nursing in exchange for their agreement to work in essential nursing services for the duration of the war. More than 124,000 nurses graduated from the program before it ended in 1948. This scholarship program was developed to meet both military and civilian nursing needs.
In June 1943, the PHS established the Division of Nurse Education within the Office of the Surgeon General to administer the Cadet Nurse Corps program. Surgeon General Thomas Parran appointed Lucile Petry (later Petry Leone) as Director of the Division. She thus became the first woman to head a major PHS division. Nursing students received the scholarship upon acceptance to one of the 1,125 schools of nursing whose curricula and nursing facilities met the standards prescribed by the Public Health Service. The scholarship included funding for tuition, uniforms, books, fees, and a stipend. A national publicity campaign ensued promoting nursing as a career. Several movies included characters that were Cadet Nurse Corps members. The Cadet Nurse Corps was featured in magazines, billboards and on the radio. A fashion contest was held at the Waldorf Astoria Hotel in New York where the stylish uniform was chosen with the fashion press making the selection. The beret concept was adapted from the beret worn by the popular British Field Marshall Montgomery. On May 14, 1944, 96,000 Nurse Corps Cadets in a NBC national radio broadcast pledged themselves to “essential nursing services.” Eleanor Roosevelt, First Lady and wife of then President Franklin D. Roosevelt, Congresswoman Frances Payne Bolton, and Surgeon General Parran were present at Constitution Hall for the ceremony. The evolution from nurse training programs with apprenticeship as the main means of teaching nursing skills to a more academic approach was influenced by the education standards set by the Nurse Cadet Corps scholarship program. The Nurse Cadet Corps scholarship program offered the opportunity of an education that otherwise for many students would not have been possible and helped establish a prominent place for nursing as a profession in the PHS. The Nurse Cadet Corps scholarship program established a precedent for federal involvement in nursing education. The federal focus on nursing research had its origin at this time when questions about the quality, quantity, and competence of nurses arose. The Cadet Nurse Corps program collected information from the nursing schools related to nursing education and nursing service problems facing the nation. Using this information the PHS and the National Committee for the Improvement of Nursing Service produced a report, Nursing of the Mid-Century. The information collected for this study created a national momentum among nurses that resulted in the establishment of the National League for Nursing in 1952.
The Public Health Service during WWII coordinated health and welfare programs with the states. There was a 141% increase in admissions at the 30 PHS Hospitals according to the 1943 Surgeon General’s Annual Report. Communicable diseases such as tuberculosis, typhus, venereal disease, and malaria control programs went into effect. Thirteen states added industrial nursing consultant staff. During the course of World War II, PHS nurses served at various posts to assist in the war effort. There were PHS nurses detailed to Public Health Service Hospitals, the Military, the Office of Civilian Defense, the Coast Guard, United Nations Relief and Rehabilitation Administration, the Migrant Health Program, the Liberian Mission, Office of Civilian Defense, Department of Agriculture, Immigration and Naturalization Centers, Quarantine stations in Europe and the Far East. World War II also led to broader changes in the PHS, including a reorganization in 1943, which divided the Service into four operating components: the Office of the Surgeon General, the National Institute of Health (NIH), the Bureau of Medical Service, and the Bureau of State Service.
The 1944 Public Health Service Act approved on July 1st of that year authorized the appointment of qualified nurses as Commissioned Officers. In July 1945, the first nurses were commissioned in the PHS, including Lucile Petry and Pearl McIver. The Public Health Service Act provided authority for the PHS to support and conduct medical research. Since that time, the PHS provides funds to universities, hospitals, laboratories, and other institutions to encourage research in the health fields. The 1946 Hill-Burton Act authorized federal assistance to build hospitals and medical centers. Resultant hospital expansion, new healthcare technologies, national economic prosperity and national viewpoints regarding expected higher levels of health led to a greater demand for nurses. The postwar era found that the locus of health care changed from the home to the hospital. During the years of 1940 – 1945 the PHS employed 16,000.
In 1946, the Malaria Control Program became the Communicable Disease Center. After the war, there were further changes in the organization of nursing services within the PHS, the Division of Nurse Education (DNE) was replaced by a broader Division of Nursing. Like the DNE, the new Division was located within the Office of the Surgeon General. Lucile Petry served as the Director. The Division of Nursing supervised all PHS nursing activities. These programs included the Office of Public Health Nursing in the Bureau of State Services, the Office of Hospital Nursing in the Bureau of Medical Services, and the Office of Nurse Education. The division’s responsibilities included the following: provide consultation to government and state agencies, determine the nursing needs of the PHS, provide leadership for legislative issues, suggest improvements regarding nursing program standards and practice, devise and implement research, and represent the PHS on national boards.
The 1948 study by Dr Estelle Brown, The Future of Nursing, called for replacing apprenticeship nurse training schools with nursing education programs within institutions of higher learning. Dr. Brown believed that the nursing apprenticeship training programs did not meet the quantitative and qualitative demands of modern health care. Dr. Brown’s report became an agenda for nursing leaders to improve and reform nurse education methods. The Office of Public Health Nursing was elevated to the status of a Division within the Bureau of State Services, and it’s Chief, Pearl McIver, a public health nurse, became the Director. This office consulted with state and local health departments, schools of nursing, and professional organizations. Its ongoing mission was to strengthen and broaden public health nursing activities in the nation through workforce studies. Those studies documented the need for more public health nurses, a specialty that brings health care directly to the public.
The reorganization of 1949 created the position of Chief Nurse Officer with the rank of Assistant Surgeon General (Rear Admiral) in the Office of the Surgeon General. Lucile Petry Leone served in this new post. She became the first nurse and the first woman to achieve flag rank in the PHS or in any of the uniformed services of the United States. RADM Petry Leone was responsible for coordinating all nursing activity within the PHS.
The 1949 reorganization abolished The Division of Nursing in the Office of the Surgeon General. Many of its functions moved to the newly created Division of Nursing Resources in the Bureau of Medical Services, headed by Margaret Arnstein. The objective of this division was to develop necessary resources to advance and improve patient care. It was determined that highly educated nurses would meet the divisions goal. Opportunities for systematic study and consultation on nursing problems arose. Continuing education for nurses was encouraged. In this period, the Civil Service System recognized Nursing as a professional group.
During the 1950’s, opportunities for nurses within the PHS expanded as the Service acquired new responsibilities. Nurses assisted cities in the 1950’s to plan Tuberculosis programs. A government reorganization in 1953 created the Department of Health Education and Welfare from the Federal Security Agency. Nationally, most nurses worked in hospitals as general duty nurses. National Nursing leaders were calling for a definition of the nurse’s function and role in the health care field. The PHS nurse consultants provided direct consultation, published papers and reports, taught training sessions, and performed demonstrations in cooperation with state public health agencies to ensure that the health information reached the public health nurse. Positions for nurses to work in research at the newly opened National Institute for Health became available in 1953. Also during this time period 5 PHS Hospitals located in ports had been converted to clinics. In 1954, sixteen PHS Hospitals were operating in major ports with specialty hospitals for tuberculosis, Hansen’s disease, psychiatric disorders, and treatment of narcotic addiction. On July 1, 1955, the PHS assumed responsibility from the Department of Interior’s Bureau of Indian Affairs for the health care of 350,000 American Indians and Alaska Natives, inheriting 3,500 staff members and numerous hospitals, field clinics, and other facilities. This transfer established a Division of Indian Health (the present day Indian Health Service) within the PHS to administer this program including nursing services.
In 1955, The Division of Nursing Research collaborated with the American Nurses Association to create the Interagency Conference on nursing statistics (ICONS0). This research network of researchers and statisticians analyzed gaps in nursing data and disseminated nursing statistics. The decade of the 1950s also witnessed the launching of a number of impressive intramural research projects by the Division of Nursing Resources. In 1956, the National Library of Medicine was created with the transfer of the Armed Services Library to the PHS. The Health Amendments Act of 1956 provided funds for practical nurse education, supported public health nurse advanced training, initiated the Professional Nurse Traineeship Program for nurses to become teachers, supervisors and administrators. Many nurses obtained baccalaureate and graduate degrees with this funding. These milestones led to establishing a scientific basis for nursing through research. By the end of the 1950’s research by the Division of Nursing had provided a visionary direction for nursing education in promoting the nations health. The Goldmark Report recommended educating Licensed Practical Nurses and Nurse Aides as assistant caregivers.
The 1960’s saw the beginning of nurse specializations. Nursing programs began to attract men, nontraditional and second career students. In 1960, the Divisions of Nursing Resources and Public Health Nursing joined into a new Division of Nursing, headed by Margaret Arnstein. In 1960, the Division of Nursing appointed a Surgeon General’s Consultant Group on Nursing (SGCGN). This group analyzed potential problems facing nursing in the coming decade and possible solutions. Their report, Toward Quality in Nursing was published in 1963. A shortage of nurses in the United States was determined by this report. The report identified that not enough students were entering baccalaureate nursing programs, salary discouraged entrance into the profession, and nurses were ineffectively utilized to provide patient care. The report proposed to increase by 130,000 the number of employed nurses. A goal of 680,000 professional nurses in active practice in the United States by 1970 was proposed. The Consultant Group estimated that nursing schools would need to increase their number of graduates by 75 percent in order to meet this goal. This report became the foundation for a new structure of federal assistance for nursing education with the Division of Nursing being the focal point.
The Consultant Group report led to the passage of the Nurse Training Act of 1964, which authorized $240 million over five years for the construction of nursing education facilities, teaching improvement, special project grants, traineeship programs, loans to nursing students, and funds to hospital schools of nursing to improve the quality of instruction. A Nurse Education and Training Branch within the Division of Nursing formed to implement the legislation. The education of nurses became vital to the nation’s health. The Federal Government undertook a leading role in ensuring the health and social welfare of the nation through promoting nursing as a profession, providing nursing educational opportunities, and establishing nurse education standards.
Many changes occurred within the PHS structure over the next decades. From 1967 to 1987, the National Institute of Mental Health (NIMH) acquired responsibility for St. Elizabeth’s Hospital. This federal hospital had opened in 1855, and provided mental health services for over a century. The Food and Drug Administration joined the PHS in 1968.
In 1970 the Division of Nursing was restructured into four primary components: Education, Manpower, Practice, and Research. The National Commission for the Study of Nursing Education sponsored by the National League of Nursing and the American Nurses Association produced the Lysaught Report, an Abstract for Action in 1970. The Secretary of Health, Education, and Welfare supported the report that promoted the expansion of the scope of nursing practice into areas formerly performed only by physicians. The Clinical Nurse Specialist and Nurse Practitioner roles expanded the scope of nurses to ensure access to care by all Americans. The Nurse Training Acts of 1971 and 1975 provided funding to educate nurses for expanded roles.
By 1980, 1.3 million nurses were practicing in the United States. There were large increases of nurses with baccalaureate, graduate, and doctoral degrees. Also occurring in 1980, the Department of Health, Education, and Welfare became the Department of Health and Human Services when a separate Department of Education formed. The 1980’s brought about the closure of the 8 PHS Hospitals and 27 clinics. The Merchant Marines (Seamen) were no longer eligible for medical care from the PHS. Nursing Research in the PHS received recognition with the creation of the National Center for Nursing Research at NIH in 1986. The placement of the Center at NIH meant that Nursing Research would be located within a broader based biomedical research environment. Nursing Research facilitated collaboration between nursing and other research disciplines. The Nurse Training Act of 1985 further promoted nurse role expansion with funding for nurse anesthetist and geriatric nurse practitioner programs. By 1989, 1.7 million nurses were practicing in the United States. The 1990’s saw the Division of Nursing’s involvement in international health. Martha Salmon, the Director of the Division of Nursing was a member of the United States delegation to the World Health Assembly. The Division of Nursing also promoted interdisciplinary collaboration resulting in the establishment of requirements for the roles of certified nurse midwives, nurse practitioners, physician assistants, and primary care physicians in primary care settings. In 1993, the National Center for Nursing Research became the National Institute of Nursing Research, thus achieving equal status with the other NIH Institutes. The PHS Nursing discipline remains committed to promoting optimum health for the disadvantaged and underserved.
The PHS has greatly expanded in scope and duties since its inception in 1799 to include disease control, health care delivery, food and drug regulation, international health, biomedical research, disease prevention, and health promotion. The 21st century finds the Commissioned Corps undergoing a transformation that is further defining its role for rapid and effective response to meet the country’s public health needs by fulfilling its mission of promoting, protecting and advancing the health of the nation. Today, the Commissioned Corps and Civil Service nurses contribute to the mission of the Public Health Service in a variety of roles, ranging from clinical practice to research or administration. In the September 1920 issue of the American Journal of Nursing an editorial that was written about Public Health Service nurses stated that, “The work has been and is still pioneer work.” PHS nurses today continue to practice with the same pioneering spirit.
Chief Nurse Officers
The Chief Nurse Officer position was established in 1949 and is located in the Office of the Surgeon General.
- 1949 Lucile Petry Leone
- 1966 Margaret McLaughlin
- 1970 Faye Abdellah
- 1987 O. Marie Henry
- 1992 Julia Plotnick
- 1996 Carolyn B. Mazzella
- 2000 Mary Pat Couig
- 2005 Carol A. Romano
- 2009 Kerry Paige Nesseler
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