Thoughts from the Last Mile Welcome to the VillageReach Blog
12.13 2012

Greetings from the VillageReach team!

As the year comes to a close, I’m excited to review our activities over the past 12 months and look ahead to our plans for 2013. Our work in 2012 reflects VillageReach’s unique position as both an on-the-ground implementer of cost-effective ways to increase access for underserved communities, and as a catalyst for comprehensive changes in global health that improve the quality and reach of healthcare delivery.

This year we collaborated with a number of organizations to develop, execute and evaluate new approaches to strengthening health systems throughout sub-Saharan Africa. In Ethiopia, we have been working with Columbia University and PATH to design information systems for community health workers. In Malawi, we supported the community of Kwitanda, working in the community and in health centers to increase prevention of disease and access to health services. We also tested how information technology can provide women with a reliable means of accessing health information and care. In Mozambique, the Dedicated Logistics System (DLS) program has expanded to four provinces, and now supports vaccine distribution to 40% of the country’s rural health centers. There are unique challenges in improving supply chains where resources are limited, but this year we have seen a marked increase in the availability of vaccines. This program is also serving as a host for other initiatives. We partnered with the Mozambique Ministry of Health and the USAID | DELIVER Project to increase the availability of a variety of medical commodities that health workers will provide to their communities – the pilot integrates use of the ODK Scan mobile device application we have been developing with the University of Washington.

Our work with a number of leading universities provides us with the opportunity to work with some of the best minds in tackling global health challenges. The William Davidson Institute at the University of Michigan supported us in documenting the range of obstacles challenging the reliable delivery of medical commodities; the MIT Sloane School of Management provided MBA students to evaluate the long term business potential and social impact of our for-profit fuel supply company, VidaGas, that serves remote health centers. And the University of Washington continues to be a key strategic partner for VillageReach: we collaborated with a team in the Computer Science and Engineering Department that co-developed the ODK Scan application, and are starting a new relationship with the University’s Global Medicines Program and the Malawi College of Health Sciences to train pharmacy assistants in Malawi to support medicines management and improve the supply chain for rural health facilities.

To improve health systems for remote communities with limited infrastructure, much of our work has focused on developing technologies that improve the communication, data collection and reporting from the field. For the DLS program in Mozambique, we issued the fourth release of the vrMIS management information system software platform that improves reporting on community health and the performance of the ministry of health. We launched the open source initiative, OpenLMIS, in 2010 to reduce the cost of information technologies for developing countries – technologies that we often take for granted at home. In 2012, the Bill & Melinda Gates Foundation joined other members, John Snow, Inc. (JSI), PATH, the Rockefeller Foundation and VillageReach in the initiative. For more information and reporting on our activities, please visit our blog and the Reports and Publications section of our website.

Looking Ahead to 2013 …

Current programs that increase health system support for remote communities will continue in the new year. We’re also adding several new initiatives. In Malawi, we’ll be working with the Barr Foundation on the Malawi Pharmacy Assistant Program, a new program to improve the public health supply chain. During the course of the program, 150 pharmacy assistants will be trained and deployed in rural health facilities that serve 4.5 million. In 2013, we will also be expanding the reach of the Chipatala cha pa Foni / Health Center by Phone program to additional communities in order to reach more families with life-saving advice, information and referrals.

In 2013, we will continue to make investments in the development of cost-effective technologies for health system use in any country. Through the OpenLMIS Initiative, we will be working with the governments of Tanzania and Zambia and the USAID | DELIVER Project to deliver a dynamic information technology platform that accurately tracks and reports on the delivery of medical commodities nationwide in both countries.

As the needs for our programs grow, so does VillageReach itself. We need to raise an additional $1 million to meet our 2013 program goals. During the new year we plan to hire additional staff to expand the reach of our community health programs in Malawi and Mozambique, support additional pharmacy assistant students to serve in rural health facilities, continue investing in high-impact data capture and communication technologies, and invest in additional infrastructure to support the distribution of vaccines and other medical commodities to remote communities.

Over the last year we have seen tremendous progress; we are very encouraged and have much hope for 2013. On behalf of the many communities and families we serve, thank you for your continuing support.

Allen Wilcox
President

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11.19 2012

In 2012, the Kwitanda Community Health Project expanded into new programmatic areas, increasing its reach by developing new maternal and newborn health activities, establishing the Kwitanda Economic Development Initiative and starting work on filling gaps in HIV care in the community.

As we start a new fiscal year, the Kwitanda Community Health Project team has reviewed the results from our 2012 evaluation. The full report is posted on the Evaluations and Assessments section here. The evaluation has been a key tool for us in reflecting on last year’s progress and areas that need improvement as well as developing strategies for next year. Here are some of the highlights from this year’s evaluation and examples of how we are using these results to inform our planning:

Access to clean drinking water significantly increased in 2011 and 2012.
During the past year, VillageReach constructed and repaired 10 boreholes to increase access to clean drinking water. Eighty-eight percent of Kwitanda residents have access to clean water and 54% have to travel less than 500 meters (< 1/3 mile) to the nearest water-source. We will continue working to improve access to clean drinking water over the next year. Access to sanitation improved between 2011 and 2012. Over the last year, VillageReach supported the installation of 220 sanplats in household latrines to improve sanitation and helped construct 1,045 tippy-taps to provide hand-washing facilities and decrease diarrhea. As a result, we saw an increase in the number of household with sanitary latrines (up to 80% from 72% in 2011) and the number of households with access to a handwashing facility (up to 43% from 14% in 2011). Next year, VillageReach plans to intensify our efforts in information, education and communication around safe water storage and handwashing and improving sanitation through implementation of community led total sanitation (CLTS). CLTS ensures that every household has a pit-latrine (and uses it) and aims to have the catchment area declared Open Defecation Free (ODF).

Malaria rates decreased significantly between 2011 and 2012. Of the households included in our sample survey, 62% reported at least one person with malaria during the last 4 months, compared to 72% last year. Though malaria rates decreased, there was a disappointing decrease in mosquito net ownership and usage. Approximately 1/3 of children who received a mosquito net from VillageReach last year reported not sleeping under a net this year. VillageReach plans to conduct follow-up with a sample of families in order to learn more about what barriers prevent these children from sleeping under a net despite receiving a net in addition to continuing with net distribution to children aged less than five years.

Baseline indicators for maternal and neonatal health highlight a need for new interventions. The maternal and neonatal health indicators from 2012 suggest gaps in current services geared toward mothers and young children, particularly in the area of facility births, exclusive breastfeeding, receiving timely postnatal care, and receiving all four recommended antenatal visits. VillageReach is well positioned to address these gaps next year and has already started addressing these gaps; VillageReach recently supported the training of all 23 Health Surveillance Assistants for Kwitanda in maternal and child health and launched outreach antenatal clinics to better serve women hard-to-reach areas. VillageReach also intends to support chiefs in establishing village models that aim to foster maternal, child health and safe motherhood programs including IEC on the importance of male involvement in maternal and safe motherhood.

We are excited about the upcoming year and look forward to intensifying our efforts to reduce malaria and diarrhea as well as expanding our reach into new areas.

Patrick Karonga Phiri
Project Manager, Kwitanda Community Health Project
Balaka, Malawi

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09.25 2012

We’re thrilled to announce important new partnerships in Malawi that will help our core work to support frontline health system capacity. In New York today we announced our collaboration with the Barr Foundation and the University of Washington Global Medicines Program in launching a new program to increase healthcare access through improvements in the public health supply chain. We will be working closely with the Malawi College of Health Sciences to train and deploy pharmacy staff, increase supply chain capacity, and improve data management and reporting of logistics data. During the course of the program, 150 pharmacy assistants will be trained and deployed in rural health facilities serving a population of approximately 4.5 million.

The Innovation Working Group (IWG) and the mHealth Alliance also announced today that VillageReach has been selected as 2012 grant winner to improve women’s and children’s health using mobile technology. The grant will be used to expand service for our pilot program applying innovative uses of information technology to expand the reach of health services for mothers and children in rural communities.

Both of these initiatives will help us build on the close partnership we have developed with the Malawi Ministry of Health since we first began our work in the country in 2008.

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09.11 2012

We are saddened to announce the passing of our dear friend, advocate and board member for the past decade, Dr. Paul Robert Kleindorfer. We join his family and many friends in celebrating a vibrant personal life and distinguished career. PaulK_2Paul held university appointments at Carnegie Mellon University, Massachusetts Institute of Technology, The Wharton School, the University of Frankfurt, and most recently, INSEAD. His career of work focused on risk management and the integration of operations, economics and finance.

Paul was a passionate supporter and articulate champion for VillageReach’s work. We owe our founding and continuing support for the underserved to his vision, generosity and charm.

For more information on Paul’s life and career, please visit the INSEAD website.

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07.19 2012

We recently sent out this latest update … here’s our news in case you missed it …

Malawi

  • update on our work to improve maternal and newborn health in Kwitanda
  • the latest on our Chipatala Cha Pa Foni (health center by phone) program, part of the Innovations for Maternal, Newborn and Child Health initiative
  • Mozambique

  • new update to our Mozambique Dedicated Logistics System (DLS) program
  • collaboration with the William Davidson Institute (University of Michigan) Supply chain & logistics study: new research to quantify the logistics challenges for a variety of medical commodities
  • Dr. Seth Berkley, President of the Global Alliance for Vaccines and Immunization (GAVI) visited the DLS program
  • Technology Initiatives

  • ODK Scan: update on our collaboration with the University of Washington’s Computer Science & Engineering to improve the quality of data collection
  • OpenLMIS: new website with updated details on activities and partners
  • Social Enterprise

  • VidaGas: our collaboration with the ghdLABs program at MIT, to evaluate the marketplace for our social enterprise in Mozambique
  • New Additions to Our Team

    Malawi:

  • George Chinkwita – Project Officer, Kwitanada Economic Development Initiative
  • Erin Larsen-Cooper – Program Associate
  • Mozambique:

  • Antonio Gaspar Tomboloco – Field Officer, Niassa Province
  • See here for details …

    Updated Financial Report

  • our recently posted 2011 independent financial audit
  • We welcome your questions and comments,

    Allen Wilcox
    President

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    07.10 2012

    In Malawi, more than eight in every one thousand women die from maternity-related causes, while almost 90 percent of childhood deaths occur during the first year of life. Malawi women have a 1 in 36 chance of dying during childbirth. Reducing the maternal mortality rate in Malawi not only saves the lives of women, but most maternal interventions will also reduce mortality and morbidity among infants. Moreover, saving the life of a mother can protect older children; orphaned children have a three to ten times greater risk of death than those with living parents.
    In October and November 2011, VillageReach conducted a needs assessment to identify the barriers to optimal maternal and neonatal healthcare in Kwitanda, Malawi through interviews and focus group discussions with health workers, health surveillance assistants (HSAs) and women in the community. The results pointed to the major barriers to optimal maternal and child healthcare as long distance to the health facility and lack of transportation for antenatal care (ANC), delivery and post-natal care, perceptions of poor treatment and safety at hospitals compared to delivering with Traditional Birth Attendants, traditional beliefs maternal and infant health practices and when and where to access care, and a general lack of knowledge regarding the importance of early post-natal care.
    To overcome these barriers, VillageReach is implementing the following programs:

    Extend the Reach of ANC services to the community Currently, ANC services are offered at Kwitanda Health Center but women have expressed a great interest in these services being provided closer to home. We will leverage existing structures to conduct ANC outreach clinics by Kwitanda Health Center staff closer the community. ANC outreach is scheduled to begin this month.

    Train Additional HSAs in Maternal and Neonatal Health With funding from The Seattle International Foundation, VillageReach will train and support additional HSAs in maternal and neonatal health to extend the cadre available to visit women in their homes. Currently, five HSAs in the Kwitanda catchment are trained in MNH. The specialized cadre of HSAs can provide home-based postnatal care to all newborns, track the health status of pregnant women, encourage ANC visits and facility-based delivery, and support women in the development of a birth plan. Nine HSAs are currently in training.

    Leverage Existing Maternal and Neonatal Health Services Provided by VillageReach VillageReach’s work with MNH through the Chipatala Cha Pa Foni (health center by phone) case-management hotline service was rolled out in the Kwitanda area in March. The hotline provides health advice and information to pregnant women and caregivers of children under-5, refers individuals to a health center or village clinic if warranted, and registers women and caregivers for an automated tips and reminders service sent to their phones or accessible through phones of community volunteers. The hotline provides direct access to a health worker for community members who may have previously had a poor perception. Thus, in addition to providing direct advice, the hotline serves to improve community trust in the health system.

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    06.15 2012

    This summer I am a VillageReach intern based in Maputo where I will be implementing a comprehensive study documenting the range of obstacles challenging the reliable delivery of vaccines, rapid diagnostic tests, and medicines to rural communities of Mozambique. While VillageReach is already actively working to address many of the known challenges in this area (such as lack of transport for vaccine and medicine delivery), the purpose of this study is to quantify the range of logistics challenges and flush out the sources of the problems. For example, is transport a problem because of lack of vehicles, lack of fuel, broken vehicles, or the bureaucracy of gaining access to a shared vehicle when it is needed? Where in the supply chain are problems most frequent: eg.,picking up the healthcare supplies from the central storehouses, or delivering them to the rural health centers? Are health center employees adequately trained in the logistic concepts necessary for effectively keeping track of supplies and forecasting the health center’s needs?

    These questions and many more will be answered using a lengthy survey that will be given in every district within the four provinces (Maputo, Gaza, Niassa, Cabo Delgado) where VillageReach currently operates. There are three separate surveys for each district: one for the medical director, one for the director of the pharmacy, and one for the director of vaccination programs. Starting this week I will be training the VillageReach field officers in implementing the survey. We will have an all day training session in our offices in Maputo and then will take two day trips into nearby district health centers to see what surprises we find in translating ideas on paper to workable information gathering in the field. In the weeks following, the Field Officers will gather the data (I will join when possible) and send it all my way for synthesis and analysis. The hope is that this study will provide more detailed information about the current challenges and thus help VillageReach and the Mozambique government prioritize their efforts to increase access to healthcare supplies to rural communities.

    First Field Visit: Namaacha

    As part of my orientation to VillageReach and the Mozambique health system, last week I joined Margarida, the VillageReach Field Officer for the Maputo Province, for a field visit to the district of Namaacha. Originally, we had planned to head to a different district for supervision, however the night before we left we got a call saying that Namaacha had an urgent need for a vaccine delivery and we needed to head south to respond to this request. Inside a Health Center
    We started our trip with a stop at the Namaacha district hospital where we met up with government staff responsible for vaccine delivery in the area. While I was shown the hospital pharmacy, stock room, laboratory, maternity ward, and the general patient area, Margarida headed to the back of the hospital to go over their records of vaccine use and disbursements in the district. She quickly identified some incomplete and inconsistent data records and immediately sat down with the staff until she was convinced they understood what was wrong and how to make it better. Margarida previously held positions as the national vaccine manager for Mozambique and as the director of the Maputo province department of health, and she not only knows her stuff inside and out, but she cares too deeply about the issues to leave a room before she thinks all present understand their role in facilitating vaccine disbursement in Mozambique.

    Once things were squared away at the district hospital we set out to visit the seven health units in the district. At each health unit, the government made their vaccine deliveries and Margarida met with the health workers to make sure they were giving vaccines on the right timetable and properly recording vaccine use. Before we left she would check that their refrigerators were functioning properly, check expiration dates on vaccines and rapid diagnostic tests, count their existing stock levels of vaccine and rapid diagnostic test supplies, and verify that the stock matched the records. A visit of this sort typically took well over an hour.

    At two of the health centers we encountered refrigerators that were having problems. The refrigerator at the Dibinduane health center was operated entirely by solar power and its performance had been somewhat erratic as of late. According to the records, the temperature inside the refrigerator had been fluctuating, but had so far not warmed beyond the threshold that was safe to store the vaccines. Just to be sure, we checked the vaccine packaging which indicates (via a color changing label) when the vaccines have been exposed to higher than permissible temperatures and thus are no longer safe to use. Happily, the vaccines were still in Margarita and Timoteo checking recordsgood shape, but Margarida left the health center workers with instructions to monitor the temperature in their refrigerator very closely. As a die-hard supporter of renewable energy, I argued that there was no actual proof that the solar power was to blame other than the mere correlation of the fridge being both erratic and solar powered. However, most of the Mozambicans (who admittedly have a lot more experience using solar power than I do) just shook their heads and took this as yet another example of the fussiness of solar energy.

    At the Kulula health center, we found a refrigerator (powered by traditional sources) that was not functioning at all. This meant we could not deliver any new vaccines and we had to take away for disposal any existing (and requiring cool storage) vaccines we found at the health center. Everyone seemed pretty glum about this situation and said a replacement refrigerator was unlikely any time in the near future. In the meantime, the district would have to send out a mobile brigade (health workers that operate from a truck and carry their supplies with them) to periodically provide vaccines to the surrounding communities.

    Before heading to Namaacha, I had found it hard to grasp the hierarchical structure of the Mozambique health system (the difference between a rural and district health center and how supplies and information moved between them) and what it meant for VillageReach to help with the logistics of getting healthcare supplies to these rural communities. After two days driving around the district with Margarida, however, I was able to get a glimpse of how far removed many of the health centers were from the district hospitals as well as some of the challenges facing the rural health care workers, the Mozambique government, and VillageReach.

    Lilly Connett
    Intern

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    06.07 2012

    I spent a couple of weeks in Mozambique recently to review our energy services social enterprise, VidaGas, that provides much-needed propane to hundreds of rural health centers throughout the north of the country. VillageReach owns the for-profit business in partnership with Oasis Fund and FDC.

    I was joined by two MBAs, Alexandra Fallon and Deborah Hsieh, from MIT’s Sloan School of Management who are enrolled in an intriguing course. ghdLABs, developed by Anjali Sastry, is focused on assessing opportunities to improve healthcare delivery through changes in management, engineering and systems. See here and here for background on the course, which includes links to blogs from Deborah and Alexandra about their experiences. The students have been assisting with our plans to help build a longer business outlook for VidaGas and also to measure the social benefit the company provides. Both efforts will be important in helping attract additional capital for the company in the coming years as it continues to grow and further support the public health system.

    Energy Improves Health

    When VillageReach first started its work to improve the last mile of delivery capacity in Mozambique’s Ministry of Health, we realized a critical gap in energy supply was affecting the performance and economics of the cold chain, and in turn limiting the ministry of health’s ability to store and distribute vaccines. VidaGas was established to address this lack of reliable energy supply.

    Since its founding in 2002, the company has progressively expanded its operations to serve more and more health centers and communities. In the past two years, the growth rate has accelerated, due in part to a critical investment made by Oasis Fund.

    The additional capital enabled VidaGas to step beyond its presence in Cabo Delgado Province in the northeast and establish additional filling and storage facilities, greatly increasing the addressable market for propane sales. By the 4th quarter of this year, VidaGas will be operating in all four northern provinces from an operational base of three filling plants in the cities of Pemba, Nampula, and its newest facility in Mocuba. More on Mocuba below.

    Operating VidaGas as a business instead of a charity addresses the critical requirement for a sustainable supply of energy for the health system. The majority of Mozambique’s population in the north resides in remote villages with no electricity and little access to transport and communications services. Health centers in these communities need a reliable supply of energy for refrigeration, lighting and sterilization in order to provide even basic medical care.

    To ensure its service to the health system is sustainable, VidaGas supports this social mission by selling gas to a variety of enterprise customers: restaurants, hotels, small factories, plus a growing retail network and several urban hospitals. VidaGas Sector Share of RevenueHere’s the share of sales across these categories for 2011 – rural health centers represent only 17%. The message is that without the private sector revenues, the company would not have the resources to support its obligations to the health system.

    VidaGas’ social benefit isn’t limited to the benefit it provides to the ministry of health. Other government ministries use propane for their facilities and a growing number of households are buying the gas for cooking, reducing the use of charcoal and wood that produce harmful indoor pollutants. Reductions in biomass consumption also contribute to limiting the rate of deforestation.

    What’s Next

    pic We’ve been at this effort since 2002. As VidaGas sales have grown, so has its reputation as a reliable supplier to the ministry of health and other customers. In 2011, VidaGas shipped more than 350 tons of propane, an increase of 35% over 2010. Now the business has identified the opportunity to supply health centers in the province of Zambezia. In April, VidaGas broke ground on a new facility in Mocuba City in central Zambezia, see this image on the right. Once the facility is completed in August, Mocuba will have the same 21-ton storage capacity as the Nampula facility you see below. With a population of nearly 4 million and more than 300 rural health centers across Zambezia Province, pic1we anticipate both strong demand and see an important opportunity to assist the health system. In 2012 we expect sales to increase at a significantly higher growth rate than the year before.

    Beyond the rural health center network VidaGas supports today are many more health centers that suffer from unreliable energy supply. To expand its social impact, VidaGas must scale further: in the future the company will require additional capital in order to invest in new facilities, equipment and personnel.

    Attracting investors is inevitably a challenge, even as the social enterprise industry matures and encourages more socially conscious investors. Our work with MIT will help support VidaGas’ future growth, helping us prepare a more robust strategic outlook for the company and producing an evaluation of anticipated financial and social returns for investors. As this review progresses, we’ll write more on our views of VidaGas, so look for additional reports on the company’s milestones and prospects for the future.

    John Beale
    Director, Strategic Development &
    Group Lead, Social Business Group

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    05.25 2012

    Rapid Diagnostic Test (RDT) Data and Distribution Systems.

    As a partner in Mozambique’s health system, VillageReach is undertaking a study about the shortage of RDTs in the rural health centres. This is the second in a series of updates we expect to provide on the work – see the first post here. The study will conclude this fall.
    The study involves gathering and analyzing data that health workers collect as they provide testing services, and using that data to analyze consumption as it informs the test distribution. Data about the use of RDTs is critical to operating a well-functioning supply chain and ensuring that health centers have the right tests at the right time. This data allows planners in the health system to purchase the right quantity of tests and distribute them throughout the health system while minimizing wastage and expiry.
    Until now, the national health system in Mozambique has not distributed standardized forms for collecting this data. However, the lower levels in the government recognized the need and value of the data and implemented their own systems. In the first visit made by the study team in January this year, it was found that the data collected was of very poor quality, due to lack of standardized instruments or forms to use for recording data and a lack of training for the health workers. The forms used to collect the data were undergoing numerous changes, which complicates the process of data collection at the service delivery point.
    Tim2
    The system for distributing tests and collecting data about tests was designed with the following flow: the RDTs are amassed at a provincial medical store, redistributed to district storage facilities, and then transported to rural health centers. The image on the left represents the ideal.
    Last week we visited again and found that key improvements had taken place in the last four months.
    1. Systems and processes are in place to collect data about the use of tests. These are being used properly and routinely. This is no small feat in a country so vast and full of infrastructure challenges that can limit access to the health centers.
    2. The Logistics Management Information System is installed and in use at the district level. That is a major accomplishment, and one that will improve the distribution and supply of medicines throughout the country.
    But this visit revealed another fundamental observation. Despite improvements over the recording and availability of data about test consumption, there continues to be shortages and stock outs of tests in the health centers. Specifically, I observed situations where there were too few RDTs and a number of them had expired before being used. If the data is there to make the system work, then what is happening?
    For many cases, we discovered the question can be answered by the following factors:
    • A lack of vehicles for transport limits regular distribution of RDTs and medicines to health centers;
    • Where there are vehicles available for transport, there is often a lack of fuel;
    • Where there are vehicles and fuel, there is a chronic lack of allowances for personnel to carry out the distribution of medicines.
    These factors greatly influence the availability of RDTs at the health center level. With delays in distribution, RDTs may expire before they are used, ultimately reducing the quality of service at the health centers. Tim1
    All this ultimately results in poor distribution system of RDTs used in the province and a higher cost of distribution. In addition, the lack of regular distributions results in incomplete and inaccurate data about the health centers being reported back to administration levels within the health system. This image on the right represents what we see in reality.
    These factors, all too common occurrences for health systems with limited resources, highlight the importance of improving the quality and capacity of the underlying infrastructure the health centers depend on in order to support so many remote communities.

    Timóteo Eduardo Chaluco, Monitoring & Evaluation Officer

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