The global perspective of the International Society of Nephrology: A decade of experience with COMGAN
2005; Elsevier BV; Volume: 68; Issue: 4 Linguagem: Inglês
10.1111/j.1523-1755.2005.00549.x
ISSN1523-1755
AutoresJohn H. Dirks, Sheila W. Robinson,
Tópico(s)Biomedical Ethics and Regulation
ResumoThe International Society of Nephrology (ISN) was founded in 1960, about 10 years after the emergence of nephrology as a medical specialty separate from general internal medicine. ISN was, from the beginning, international in both composition and outlook in its pursuit of the worldwide advancement of education, science, and better patient care. Initially, this was done through the ISN Congresses and though the Society journal, Kidney International. These also served to promote networking within a very diverse constituency. In 1981 President-elect Donald W. Seldin proposed that US $30,000 should be made available for ISN-sponsored postgraduate continuing education courses in developing countries1.Robinson R. Richet G. History of the ISN.Kidney Int. 2001; 59: S36Google Scholar. This marked the first foray by ISN into substantively supported educational meetings beyond its own congresses. In 1985, ISN launched the Fellowship Program in order to offer nephrology training opportunities to young physicians from developing nations with the ultimate aim of improving standards of training and care when they returned to their home country. Fellows received hands-on training at a host research institution in basic and clinical nephrology, dialysis, transplantation, epidemiology, and more. They then became teachers and leaders in their home countries, where the need for more knowledge and improved care was critical. In 1990, at a strategic planning retreat in Toronto, Ontario, chaired by Barry Brenner, it was recommended that sessions with the leaders of national societies should be held to discuss the needs of developing countries2.Robinson R. Richet G. History of the ISN.Kidney Int. 2001; 59: S53Google Scholar. In 1991, a strategic planning retreat again suggested expanded programs in support of developing countries3.Robinson R. Richet G. History of the ISN.Kidney Int. 2001; 59: S54Google Scholar and, in 1992, the membership of ISN offered qualified endorsement to the support of nephrology in such regions4.Robinson R. Richet G. History of the ISN.Kidney Int. 2001; 59: S56Google Scholar. Roscoe Robinson, President of the ISN from 1990 until June 1993, pointed out in his final speech at the Jerusalem World Congress that only one fourth of the world's population were benefiting from the knowledge available in the developed world, and he emphasized the Society's programs which were supporting the growth of nephrology in these regions. J. Stewart Cameron, who succeeded Roscoe Robinson, immediately noted that the “focus of ISN has rightly turned to those areas of the world where the Society is most needed, the developing world”5.Cameron J.S. Report of the Incoming President.Kidney Int. 1994; 45: S5519-S5520Google Scholar. It was clear by 1993 that the ISN was embarked on a unique course. Given the direction in which it was moving, it is not surprising that in 1993 President-elect Robert W. Schrier proposed a commission on nephrology in developing countries to coordinate ISN activities in the developing world, COMGAN, or the Commission for the Global Advancement of Nephrology, as it later became known. In November 17, 1993, all officers and councilors of ISN met in Boston to discuss the purpose and program of the new commission. A number of problematic issues were recognized during the meeting: the differing strengths, weaknesses, and needs of various regions; the difficulty of reaching practitioners in the field, often far removed from developed centers; the need to include and draw support from national/regional societies; and the need to assess local resources and practices before determining programs. COMGAN was officially formed in 1995 with Barry Brenner and John Dirks serving as co-chairs. When Barry Brenner stepped down in1999, John Dirks remained as sole chair and will continue to serve in this role until December 2005. A budget of US $137,000 was allocated by ISN to support the new commission and its programs. From its beginning in 1995, ISN COMGAN established a number of specific goals, most of which have remained remarkably constant: (1) to assist in strengthening patient care, research, and education; (2) to provide regional postgraduate courses; (3) to solicit and establish institutional partnerships; (4) to create a leadership council of representatives from developing countries; and (5) to strengthen the programs of national societies6.Robinson R. Richet G. History of the ISN.Kidney Int. 2001; 59: S62Google Scholar. Very quickly the Continuing Medical Education (CME) courses became the principal mechanism for achieving these goals. It was agreed that five regional subcommittees should be formed to oversee and encourage ISN COMGAN activities within each region, and each one would be given US $15,000 in support. They would include Asia (Kiyoshi Kurokawa and Visith Sitprija), Africa (Claude Amiel and Rashad Barsoum), Russia (Barry Brenner and John Dirks), Eastern and Central Europe (Roscoe Robinson and Franciszek Kokot), and South America (Gerhard Malnic and Saulo Klahr). Each subcommittee had members who were, as much as possible, recruited from the region they represented. Many current ISN Councilors began as members of regional subcommittees, where the organizational structure provided opportunities for nephrologists from the emerging world to develop leadership skills and exercise them in the broader international arena. The culture of COMGAN, as envisioned by its creators, has been consistent during its first decade. It is deliberately and firmly politically neutral, international, and global. It is at the forefront of basic and clinical science, employing a network of leading authorities in the field to achieve global outreach in education and training. It maintains an ethos of cooperation and equality in its partnerships with regional and national societies. Above all, it is humanitarian, and everything COMGAN attempts and achieves flows from this. In 1998, an article by Jan Weening, Barry Brenner, John Dirks, and Robert Schrier, which summarized the activities of ISN to date, appeared in Kidney International7.Weening J. Brenner B. Dirks J. et al.Towards Global Advancement of Medicine: The International Society of Nephrology experience.Kidney Int. 1998; 54: 1017-1021Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar. In April 2000, John Dirks wrote a “Blueprint for the Next Five Years”8.Dirks J. Brenner B. ISN COMGAN Mission 2000-2005.April 2000Google Scholar, which was approved by the Executive Committee of the ISN. It has been largely implemented since that time. In 2000 and 2001, John Dirks formed a number of advisory committees to ensure that the teaching of the various subspecialties in nephrology remained state-of-the-art. In addition to the already existing Informatics Commission (established in 1997), he created the Education Subcommittee (Michael Field and Asghar Rastegar) to develop nephrology training guidelines that would create a realistic minimum standard for the developing world. The COMGAN Research Committee (Giuseppe Remuzzi) was formed in 2001 after the Executive Committee meeting in Toronto, Ontario, and shortly thereafter ISN formally adopted the mission of prevention. The Hemodialysis Advisory Committee (Nathan Levin) was established late in 2000. Its role is to advise and update COMGAN on hemodialysis and its complications, suggest speakers for CME meetings, develop consensus conferences on quality of dialysis, and to make available education and training material which will lead to improved quality of dialysis. The committee is now looking at ways to study the general problems of providing affordable hemodialysis and peritoneal dialysis in the developing world. Other advisory subcommittees and their current chairs are Renal Pathology (Agnes B. Fogo, United States), Peritoneal Dialysis (Sarah Prichard, Canada), Indigenous Peoples (David Pugsley, Australia), Renal Registries (Francesco Paolo Schena, Italy), and Tropical Nephrology (Emmanuel Burdmann, Brazil). COMGAN also maintains individual advisors on Hypertension (Chris Wilcox, United States), Transplantion (Mohamed Sayegh, United States), and Nephrolithiasis (David Bushinsky, United States). In 2001, the subcommittee structure was expanded to reflect the growing activities and commitments of COMGAN in the developing world. A Middle East Committee was formed (chaired by John Dirks). In 2002, due to the increasing activities by COMGAN, the Asia Subcommittee was broken down into three separate regions and, in 2003, a new regional subcommittee was added. This brought the total number of regional committees to nine: Africa (Sarala Naicker, South Africa), South Asia (Kirpal S. Chugh, India), East Asia (Hideto Sakai, Japan, succeeded in 2004 by Giuseppe D'Amico, Italy, and Haiyan Wang, China), Southeast Asia (Visith Sitprija, Thailand), Indonesia-Philippines-Pacific Islands (William Couser, United States, succeeded by David Harris, Australia), Eastern and Central Europe (Eberhard Ritz, Germany), Latin America (Bernardo Rodríguez-Iturbe, Venezuela), Middle East and Russia CIS (John Dirks). Close to 200 nephrologists from 52 different countries now serve on the regional and advisory subcommittees and constitute the core of ISN's leadership in the developing world. The creation of COMGAN in 1995 began a decade that has seen the ISN lead the largest specialty medical outreach program in the world, reaching areas of the globe previously limited in exposure to formal nephrology training and practice. How successful has ISN COMGAN been? In 2004, its CME programs provided state-of-the-art teaching and training to more than 17,000 physicians, nurses, and health care workers Figure 1. It is currently active in 77 countries and calls on over 200 of the world's top nephrologists who volunteer to travel the world as faculty for these meetings. During the early years, COMGAN established a method of operating in developing countries that has proved both unique and effective. The three-step approach includes (1) identifying the educational and clinical needs of developing countries; (2) addressing those needs through organization and/or support for CMEs, fellowship programs, and library enhancement programs; and (3) initiating screening and surveillance programs as a means of prevention. The first approach to a developing country with few or even no local nephrologists is in the form of a site visit. An important goal is meeting local nephrologists and/or primary care physicians, hospital administrators, and members of the Department of Health, partly to identify a local leader(s) who will become the liaison person for further COMGAN activities and partly to assess the level of nephrology care and the training and the education needs. Some of COMGAN's regional leaders and most promising fellows, particularly in Africa, were recruited in this way. Early on, the number of site visits each year outnumbered those made by the CMEs Figure 2. Another practice unique to ISN COMGAN is the development of ongoing relationships within each country. The Society does not simply partner in a CME and then move on to another part of the world. Developing and maintaining lasting relationships between COMGAN and the local nephrologists is an integral part of its activity and this is done very promptly and proactively. Typically, a CME will be organized every year, or every 2 or 3 years, and ISN COMGAN provides several top-ranked teaching faculty to assist the more numerous local faculty. The site visit is typically followed by a modest and ISN-subsidized CME. COMGAN assists with organizing and then gradually encourages the local community to assume more responsibility. Except in the very poorest countries, COMGAN often partners with local, regional, or national nephrology societies to put on CME courses. Typically, accommodation and meeting costs are covered locally. COMGAN covers the travel costs of visiting faculty who donate their expertise and their time. This enables nephrologists from the developing world to raise the level of care they can provide as a result of learning better methods of clinical care. Further, it brings them into the world community of nephrology and encourages more young doctors to develop skills in this area. The increased membership in ISN from within the developing world is testament to the effectiveness of the COMGAN method. A portrayal of the scope of COMGAN CME meetings is shown in Figure 3. COMGAN has sponsored or partnered 56 meetings and site visits in Latin America during the past decade and has contributed significantly to the development of nephrology. Close ties with national societies have been established. COMGAN has been particularly active in Brazil, Mexico, Argentina, and Chile, from whence a number of outstanding local leaders have emerged. In some countries within this region there was very little access to updated medical information before COMGAN became active. COMGAN is now almost routinely asked to offer advice and expertise by many Latin American countries as they organize their meetings, and in fact, shares responsibility for the topics and themes that take front stage. Overall, COMGAN has helped to shape the prevention and detection strategies within some of these countries. In addition, ISN COMGAN has helped to generate research programs in both Bolivia (where there is also a fruitful Bolivia-Italy Model Sister Center) and Mexico. It has also offered expertise to help with the design and maintenance of local centers of excellence. The ISN's largest biennial partnered meeting is with the Brazilian Society of Nephrology. Over 2000 physicians, nurses, and allied renal professionals meet for a 4-day scientific meeting. This is a rigorous and dynamic scientific and clinical meeting with a special Brazilian flavor. In recent years, COMGAN has sponsored symposia in Salvador de Bahai, Porto Alegre, Natal, and Brasilia. The ISN has also participated in regional meetings in San Paulo, and will do so again in September 2005. Outstanding leaders such as Nestor Schor, Emmanuel Burdmann, Miguel Riella, Gerhard Malnic, and Roberto Zatz have contributed much to the ISN. COMGAN supports three different and generally large meetings in Mexico, those organized by the Mexican Institute of Nephrological Research (IMIN), the Mexican Society of Nephrology, and the annual Mexico City Postgraduate Course. In 2001, COMGAN sponsored the first nephrology research meeting in Mexico, organized by Guillermo Garcia Garcia, Alfonzo Manzano, and Gregorio Obrador. Its primary purpose was to determine why there is a scarcity of scientific production in nephrology and to suggest initiatives to improve the situation. All coordinators of nephrology residency training were invited, along with anyone involved in, or administering over, nephrology research in Mexico. Subsequently, in 2004, Ricardo Correa-Rotter developed a potentially far-reaching project entitled “Development and Validation of an Educational Program for Diagnosis and Prevention of Diabetic Nephropathy Directed to General and Family Practitioners Working in the Public Health System.” It has received funding from Mexico's National Council of Science and Technology and has academic sponsorship from ISN COMGAN. Cuba is another Latin American country with which COMGAN has been active, starting with site visits in 1998 and 1999, and then partnering in CMEs in 2000, 2003, and 2005. The first CME provided state-of-the-art courses, provision of journals, and help with developing computer network. Shortly thereafter, the first-ever article of a Cuban nephrologist's research was accepted for publication by Kidney International. COMGAN also arranged to have 48 dialysis machines from Toronto sent for use in Cuba. The major Nefrologia 2005 Prevention Course for Central America and the Caribbean, held in Cuba in May 2005, boasted 500 registrants from more than 20 countries. In November 2003, 90 nephrologists gathered at Ensenada, in Baja, California, to discuss the epidemic of chronic kidney disease in minority populations and emerging nations. David Pugsley, Larry Agodoa, Jamie Hererra, and Keith Norris organized the meeting. Among the causes of chronic kidney disease, diabetic nephropathy is the most common and the fastest growing and, within these ethnic groups hypertension appears both common cause and a serious consequence of renal disease. One of the main problems in Latin America is the lack of available resources. Less than half of the cases of end-stage renal failure are accepted for renal replacement therapy. There was general agreement that increasing emphasis needed to be placed on disease prevention. Furthermore, the fact that existing programs in the developed countries has not achieved the hoped-for successes suggests that some rethinking or realignment of priorities will have to take place. The contribution that underlying problems such as low birth weight and low nephron number might take to the progression of renal disease in such diverse renal conditions as post-streptococcal nephritis and hemolytic uremic syndrome was discussed. While there was recognition that much has been achieved by the vigorous promotion of strategies developed by ISN COMGAN, much work remains to be done. Given the reality that there is not enough money for health care in Africa, the goal to promote education, training, and prevention strategies at all levels is absolutely vital. The first ISN-sponsored course in Africa was held in Cairo in February, 1987, and Egypt along with South Africa has remained a key region for COMGAN in Africa. At that first meeting, 13 African countries were represented and there were 10 speakers from the developed world9.Robinson R. Richet G. History of the ISN.Kidney Int. 2001; 59: S43Google Scholar. Under the aegis of ISN COMGAN, 51 site visits and CME courses have been held there since 1995. Many of them have taken place over the past 2 years, as COMGAN has sharply ramped up its activities under the leadership of Sarala Naicker. Under her chairmanship, the Africa Subcommittee has grown to 20 members, the majority from African nations. During 2003, nine CMEs were held in Africa, and in 2004 five meetings attracted an average of nearly 400 registrants each, amazing statistics for a continent that has a real shortage of nephrologists. ISN COMGAN has established close ties with both the Egyptian Society of nephrology and the South African Renal Association and has partnered in a number of large and successful CME courses in both countries. The Soweto Project, under the guidance of Ivor Katz, has been a particularly fruitful in elevating the level of teaching and prevention in South Africa. The next 5 years should show a number of prevention programs in other countries in Africa. In addition to its CME activities, COMGAN sponsored site visits during 2004 to Nairobi (Kenya), Dar Es Salaam (Tanzania), Kampala (Uganda), Togo and Benin, and Dakar (Senegal). Site visits have also been made to Kigali (Rwanda), Benin and Togo, and Sudan in the first half of 2005. As a result of the visit to Kigali, a renal unit is now being planned there. More site visits are planned for Angola, Malawi, Zambia, Mozambique, Botswana, Namibia, Madagascar, and Mozambique over the next 12 months. Many of these are countries where ISN has had no real presence before, and where there may be few or even no nephrologists. The recent site visits to Rwanda, Tanzania, Uganda, and Kenya confirmed that the most pressing need is for better training in both nephrology and pathology, followed by more access to affordable dialysis. The ISN presence in Africa is gradually encouraging the development of the physicians who will lead the field of nephrology over the next decade; Ebun Bamgboye in Nigeria, Linda Ezekiel in Tanzania, Ahmed Twahir in Kenya, and Boucar Diouf in Senegal, who was instrumental in founding a West African Association of Nephrology in March 2005. COMGAN began its official outreach in June 1995, with a visit to Moscow. Since that time there have been 22 additional CME meetings in Russia, the Ukraine, and Belarus. The original meeting was to have major consequences for nephrology in Russia. During the Soviet era there were few opportunities for exchanges with the nephrologists of the Soviet Union and surprisingly little was known of each other's activities. Nearly 300 nephrologists from Russia and neighboring countries attended the initial 1995 meeting. About a dozen of the world's best nephrologists from the developed world covered the full spectrum of current nephrology, from transplantation to immune nephritis to technical aspects of dialysis. A simultaneous course was held for nurses and technicians. Slides in Russian and English of all the sessions were made in advance. After this successful meeting of nephrologists from St. Petersburg to Vladivostok, and Moscow to Tbilisi, the speakers took a night train to St. Petersburg and repeated the course. Again the attendance was close to 300 people. The ISN group then flew to Tartu and repeated the course a third time in the university city of Estonia, with the same enthusiastic response from Baltic nephrologists. The tour was both exciting and invigorating and left an indelible mark on all those who participated. These inaugural meetings were the forefront of biannual meetings in Moscow and St. Petersburg and have led to subsequent meetings in cities such as Kazan, Novosibirsk, Kaunas, Yekatherinburg, and Minsk. The ISN is grateful to Fred Finkelstein, Ellin Lieberman, Art Cohen, and their Russian counterparts, including Natalia Tomilina, Konstantin Gurevich, Andrey Nazarov, and others who have provided a decade of leadership in the region. The outcome has been the establishment of a national society, the development of new dialysis centers, the introduction of peritoneal dialysis and renal transplantation, renal pathology, acute renal failure, and electrolyte and acid-base workshops. Similar events have taken place in Minsk, Belarus, and the Ukraine, led by Andrey Cybulsky of McGill University. Short courses have been carried out in Kiev, Donetsk, Odessa, Dnepropetrovsk, Kharkov, and Zaporizhya, where the local nephrologists were too poor to travel. ISN fellowships have been awarded to seven young nephrologists in the Ukraine and four in Belarus. ISN has made a real difference Russia assisted greatly by the leadership of Natalia Tomilina, co-chair of the COMGAN Russia Subcommittee. Since the first visit of COMGAN in 1995, the ISN course “Nephrology Update” has been organized every second year and has become a kind of CME for Russian nephrologists. But the importance of ISN COMGAN activity for the nephrology community is not limited to the educational program. The contacts with COMGAN helped to revive the activities of Russian nephrologists after perestroika and the reforms, resulting in the organization of the Russian Dialysis Society and the Creative Association of Pediatric Nephrologists. The resulting local meetings of nephrology have been of great importance for the development of nephrology in Russia. According to Dr. Tomilina, “your contribution in the development of nephrology in Russia is difficult to overestimate”10.Tomilina N. letter to John Dirks.2005Google Scholar. Partly as a result of Russia's renewed contact with international nephrologists, there has been a desire within the country to bring training and research in line with the rest of the world. New regulations by the Russian Ministry of Health stipulate that nephrology training should now include 1 year of internal medicine followed by 2 years of nephrology training. While this will coexist with the old system for the time being, it is a definitely a major step in the right direction. Nephrology practice in Russia has been difficult because of the massive recession and low priority given to medicine in the formative years of the democratic republics. Improvement is now taking place. The Moscow Update attracts attendees from areas such as east Siberia, Chechnya, the north of Russia, Kazakhstan, Belarus, Georgia, the Ukraine, and even the Far East. The annual St. Petersburg meeting also draws widely. Not only do these meetings provide an opportunity for training, they stimulate local activity. The result has been locally organized and corporately supported meetings in areas like Ekatherinburg, Khaborovsk, Kazan, Omsk, Novosibirsk, Krasnodar, Khanty-Mansyisk, and Samara. The development of nephrology in the former Warsaw Pact countries over the past decade has been impressive under the able leadership of Eberhard Ritz, chair of the Eastern Europe Subcommittee for ISN COMGAN. Regular participation in over 50 CME meetings has occurred in every country, including Romania, Slovakia, Poland, Croatia, Slovenia, Bosnia and Herzegovina, Hungary, and the Czech Republic. A special hallmark has been the Budapest School, an annual meeting now in its twelfth year. About 60 to 100 nephrologists, particularly younger trainees, have received each year an intensive course in contemporary basic, clinical and technical issues relating to kidney disease. The participants are largely drawn from the neighboring countries of Bulgaria, Croatia, Estonia, Hungary, Kosovo, Poland, Romania, Russia, and Slovenia. Laszlo Rosivall has played the key leadership role along with Professor Ritz and others. A postgraduate training course organized by ISN (Eberhard Ritz), European Renal Association (ERA) (Andrzej Wiecek) and the Institute for Postgraduate Medical Education in collaboration with the Czech Society Nephrology (Vladimir Teplan) and held each January for the past 5 years in Prague (Czech Republic). This event has been a wellspring for educating younger trainees and investigating current research issues in nephrology. In Romania, led by Adrian Covic, and co-sponsored by ISN and ERA/European Dialysis and Transplantation Association (EDTA), several “Renal Failure Academy” meetings have been held, again aimed at younger nephrologists from Eastern European countries. In addition, the three Baltic Sea countries of Estonia, Latvia, and Lithuania meet biannually in a regional meeting co-organized by the ISN (Eberhard Ritz) and ERA (Andrzej Wiecek) in collaboration with the local Baltic societies. The level of clinical nephrology has substantially progressed in these regions not to the least because of these activities. All of these regional courses help to address the two major problems that persist in Eastern Europe, namely, the lack of postgraduate courses in the region, and the inability of nephrologists to attend international conferences either because of financial circumstance or visa problems. The fragmented nature of Eastern Europe presents a unique problem for training and education. In some countries, such as Poland, the Czech Republic, Turkey, and Hungary, the level of nephrology practice reaches current guidelines, while in others it varies widely. The challenge is to provide CMEs that target the particular audience. Regional meetings have proved both effective and popular for this. ISN has worked closely with the Balkan Cities Association of Nephrology, Dialysis, Transplantation and Artificial Organs (BANTAO) in the Balkan countries to create regional meetings. Between 2000 and 2004 there were three “Update in Nephrology” meetings, one in February 2000, a second in June 2002, and the third in October 2004. The meetings were held in Belgrade and attended by approximately 120 physicians mostly from Serbia and Montenegro, but also from Macedonia, Serbian Republic, Bosnia and Herzegovina, and by Council Members of BANTAO. During the same period, Serbian doctors were invited to and participated in COMGAN-supported meetings in Romania, Hungary, and the Czech Republic. The CMEs have significantly improved local nephrology after 10 years of isolation, and they have also helped to establish scientific collaboration in the region. The ISN has also been very actively involved in nephrology in Turkey. The Turkish Society of Nephrology (TSN) was launched in 1970, and, in 1978, the ERA/EDTA met in Istanbul. In 1997, an ISN group visited the meeting of the TSN in Istanbul after an initial meeting in Moscow. It was an outstanding cast of speakers, including Craig Tischer, Richard Glassock, Eberhard Ritz, Robert Schrier, Norbert Lameire, and John Dirks, and was very well received. The close relationship with Turkish nephrologists led to a collective membership in ISN by every single member of the TSN. Professor Ekrem Erek, President of the TSN from 1995 to 2000, and the current President, Kamil Serdengecti, have guided the expansion of nephrology in Turkey in every area. They established an excellent renal registry in 1990 and the number of dialysis units has grown to 4731.Report of the Turkish Society of Nephrology: A Synopsis.2006Google Scholar. Nearly 27,000 patients per year receive hemodialysis and peritoneal dialysis. About 550 patients per year receive transplants in 22 different centers and about 66% involve live donors. Since 2000, 1000 general physicians have joined 200 Turkish nephrologists and 400 nurses annually at meetings in places like Istanbul, Izmir, Antalya, and Cappadocia. The growth in such meetings is not only in attendance, but more significantly, in scientific contributions. Testament to this growth is the amount of first-class clinical research being generated by Turkish nephrologists. They are now among the leaders in submitting abstracts to the ISN and ERA meetings. There is still a need for more basic research in Turkey, as in most low and middle income countries; however, in its decade of association with ISN, Turkish nephrology has grown steadily in both activity and reputation. During this same period, two earthquakes in the Istanbul area occurred near Izmet (1999) and Bingol (2003). At the Bingo
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