Society of Asian Academic Surgeons Presidential Address: A Is for American. Asian. Ally
2022; Elsevier BV; Volume: 277; Linguagem: Inglês
10.1016/j.jss.2022.02.052
ISSN1095-8673
Autores Tópico(s)Healthcare Systems and Challenges
ResumoIt has been 2 years since we last met at our Annual Meeting at Boston Medical Center. The ability to have this meeting this weekend is because of everyone in this audience, for submitting your scientific research, and for supporting the mission and the activities of SAAS, which made a difficult decision to plan for a mostly in-person meeting a bit easier, this past spring. And before I begin, I do want to take a moment to thank Drs Karl Bilimoria, Hasan Alam, Tony Yang, and Jeff Matthews for helping to sponsor this year's meeting and being instrumental in coordinating the logistics, including our session tomorrow on the use of our voice in public speaking and our upcoming virtual session on Bystander Intervention Training with the Chicago branch of Asian Americans Advancing Justice.Two years since our last meeting also means that I have had 2 years to think about what to talk about today, three if you include my year as President-elect. I remember being out for a run in downtown Milwaukee on January 1, 2020—it was a beautiful winter day, and I was starting to formulate my thoughts for what I thought would be a September 2020 presidential address. And then, 2020—and 2021—happened COVID. The social justice movement of Black Lives Matter and the national discussion on systemic racism, diversity, and equity. The rise in anti-Asian racism, accentuated by COVID-19-related rhetoric. All that has happened in the past 18 mo has obviously profoundly impacted all of us in many different ways—personally and professionally—and these events have also affected the Society of Asian Academic Surgeons (SAAS), as an organization—as we joined with other surgical societies, such as the Association for Academic Surgery (AAS), Society of University Surgeons (SUS), the American College of Surgeons (ACS), the American Surgical Association (ASA), Society of Black Academic Surgeons (SBAS), Association of Women Surgeons (AWS), Latino Surgical Society (LSS), and others, in examining the systemic inequalities and inequities in academic surgery, and in our society, more urgently than we had before.For me, it accelerated a learning process that I am very much still on. Over the past year and a half, as the current President, I was often asked to speak on behalf of SAAS, and I have to admit, I felt an increased responsibility for being authentic to the Asian American voice and perspective. And it has made me reflect on who our organization represents, and more fundamentally, not only what it means to be Asian in America, but also what it means to identify as an Asian American. My disclosure: I am not an expert on this. I am not a historian, and I am not a sociologist, and so while the ideas and topics I will touch on today are ones that many of us have had in conversation with each other, my talk today can in no way reflect the depth and complexity of the topic. Most importantly, I can only speak through the lens of who I am and my own experiences. But what I hope to bring across today is a bit about the history of Asians in the United States and of the term "Asian American"—why that history is important, and the implications it might have for SAAS and our place in academic surgery, but more broadly, across our national conversations on race.Who Are You?To quote the title of Herb Chen's American Association of Endocrine Surgeons Presidential Address in 2019, "Who Are You?"1Chen H. Who are you?.Surgery. 2020; 167: 4-9Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar I was born and raised in Poughkeepsie, New York—a town along the Hudson River. There was a fairly strong Asian community in Poughkeepsie because it was home to IBM, where my father worked. Growing up, we spent a lot of time with maternal aunts, uncles, and cousins who lived in the tri-state area (of NY, NJ, and Connecticut) and family friends, also Chinese, and their extended families. Growing up, I never really thought of myself as Asian, per se, and always thought of myself as Chinese—Chinese American, specifically because both of my parents were from Shanghai, via Hong Kong, where both my paternal and maternal grandparents lived. I even more narrowly associated with aspects of Chinese culture specific to those two cities. The closest I probably got to thinking about being Asian was at some point as a teenager, when I realized that the term "Oriental" was derogatory—who else remembers telling people that "Rugs are Oriental, People are Asian?"It might have been during college that I began to associate myself as being Asian American. I even took a course in Asian American history, but still, I did not really think about what the term meant or who it was referencing. And while many of my friends were Asian and some were more involved in the Asian American community, I distinctly remember feeling disengaged from the message of the community. This was, at least in part, because Brown University used the term "Third World" for all students of color. I had actually never really thought of why, until preparing this talk and found this explanation: "Students first began using the term 'Third World' over 'minority' because of the negative connotations of inferiority and powerlessness with which the word 'Minority' Is often associated…a cultural model of empowerment. Using the term "Third World" reminds students of the power they have in coalescing, communicating, and uniting across marginalized communities to create a safer and more open place for all individuals…to define themselves instead of being defined by others."2https://www.brown.edu/campus-life/support/students-of-color/historyDate accessed: September 6, 2021Google Scholar Reading this now, 25 years after I graduated, really resonated with me, because I think is not dissimilar to what we, SAAS, and other societies are trying to create for the community of academic surgery. As an aside, in 2014, the Third World Center released a new strategic plan, including a new name, the Brown Center for Students of Color, and a new mission statement: Visualize. Vocalize. Mobilize.Who Counts as Asian?So what does it mean to be Asian American, and who are we talking about when we use the term? Based on US Census and Pew Research data, there are now about 23 million Asians in the United States, approximately 6%-7% of the US population. The population of Asians has doubled since 2000 and is projected to double again by 2060.3Budiman A.R.N. Key Facts about Asian Americans, A Diverse and Growing Population. Pew Research Center, Washington, D.C.2021https://www.pewresearch.org/fact-tank/2021/04/29/key-facts-about-asian-americans/Date accessed: September 5, 2021Google Scholar But who is included in these 23 million people?The US Census Bureau categories of race are guided by the 1997 Office of Management and Budget (OMB) standards on race and ethnicity and "generally reflect a social definition of race recognized in this country" (Table 1).4About the topic of race.https://www.census.gov/topics/population/race/about.htmlDate accessed: December 17, 2021Google Scholar What stands in the options for race in the census? First, those of Middle Eastern and North African (MENA) descent continue to be considered "White." After the 2010 census, a working group convened by President Obama did recommend that MENA be added as a separate category; this was not adopted in the most recent 2020 census. Second, the definition of "Asians" includes only individuals whose origins include the Far East, Southeast Asia, or South Asia because as of 1997, Native Hawaiian and Pacific Islanders were separated from Asians in the census. This current census definition means that Asians in the United States trace their origins to more than 20 different countries, representing more than 50 ethnic groups and over 100 languages. Interestingly, just six origin groups comprise approximately 85% of Asians in the United States: Chinese, Indian, Filipino, Vietnamese, Korean, and Japanese Americans, with Indian Americans now representing the highest percentage of Asian Americans (Fig. 1).5Lee J. Ramakrishnan K. Who counts as Asian, and what counts as Anti-Asian hate?.https://stopasianhate.medium.com/who-counts-as-asian-and-what-counts-as-anti-asian-hate-37e5b455eeddDate: 2021Date accessed: September 20, 2021Google Scholar This does include the approximately 15% of people who identify as multiracial, specifically Asian and one or more race, but who do not identify as Hispanic (as of 2000, individuals were allowed to self-identify as more than one race).3Budiman A.R.N. Key Facts about Asian Americans, A Diverse and Growing Population. Pew Research Center, Washington, D.C.2021https://www.pewresearch.org/fact-tank/2021/04/29/key-facts-about-asian-americans/Date accessed: September 5, 2021Google Scholar, 4About the topic of race.https://www.census.gov/topics/population/race/about.htmlDate accessed: December 17, 2021Google Scholar, 5Lee J. Ramakrishnan K. Who counts as Asian, and what counts as Anti-Asian hate?.https://stopasianhate.medium.com/who-counts-as-asian-and-what-counts-as-anti-asian-hate-37e5b455eeddDate: 2021Date accessed: September 20, 2021Google ScholarTable 1United States census bureau categories of race.4About the topic of race.https://www.census.gov/topics/population/race/about.htmlDate accessed: December 17, 2021Google ScholarWhiteA Person Having Origins in Any of the Original Peoples of Europe, the Middle East, or North AfricaBlack or African AmericanA person having origins in any of the Black racial groups of AfricaAmerican Indian or Alaska NativeA person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachmentAsianA person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and VietnamNative Hawaiian or Pacific IslanderA person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. Open table in a new tab Does this official definition by the Census bureau align with who Americans—as a general public—see as "Asian," and how/if individuals identify themselves as Asian? The United Nations Statistics Division recognizes six subdivisions of the continent of Asia: North Asia (Russia and Siberia), Central Asia (the Stans), East Asia, Southeast Asia, South Asia, and Western Asian (also referred to as the "Middle East" or the "Near East"). This vast diversity in the geography of Asia has sometimes been described as a "cultural artifact of European conceptions of the world being imposed onto other cultures, an imprecize concept causing endemic contention about what it means." I think that this idea of being a cultural artifact also aligns with definitions of Asian American, which I will discuss over the course of this talk and despite this broadness of what is considered geographical "Asia," for many in the United States, the default interpretation of who is "Asian" and "Asian American" falls only into those who are East Asian. It is an idea that has come up often in the conversation about SAAS—people who do not feel that they should—or could—join SAAS, not because they are White, Black/African American, or Latino/Latinx, but because they are NOT Chinese, Taiwanese, Korean, or Japanese.So "Who Counts as Asian?" In a study that of the results of the 2016 National Asian American Survey, a telephone survey of almost 4400 Asian Americans including 10 different Asian groups and just over 1000 non-Asian respondents, Jennifer Lee and Karthick Ramakrishnan examined the "disjuncture between in-group and out-group racial assignment."6Lee J. Ramakrishnan K. Who counts as Asian.Ethn Racial Stud. 2019; 43: 1733-1756Crossref Scopus (32) Google Scholar Their framework distinguishes between whether individuals or groups are the focus of analysis (Fig. 2). For individuals, this is how one self-identifies, how others identify that person, and finally, the official or governmental assignment of racial identity. For groups, in-group assignment is how an individual believes their group fits into societal or governmental rubrics of racial classification, and out-group assignment is how an individual feels that others would classify this person into a racial class.Fig. 2(A). Typology of racial classification. Adapted from Lee and Ramakrishnan.6Lee J. Ramakrishnan K. Who counts as Asian.Ethn Racial Stud. 2019; 43: 1733-1756Crossref Scopus (32) Google Scholar (B). Example of racial classification typology. ∗Classified as "White" because "Middle East/North African (MENA)" is not an option on the US census.View Large Image Figure ViewerDownload Hi-res image Download (PPT)This took me a bit to wrap my head around, so as an example, I will compare the racial assignment of myself, a Chinese American, and one of my partners in Endocrine Surgery at the Medical College of Wisconsin, Sophie Dream, MD, who identifies as Iranian American. For this purpose, the "Other" was Kimberly Moriarty, a nurse practitioner that both Sophie and I work with. For me, it's pretty straightforward: I consider myself Asian, I think most people, including Kim, consider me to be Asian, and the government considers me to be Asian. I also consider Chinese people to be Asian, as does Kim and the official governmental (US Census bureau) definition. But what about Sophie? When I asked her how she identifies, her immediate response was, "this is a really hard question," because while she does identify as Asian, based on her lived experiences, she felt that others might not identify her as Asian, but would say that she was "not White." Indeed, this is true; when asked how she would identify Sophie, Kim stated that "most would call her White. But I know that's not true." And for how she would identify people from the Middle East, in general, she said, "Probably White, but really Middle Eastern." But Middle Eastern is not an option, and so the default racial assignment for Sophie is White.This comparison between the racial assignment of myself and Sophie, by each of us as individuals, by another person, and by the governmental definitions of race, is consistent with the findings of the Lee and Ramakrishnan study that the default "Asian" is East Asian.6Lee J. Ramakrishnan K. Who counts as Asian.Ethn Racial Stud. 2019; 43: 1733-1756Crossref Scopus (32) Google Scholar They found that 81% of respondents said that Chinese people were Asian or Asian American, compared to 46% of respondents who said that Indians are Asian or Asian American and 31% who said that Arabs were Asian or Asian American. They also found that while Asians, on average, are more inclusive than non-Asians in racial assignment of all Asian groups, inclusivity in the racial assignment was strongest among the Indians and Pakistanis surveyed. In other words, they were far more likely to assign themselves as Asian than East Asians, and Southeast Asians were in assigning themselves as Asian (Table 2).6Lee J. Ramakrishnan K. Who counts as Asian.Ethn Racial Stud. 2019; 43: 1733-1756Crossref Scopus (32) Google ScholarTable 2Proportion of Asian respondents indicating that the reference category is likely ("very likely" or "somewhat likely") to be Asian or Asian American.Adapted from Lee and Ramakrishnan.6Lee J. Ramakrishnan K. Who counts as Asian.Ethn Racial Stud. 2019; 43: 1733-1756Crossref Scopus (32) Google ScholarReference CategoryBangladeshiCambodianChineseFilipinoHmongIndianJapaneseKoreanPakistaniVietnameseChinese87%92%95%84%90%91%88%80%93%79%Japanese85%89%89%84%86%86%93%73%91%84%Korean83%88%88%83%87%88%88%83%92%81%Filipino83%85%86%93%71%88%81%76%91%79%Indian86%76%∗Indicates statistically significant differences from every East Asian reference category (Chinese, Japanese, Korean) at the 95% confidence level or higher.66%∗Indicates statistically significant differences from every East Asian reference category (Chinese, Japanese, Korean) at the 95% confidence level or higher.67%∗Indicates statistically significant differences from every East Asian reference category (Chinese, Japanese, Korean) at the 95% confidence level or higher.55%∗Indicates statistically significant differences from every East Asian reference category (Chinese, Japanese, Korean) at the 95% confidence level or higher.94%62%∗Indicates statistically significant differences from every East Asian reference category (Chinese, Japanese, Korean) at the 95% confidence level or higher.70%93%72%∗Indicates statistically significant differences from every East Asian reference category (Chinese, Japanese, Korean) at the 95% confidence level or higher.Pakistani75%64%∗Indicates statistically significant differences from every East Asian reference category (Chinese, Japanese, Korean) at the 95% confidence level or higher.51%∗Indicates statistically significant differences from every East Asian reference category (Chinese, Japanese, Korean) at the 95% confidence level or higher.51%∗Indicates statistically significant differences from every East Asian reference category (Chinese, Japanese, Korean) at the 95% confidence level or higher.41%∗Indicates statistically significant differences from every East Asian reference category (Chinese, Japanese, Korean) at the 95% confidence level or higher.82%45%∗Indicates statistically significant differences from every East Asian reference category (Chinese, Japanese, Korean) at the 95% confidence level or higher.41%∗Indicates statistically significant differences from every East Asian reference category (Chinese, Japanese, Korean) at the 95% confidence level or higher.92%40%∗Indicates statistically significant differences from every East Asian reference category (Chinese, Japanese, Korean) at the 95% confidence level or higher.Arab52%∗Indicates statistically significant differences from every East Asian reference category (Chinese, Japanese, Korean) at the 95% confidence level or higher.64%∗Indicates statistically significant differences from every East Asian reference category (Chinese, Japanese, Korean) at the 95% confidence level or higher.23%∗Indicates statistically significant differences from every East Asian reference category (Chinese, Japanese, Korean) at the 95% confidence level or higher.45%∗Indicates statistically significant differences from every East Asian reference category (Chinese, Japanese, Korean) at the 95% confidence level or higher.37%∗Indicates statistically significant differences from every East Asian reference category (Chinese, Japanese, Korean) at the 95% confidence level or higher.53%∗Indicates statistically significant differences from every East Asian reference category (Chinese, Japanese, Korean) at the 95% confidence level or higher.27%∗Indicates statistically significant differences from every East Asian reference category (Chinese, Japanese, Korean) at the 95% confidence level or higher.34%∗Indicates statistically significant differences from every East Asian reference category (Chinese, Japanese, Korean) at the 95% confidence level or higher.71%∗Indicates statistically significant differences from every East Asian reference category (Chinese, Japanese, Korean) at the 95% confidence level or higher.26%∗Indicates statistically significant differences from every East Asian reference category (Chinese, Japanese, Korean) at the 95% confidence level or higher.∗ Indicates statistically significant differences from every East Asian reference category (Chinese, Japanese, Korean) at the 95% confidence level or higher. Open table in a new tab The incongruity between identity and racial assignment matters because when only some Asian groups are counted as Asian, then the narrative about Asian Americans is incomplete and biased, which has implications for not just our conversations about race in America, but also for Asian American representation in national political polling and research on health and health care disparities; the latter is discussed by Drs Ankush Gosain and Lillian Kao in recent Advances in Surgery Channel session entitled "Lessons learned from Asian Academic Surgeons (https://aischannel.com/live-surgery/lessons-learned-from-asian-academic-surgeons/)." Asian Americans are often not reported in polling and research, in part because of our relatively low representation, making subgroup reporting challenging, and incongruent racial assignments can worsen this disparity.7Kennedy C.R.N. Polling Methods are Changing, but Reporting the Views of Asian Americans Remains a Challenge. Pew Research Center, Washington, D.C.2020https://www.pewresearch.org/fact-tank/2020/07/01/polling-methods-are-changing-but-reporting-the-views-of-asian-americans-remains-a-challenge/Date accessed: September 6, 2021Google Scholar, 8Chen S. Why Asian Americans often appear underrepresented in polling and research.https://abcnews.go.com/Politics/asian-americans-underrepresented-polling-research/story?id=77608474Date: 2021Date accessed: September 7, 2021Google Scholar, 9Tong J. Redefining the 'other' and what it means to be an Asian American.https://www.inquirer.com/opinion/commentary/asian-american-aapi-hate-racism-medicine-other-20210329.htmlDate: 2021Date accessed: September 5, 2021Google ScholarWhy is there a disconnect in identifying certain people as Asian American, and what might it mean for organizations like SAAS? I'd like to explore some potential reasons for this, specifically: (1) A brief overview of some of the history of Asians in the United States, with a focus on some of the national policy around Asian immigration (although I will not discuss the different immigration patterns from different countries, as George Yang, MD, PhD, gave a fantastic overview of that in his Joel Roslyn address at the 2019 Academic Surgical Congress, "Why We Rise"); (2) the origin of the term "Asian American"; and (3) the persistent view of Asians as "foreigners." Last, I hope to discuss how these reasons tie into why I think it is important that we (SAAS) are advocates, not just for Asian Americans in academic surgery, but allies to others who are underrepresented.Asian Immigration to the United StatesThis is a somewhat simplified overview of some of the policies surrounding Asian immigration in US history, starting in 1790, when the Naturalization Act was passed. This allowed immigrants, "aliens,"' to become US citizens, so long as they had lived in the United States for at least 2 years and were "free white persons"; a later provision was added that immigrants needed to speak English. These Acts were upheld by the US Supreme Court in two different cases, with two different arguments. The first was Ozawa versus the United States in 1922, in which Takao Ozawa was denied citizenship because he was not White or Caucasian. The second was 1 year later, in which Bhagat Singh Thind argued that South Asians were Aryans, and therefore, Caucasians, should be allowed citizenship in the United States. This time, the Supreme Court ruled that while they (a "blond Scandinavian and a brown Hindu") may have a common ancestor, "the average man knows perfectly well that there are unmistakable and profound differences between them today."10Lee E. The Making of Asian America: a History.First Simon & Schuster hardcover edition. Simon & Schuster, New York, NY2015Google Scholar, 11Wu F.H. Yellow: race in America Beyond Black and white. Basic Books, New York, NY2002Google Scholar, 12Lee J. Reckoning with Asian America and the new Culture war on affirmative action.Sociol Forum. 2021; 36: 863-888Crossref Scopus (4) Google Scholar In essence, Asians were either not white—or not White enough—to be citizens of the United States. The 1790 Act set the precedent for multiple laws that, until the middle of the 20th Century, continued to restrict the immigration and naturalization of any person that was not White. In fact, in 1896, in the Plessy v. Ferguson case that upheld legal segregation, Justice John Marshall Harlan wrote: "There is a race so different from our own that we do not permit those belonging to it to become citizens of the United States. Persons belonging to it are, with few exceptions, absolutely excluded from our country. I allude to the Chinese race."Specific to Asian Americans, many of the late 19th and early 20th Century laws were specifically targeted to Chinese immigrants, such as the 1875 Page Act and the 1882 Chinese Exclusion Act. The Page Act was the first restrictive federal immigration law in the United States and prohibited the recruitment of laborers and women for "immoral purposes," but was enforced primarily against Chinese immigrants, specifically Chinese women. The 1882 Chinese Exclusion Act further prohibited the immigration of Chinese people and prohibited the naturalization of Chinese citizens. The Chinese Exclusion Act was subsequently extended by the Geary Act of 1892 (and again in 1904) and upheld by the Supreme Court, and while the laws were aimed at the Chinese, these laws would ultimately affect all immigrants from the Asian continent. This includes the Immigration Act of 1917, also known as the Barred Zone Act, which both instituted a literacy test and also limited immigration across Asia, including South Asia, Southeast Asia, and the Middle East. Because most of East Asia's immigration had already been restricted, this Act served to not only expand the restriction from Asia but was targeted directly at South Asians and those in the Middle East. The 1924 Immigration Act further limited immigration by implementing a quota system, which served to favor Western European countries and further limit immigration from Asian countries and in 1934, when Congress granted the Philippines eventual independence, Filipinos became excluded from immigration, essentially limiting all immigration from Asian countries.10Lee E. The Making of Asian America: a History.First Simon & Schuster hardcover edition. Simon & Schuster, New York, NY2015Google ScholarImmigration policies began to be relaxed during World War II, beginning with the repeal of the Chinese Exclusion Act in 1943. What followed was a series of laws that reformed the most discriminatory restrictions, culminating in the Immigration and Nationality Act of 1965, the Hart-Celler Act. The Hart-Celler Act eliminated the national origins quotas system, although it maintained caps by category and on total immigration. But there was now a preference for certain categories, including highly skilled and educated immigrants, fundamentally shifting the balance of immigrants and of the United States population, as there was an increase from Asia, Africa, and Latin American countries.The Model Minority Myth and the Origins of the Term "Asian American"The influx of educated and skilled immigrants coincided with the post-Cold War development of the "model minority," a stereotyped image of Asian Americans as a generally polite, law-abiding group of people that have achieved success through a particular work ethic or inherent difference from other minority groups (Fig. 3).10Lee E. The Making of Asian America: a History.First Simon & Schuster hardcover edition. Simon & Schuster, New York, NY2015Google Scholar,11Wu F.H. Yellow: race in America Beyond Black and white. Basic Books, New York, NY2002Google Scholar,13Chow K. 'Model minority' myth again used as a racial wedge between Asians and Blacks.https://www.npr.org/sections/codeswitch/2017/04/19/524571669/model-minority-myth-again-used-as-a-racial-wedge-between-asians-and-blacksDate: 2017Date accessed: September 20, 2021Google Scholar, 14Blackburn S.-S. What is the model minority myth.https://abcnews.go.com/Politics/asian-americans-underrepresented-polling-research/story?id=77608474Date: 2019Date accessed: September 5, 2021Google Scholar, 15Kawai Y. Revisiting the 1966 model minority myth: a narrative criticism of its textual origins.Kaleidoscope. 2003; 2: 50-69Google Scholar, 16Chou R. Feagin J.R. The Myth of the Model Minority: Asian Americans Facing Racism.2nd ed. Paradigm Publishers, Boulder, CO2015Crossref Google Scholar There are two articles that are widely viewed as being responsible for the construction of the model minority myth; one published in the New York Times Magazine in January 1966 and the second in the US News and World Report in December 1966. Both pit Asian Americans, first Japanese Americans, in the New York Times Magazine article, and Chinese Americans, in the US News and World Report article, against Black Americans, in terms of work ethic, overcoming hardships, and achieving "success".10Lee E. The Making of Asian America: a History.First Simon & Schuster hardcover edition. Simon & Schuster, New York, NY2015Google Scholar,11Wu F.H. Yellow: race in America Beyond Black and white. Basic Books, New York, NY2002Google Scholar,15Kawai Y. Revisiting the 1966 model minority myth: a narrative criticism of its textual origins.Kaleidoscope. 2003; 2: 50-69Google Scholar In doing so, the model minority myth dismisses the role of race and discrimination as a social determinant and pits Asian Americans against other ethnoracial groups. Furthermore, given the tremendous diversity in the Asian American population, not only is the model minority stereotype not true, but its perpetuation has led to Asian Americans being viewed as a monolith and as "different" or "foreign."Fig. 3"We Are More" by Amanda Phingbodhipakkiya. https://www.morethan.art/.License for reproduction: https://creativecommons.org/licenses/by-nc-nd/4.0/.View Lar
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