Health Care Dysfunction Makes It to the Presidential Debate

Yves here. We’ve been republishing posts from Health Care Renewal for a very long time, but the recap below of the many causes of health care industry dysfunction is staggering. There is a lot of work that needs to be done.

By Roy Poses, MD, Clinical Associate Professor of Medicine at Brown University, and the President of FIRM – the Foundation for Integrity and Responsibility in Medicine. Originally published at Health Care Renewal

In last night’s debate which included leading candidates from the Democratic Party for its presidential nomination, as reported by Mother Jones, Senator Bernie Sander (D-VT) said (per Mother Jones).

the current health care system is not only cruel, it is dysfunctional

The video is here.

So the concept of health care dysfunction has officially made it to the big time.

You Heard It Here First

What took so long?

We have been talking about health care dysfunction for a very long time, starting with a publication in 2003.

To better understand health care dysfunction, I interviewed doctors and health professionals, and published the results in Poses RM.   A cautionary tale: the dysfunction of American health care.  Eur J Int Med 2003; 14(2): 123-130. (link here).  In that article, I postulated that US physicians were demoralized because their core values were under threat, and identified five concerns:

1. domination of large organizations which do not honor these core values
2. conflicts between competing interests and demands
3.  perverse incentives
4. ill-informed, incompetent, self-interested, conflicted or even corrupt leadership
5.  attacks on the scientific basis of medicine, including manipulation and suppression of clinical research stuides

After that my colleagues and I have tried to raise awareness of these and related issues, now mainly through the Health Care Renewal blog.  We also set up FIRM – the Foundation for Integrity and Responsibility in Medicine,  a US non-profit organization, to try to provide some financial support for the blog.

Health Care Dysfunction is Multi-Dimensional

Unfortunately, one sentence in a presidential debate hardly does justice to a huge and multi-faceted set of concerns.

Since 2003 we have broadened our thinking about what constitutes and causes US (and more global) health care dysfunction. Early on we noticed a number of factors that seemed to enable increasing dysfunction, but were not much discussed.  These factors notably distorted how medical and health care decisions were made, leading to overuse of excessively expensive tests and treatments that provided minimal or no benefits to outweigh their harms.  The more we looked, the more complex this web of bad influences seemed.  Furthermore, some aspects of it seemed to grow in scope during the Trump administration.

A brisk summary of these often complex issues follows.

Threats to the Integrity of the Clinical Evidence Base

The clinical evidence has been increasingly affected by manipulation of research studies.  Such manipulation may benefit research sponsors, now often corporations who seek to sell products like drugs and devices and health care services.  Manipulation may be more likely when research is done by for-profit contract research organizations (CROs). When research manipulation failed to produce results to sponsors’ liking, research studies could simply be suppressed or hidden.  The distorted research that was thus selectively produced was further enhanced by biased research dissemination, including ghost-written articles ghost-managed by for-profit medical education and communications companies (MECCs). Furthermore, manipulation and suppression of clinical research may be facilitated by health care professionals and academics conflicted by financial ties to research sponsors.

Deceptive Marketing

The distorted evidence base was an ingredient that proved useful in deceptive marketing of health care products and services. Stealth marketing campaigns became ultimate examples of decpetive marketing.  Deceptive marketing was further enabled by the use of health care professionals paid as marketers by health care corporations, but disguised as unbiased key opinion leaders,another example of the perils of deliberate generation of  conflicts of interest affecting health care professionals and academics.

Distortion of Health Care Regulation and Policy Making

Similarly, promotion of health policies that allowed overheated selling of overpriced and over-hyped health care products and services included various deceptive public relations practices, including orchestrated stealth health policy advocacy campaigns.  Third party strategies used patient advocacy organizations and medical societies that had institutional conflicts of interest due to their funding from companies selling health care products and services, or to the influence of conflicted leaders and board members.  Some deceptive public relations campaigns were extreme enough to be characterized as propaganda or disinformation.

More recently,  as we noted here, we became aware of efforts by foreign powers to spread such disinformation for political, not just financial gain, e.g., in April, 2019, we discussed evidence that Russia had orchestrated a systemic disinformation campaign meant to discredit childhood vaccinations, particularly for the measles, which was likely partly responsible for the 2019 measles outbreak

Furthermore, companies selling health care products and services further enhanced their positions through regulatory capture, that is, through their excessive influence on government regulators and law enforcement.  Their efforts to skew policy were additionally enabled by the revolving door, a species of conflict of interest in which people freely transitioned between health care corporate and government leadership positions.

In the Trump era, we saw a remarkable increase in the incoming revolving door, people with significant leadership positions in health care corporations or related groups attaining leadership positions in government agencies whose regulations or policies could affect their former employers (look here).   We found multiple managers from and lobbyists for big health care corporations being put in charge of regulation of and policy affecting – wait for it – big health care corporations, a staggering intensification of the problem of the revolving door.

Bad Leadership and Governance

Health care leadership was often ill-informed.  More and more people leading non-profit, for-profit and government have had no training or experience in actually caring for patients, or in biomedical, clinical or public health research.  Lately, during the Trump administration, we began to find striking examples of top government officials expressing ill-informed, if not outright ignorant opinions about medical, health care and public health topics look here).  We had not previously expected leaders of government to be personally knowledgeable about health related topics, but traditionally they consulted with experts before making pronouncements.

Health care leaders often were unfamiliar with, unsympathetic to, or frankly hostile to their organizations’ health care mission, and/or health care professionals’ values. Often business trained leaders put short-term revenue ahead of patients’ or the public’s health.  In addition, we began to see evidence that leaders of health care corporations were using their power for partisan purposes, perhaps favoring their personal political beliefs over their stated corporate missions, patients’ and the public’s health, and even  corporate revenues. Then, we started seeing appointed government health care leaders who lacked medical, health care or public health background or expertise but also whose agenda also seemed to be overtly religious or ideological, without even a nod to patients’ or the public’ health (look here).

Leaders of health care organizations increasingly have conflicts of interest.   Moreover, we have found numerous examples of frank corruption of health care leadership.  Some have resulted in legal cases involving charges of bribery, kickbacks, or fraud.  Some have resulted in criminal convictions, albeit usually of corporate entities, not individuals.

In the Trump administration, corrupt leadership extends from the corporate world to the highest levels of the US government.  We discussed the voluminous reports of conflicts of interest and corruption affecting top leaders in the executive branch, up to and including the president and his family (look here).  One cannot expect effective enforcement of ethics rules and anti-corruption laws in such an environment

Abandonment of Health Care as a Calling

A US Supreme Court decision was interpreted to mean that medical societies could no longer regulate the ethics of their members, leading to the abandonment of traditional prohibitions on the commercial practice of medicine.  Until 1980, the US American Medical Association had  ruled that the practice of medicine should not be “commercialized, nor treated as a commodity in trade.”  After then, it ceased trying to maintain this prohibition. Doctors were pushed to be businesspeople, and to give making money the same priority as upholding their oaths. Meanwhile, hospitals and other organizations that provide medical care are increasingly run as for-profit organizations. The physicians and other health care professionals they hire are thus providing care as corporate employees, resulting in the rise of the corporate physician.  These health care professionals may befurther torn between their oaths, and the dictates of their corporate managers.

Perverse Incentives Put Money Ahead of Patients, Education and Research

We have extensively discussed the perverse incentives that seem to rule the leaders of health care. Financial incentives may be large enough to make leaders of health care organizations rich.  Incentives often prioritize financial results over patient care.  Some seem to originate from the shareholder value dogma promoted in business school, which de facto translates into putting current revenue ahead of all other considerations, including patient care, education and research (look here).

Cult of Leadership

Health care CEOs tend now to be regarded as  exalted beings, blessed with brilliance, if not true “visionaries,” deserving of ever increasing pay whatever their organizations’ performance.  This pheonomenon has been termed “CEO disease” (see this post).  Afflicted leaders tend to be protected from reality by their sycophantic subordinates, and thus to believe their own propaganda.

Managerialism

Leadership of health care organizations by managers with no background in actual health care, public health, or biomedical science has been promoted by the doctrine of managerialism which holds that general management training is sufficient for leaders of  all organizations, regardless of their knowledge of the organizations’ fundamental mission.

Impunity Enabling Corrupt Leadership

Most cases involving corruption in large health care organizations are resolved by legal settlements.  Such settlements may include fines paid by the corporations, but not by any individuals.  Such fines are usually small compared to the revenue generated by the corrupt behavior, and may be regarded as costs of doing business.  Sometimes the organizations have to sign deferred prosecution or corporate integrity agreements.  The former were originally meant to give young, non-violent first offenders a second chance (look here).  However, in most instances in which corruption became public, are no negative consequences ensue for the leaders of the organizations on whose watch corrupt behavior occurred, or who may have enabled, authorized, or directed the behaviors.

Taboos

Some of the above topics rarely appeaedr in the media or scholarly literature, and certainly seem to appear much less frequently than their importance would warrant. We have termed the failure of such issues to create any echoes of public discussion the anechoic effect.

Public discussion of the issues above might discomfit those who personally profit from the status quo in health care.  Those involved in the leadership and governance of health care organizations and their cronies, also have considerable power to damp down any public discussion that might cause them displeasure. In particular, we have seen how those who attempt to blow the whistle on what really causes health care dysfunction may be persecuted.

However,in the Trump administration,  we began to also note examples of government officials attempting to squelch discussion of scientific topics that did not fit in with its ideology, despite constitutional guarantees of speech and press free from government control (look here).

What a witches’ brew, surely leading to a cruel and dysfunctional system.

Discussion

In 2017, we said that it was time to consider some of the real causes of health care dysfunction that true health care reform needs to address, no matter how much that distresses those who currently most personally profit from the status quo.

Furthermore, in 2019 we asserted that all the trends we have seen since 2017 are towards tremendous government dysfunction, some of it overtly malignant, and much of it likely enabling even worse health care dysfunction.

Now that health care dysfunction is in the headlines, we hope health care and public health professionals, patients, and all citizens will have a much more vigorous response to it.  US health care dysfunction was always part of the broader political economy, which is now troubled in new and dangerous ways.  We do not have much time to act.

If not now, when?

If not us, who?

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36 comments

  1. cripes

    Forty years ago I felt confident we would enact universal health care, end the war on drugs and maybe, just maybe, end the quarter century of permanent war against the rest of the world by the turn of the 21st century.

    I underestimated the stupidity of the American elite in their single minded pursuit of profits, regardless of the consequences.

    Reply
    1. Alex Cox

      What a relief to know that the Russians are behind the scare about vaccines! I thought it had to do with mercury and the abandoning of the precautionary principle by Big Pharma. Glad to be set straight as to the real culprits.

      Reply
  2. Synoia

    Not one comment on the Higher Education cost of becoming a Doctor.

    We have a systemic set of byzantine interlocking issues in the US, all driven by greed. One cannot be addressed without addressing the others.

    This leads to a collapse, not a reform.

    In the US’ case it appears any collapse would be accompanied by a stunning set of violence acts, as the only large well funded Government institution are those provoking War, the MIC including the Intelligence apparatus.

    With us thanking them for their Service.

    Reply
    1. Brooklin Bridge

      Though I see your point, or think I do, I don’t see any effort in this article to hide anything -quite the contrary- and the cost of medical education might go either way; it’s not automatically central to health care dysfunction, but rather to that of dysfunction in the system of education though you correctly point out the close relation of the two very broad subjects. Perhaps a paragraph on education costs might be warranted, but that said, it’s not a major weakness.

      As to the interconnections of all things, and I may be missing your point, but it seems a pretty broad subject on its own, and doubtful one can even address all things related to a given topic in such a finite space so as to fully illustrate one of them (leave nothing out). By convention, it’s the other way around and even with that limitation I find the article is highly evocative of a more general and intractable societal dysfunction.

      Reply
      1. Brooklin Bridge

        Moreover, and I should have focused more on this above, the sheer number of issues covered (with in depth links) in this article is already breathtakingly sobering.

        Reply
          1. Yves Smith Post author

            I disagree. When I was a kid and college and grad school were not terribly expensive, everyone knew that being a doctor was an upper middle class profession. Doctors were actually more affluent on a relative basis then than now. For instance, doctors were prized clients of retail brokers because they’d have enough investable assets to be worth targeting and weren’t all that sophisticated.

            There was most assuredly a money motivation back then too. It’s not driven by status, it was and continues to be driven by the fact that getting a degree from an at least OK school assures you of being able to work at a good to high level of pay.

            Reply
          2. Jeremy Grimm

            I would state your comment at 11:27 am differently. The high Cost of Education coerces even those who enter medicine as a true calling to look for ways to pay off those costs. However, I also agree with Yves point. Most of the pre-med students I knew when I went to college — during the 1970s — were motivated by a desire for a high income. Of the few I knew who seemed to possess a calling few succeeded in getting into medical school [a side note — most of these were women — which is why I tend to seek out female physicians].

            Some of the stories I heard about the pre-med classes from my roommate who was premed [he failed to get in to any med school and his bona fide desire to serve was amply demonstrated when he went back to school to get a credential for social work] left in me with a long-lasting bad impression of U.S. physicians. It was commonplace for pre-med students to deliberately sabotage other students. The genetic lab at my school — one of the many ‘wash-out’ classes all pre-meds had to take — involved deciphering the genetic traits of a pair of fruit flies. A flask with one pair of fruit flies went to each student in the beginning session of the class. To determine the genetic traits of this pair a student had to go into the genetics lab every 24 hours, anesthetize a generation of flies, and count and categorize some of their physical genetic traits like eye-color. It was common for a student to come to the lab and find their flask emptied of flies or another trick was to insert a few wild flies into a flask. This would sabotage the victim’s grade and perhaps their self-confidence as a side bonus.

            Later I worked graveyard switchboard at a private hospital where the star physician with admitting privileges to the hospital worked medical patients. The nurses I talked with on break told me he pulled in a million a year [in the 1970s] by seeing up to 200 patients per day. I recall one night when I came in when one of the charge nurses warned me about her request that I call this doctor to come in to handle problems with one of his patients her station handled. She told me to go very gently because the doctor was in a bad mood. One of his patients came to the office during the day reporting classic symptoms of the onset of a heart. The doctor prescribed some anti-acid pills and sent the guy on his way. The guy had the temerity of dying right in the doorstep of the doctor’s office — which was very bad for business. On another occasion this same nurse told me about one of the surgeons who took out a hypochondriac’s gall bladder to make a last payment on his Winnebago.

            Reply
  3. Brooklin Bridge

    Incredible. Staggering indeed. This article, perhaps more than any other I have read, brings to the surface in a way one can begin to grasp what a desperate and frightening if not horrifying situation we are in globally. Yves next remark, A lot of work to be done, is – so typically – a deeply healthy one.

    Reply
  4. ambrit

    As a pair of aging Citizens first, and Consumers second, we two once expected a, if not opulent retirement and health care, at least an adequate one. The reality is becoming that neither is ‘on offer’ for our socio-economic class. The ‘Neo Dispensation’ is that the categories of social ‘existence’ are reversed. People are expected in this “best of all brave neo worlds” to fulfill the roles of Consumer first, and Citizen second, if at all.
    Dysfunction is the perfect word with which to describe the American medical system. We encountered exactly that this week in relation to pain medications for Phyl’s cancer. Tying in several of the themes of the Post above, this farrago involves the pernicious effects of the War on Drugs on the provision of medical treatment. Specifically in this case, the institutional limitation as to what a MD can prescribe to a patient in the way of pain relief medications. Believe us, that limiting effect is very real. Further explication would amount to hijacking this thread, so I will wait for a better time to comment more.
    Secondly, I noticed a touch of Trump Derangement Syndrome in the post. Has this meme propagated that far? Are otherwise sane and reasonable people now ‘functioning’ within the constraints of a mental Noeliberal pocket universe? If such be true, then I can only surmise that the collapse of the present ‘dysfunctional’ system, socio-political in essence, will be much greater and much more dislocative than any of us imagine.

    Reply
      1. ambrit

        Agreed about the “regrettableness” of the inclusion of the memes in an otherwise very good piece.
        My worry is that these delusions will be included in any set of ‘fixes’ proposed for the problems mentioned. To that end, such memes can be useful tools for misdirection. Fixes focused on the false problems can be used to stymie proposed fixes for the actual causes of the problems.
        That said, I wonder if the author actually believes the TDS and Russophobia memes, or is including them to assure inclusion of the article in “officially recognized” venues? That would make a serious difference in my respect for and trust in the author’s sagacity.

        Reply
        1. Elizabeth

          I agree – an otherwise excellent discussion of our horrible medical system. The paragraph about Russia spreading disinformation about measles vaccine left me wondering is Russia responsible for everything gone wrong in this country. It’s incredible and shocking to see this in such a discussion of healthcare. I also noted a bit of TDS in it – Trump isn’t responsible for the sad state of healthcare since it’s been decades in the making. As Ambrit noted, I’m wondering if the author just mentioned this as “tokenism” to be taken seriously by some.or out of real belief, This really needs to stop.

          Reply
        2. Joe Well

          For me, the conspiracy theorizing is enough to call the entire article, and the group that wrote it, into question. I actually followed the link their blog post that they used as a source for their Russophobic paragraph, and it is the usual Russiagate nonsense (like jumping directly from the 1980s KGB to today’s Russian government) and TDS (they use the phrase “Trump regime”).

          How can you trust conspiracy theorists?

          Reply
          1. ambrit

            Re, “How can you trust conspiracy theorists?”
            When ‘they’ turn out to have been right all along. This is becoming more clear as time goes by. There really is a CIA run ‘mind control’ experimental program. (The LSD experiments, which went on for a long time.) There really is a program to ‘control’ the media. (Operation Mockingbird.) All of Snowden’s revelations concerning the Intelligence agencies ‘covert’ wars and plain flouting of domestic American laws. The Syrian ‘gas attacks’ were stage managed by Western ‘assets.’ (The White Helmets creating footage of gas attack ‘victims’ in Egypt.)
            As I age, painful experience teaches me that; “One can never be too cynical.”
            Mind you, we must make the distinction between “official” conspiracy theorists, and the “wild” variety of conspiracy theorist. The “official” version is employed by power elites to sow discord and confusion by muddying the waters of the public discourse. The “wild” variety is responding to a ‘vague notion’ that disturbs them. Then evidence comes to light. The argument with true conspiracy theories is in the quality of the evidence. Mere dismissals of the whole theory due to appeals to authority or ad hominem attacks are poor logic and dishonourable exercises in propagandizing. But there is where we are today. Our entire socio-political culture has become one massive “appeal to authority.”

            Reply
    1. Brooklin Bridge

      Ambrit,

      I’m so very sorry you and your wife are caught up in this issue generally, and particularly that an already tragic situation of cancer is made worse by the political/pharmacutical/administrative/insurance (ugg) disinfluence on the medical profession and in particular on prescription of appropriate pain medication. Within the last year I have suffered a terrible and brutally tragic personal loss, too painful to go into, but again, (last time it was dental and a pittance by comparison), my sorrow is heartfelt.

      I’m not sure Trump syndrome is quite accurate though calling it “a touch” is. But you’re spot on that the author falls prey at the very minimum to a touch of Russia-gate (following the links) and his other assertions about historical Russian medical disinformation aimed at the US as well as corruption within the Trump administration may also suffer from exposure to that bubble. Still, based on many Trump appointments I find it hard to believe his administration is NOT corrupt, and I suspect Russia has been guilty of mischief quite independently of the more recent Clinton nightmarish concoctions and their forced consumption down our throats by the Democratic party and the main stream media.

      That said, you raise a valid issue making me a little more cautious in what may have been an overly wholesale acceptance of the author’s general frame of reference.

      Reply
      1. ambrit

        Sorry to hear that you have suffered similarly to Phyl and I. It does indeed “suck.” You were somewhat ‘missing in action’ for a while. Now i understand better. Staying strong is as much of a struggle as the underlying problem. Since you mentioned it, my former dental problems were as nothing compared to Phyl’s cancer. No doubt about it. A sobering experience indeed to consider the idea of pain level ‘triage.’
        While I agree that Trump is governing in a long and honoured Republican Party tradition; nepotism, cronyism, business ‘friendly,’ and inherently corrupt, I would rate him as average for the grifters and Quislings that preceded him. What is different here, and, alas, even though I wear my Lefty pin with pride, I fully agree with the lot over at Sic Semper Tyrannis, this situation looks awfully like an attempt at a “coup.”
        The upshot of all this, added to the DNC Horror Show, is that I feel that there is no institutional “place” for me and my hopes in America today.
        As for Russia, well, as a fully independent foreign power, the Russian government would be derelict in it’s responsibilities to Russia and her people if they did not try to influence America.
        Be safe and warm!

        Reply
        1. Brooklin Bridge

          Thanks so much for such a kind reply, Ambrit and strong well wishes -as much as can be- back at you and Phyllis. I think of you both often.

          Reply
          1. ambrit

            Thanks again Brooklyn Bridge. You take care of you and yours. Human social organization is still based upon the family and clan units.

            Reply
  5. Paradan

    The Russia stuff may be true, but it’s probably good to keep in mind the fact that the CIA/NSA/etc., had software tools designed to falsely attribute cyber attacks. I wouldn’t put it beyond them to cause a small measles out brake so they could frame Russia.

    Reply
  6. KLG

    There is hope. Had a discussion with an older friend last night. He is what might be called a True Believer in GOP Orthodoxy who has also made his peace with Donald Trump. He said, and I quote, “What we need in this country is health care, not health insurance!” We are off to watch a golf tournament in paradise this morning, so I’ll leave it there. For now.

    Reply
  7. Brooklin Bridge

    Ambrit,

    I’m so very sorry you and your wife are caught up in this issue generally, and particularly that an already tragic situation of cancer is made worse by the political/pharmacutical/administrative/insurance (ugg) disinfluence on the medical profession and in particular on prescription of appropriate pain medication. Within the last year I have suffered a terrible and brutally tragic personal loss, too painful to go into, but again, (last time it was dental and a pittance by comparison), my sorrow is heartfelt.

    I’m not sure Trump syndrome is quite accurate though calling it “a touch” is. But you’re spot on that the author falls prey at the very minimum to a touch of Russia-gate (following the links) and his other assertions about historical Russian medical disinformation aimed at the US as well as corruption within the Trump administration may also suffer from exposure to that bubble. Still, based on many Trump appointments I find it hard to believe his administration is NOT corrupt, and I suspect Russia has been guilty of mischief quite independently of the more recent Clinton nightmarish concoctions and their forced consumption down our throats by the Democratic party.

    That said, you raise a valid issue making me a little more cautious in what may have been an overly wholesale acceptance of the author’s general frame of reference.

    Reply
  8. krisalman

    1980. A pivotal year in health care, and the year I started medical school. Trickle down economics was the engine for commercialization of medicine. Neoliberalization on steroids.

    Since I specialized in endocrinology, I will point out that there are anabolic (e.g. testosterone) and catabolic (e.g. cortisone) steroids. Building up or breaking down. As trickle down economics worked, the financial elite thrived by breaking down the middle class, growing their strength in overt class warfare. Democracy atrophied.

    As I have learned through reading NC over the past few years, neoliberalization was embraced by both parties and in all professions. The sorting hat for medical students is driven by ROI. If you have a $500k debt, how do you pay it back? Not by specializing in primary care (or endocrinology)! Choose a profession where the AMA derived CPT codes give preference to procedure-oriented care. And then unleash these specialists to use their hammer and nails! (Never mind if spinal surgery makes your life worse!)

    The 21st Century version of the Hippocratic Oath: the Hypocritical Oath.

    Reply
  9. flora

    2003? See Billy Tauzin and Medicare part D (manditory drug coverage):
    https://www.nejm.org/doi/full/10.1056/NEJMp068116

    During which Rep. Tauzin ( who was a D until 1995, then switched to R) was negotiating a 2 million a year job as a lobbyest for Pharma.

    https://www.propublica.org/article/medicare-drug-planners-now-lobbyists-with-billions-at-stake-1020

    Did the then Dems try to improve the deal? No. See: John Breaux, above. I’ll spare readers the Tom Daschle (D) and Joe Lieberman (D), among many, links.

    Reply
    1. howseth

      Billy Tauzin – I was trying to remember the SOB’s name. I seem to recall a 60 Minutes segment, of him laughing at everyone – knowing he was going to get away with his awful legislation – and it’s non negotiable drug pricing – and land golden in a cushy lobbying job waiting for him the moment he left office. Does my memory serve accurately?

      He is a text book case of something.

      Reply
      1. ambrit

        Billy is a textbook case of Louisiana politics spreading to the rest of the country. Louisiana has long been touted as America’s Banana Republic. Tauzin is just a highly visible example of the corruption that plagues such organizations.

        Reply
  10. Danny

    Joe Biden claims he has a list of 160m Americans who like their health insurance.
    Could he post part of it?
    I’d like to hear from any of them who have had to use a hospital for something major.

    Reply

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