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Association
of American Physicians and Surgeons, Inc.
A Voice for Private Physicians Since 1943
Omnia pro aegroto |
Talk for AAPS Conference in San Antonio, Texas
Oct. 8. 1993
The Holocaust Memorial, Ayn Rand, and Politics
in
Pre-Revolutionary New York: Lessons for Today
Joseph M. Scherzer, M.D.
As American physicians we are painfully aware that our future
promises increasingly restrictive and intimidating governmental
regulations. They are growing like kudzu. We foresee nothing but
the progressive diminution of our professional autonomy along with
decreasing incomes. Given such circumstances, shall we remain
silent?
Faced with adversity, why are most of us mute? Why do those
who prefer to remain dumb criticize those of us who dare to be
outspoken in the face of almost certain failure in our gargantuan
battle with the federal government? Are the problems confronting
us unique?
Our organization - the AAPS - is 50 years old this year, and
last April also marked the 50th anniversary of the uprising of the
Warsaw Ghetto. Might the Holocaust hold any lessons for us? My
answer is a resounding "Yes!" History should convince us that we
have no recourse save action; that we cannot afford not to speak
out. This message has been cast in concrete and steel in the form
of the United Sates Holocaust Memorial Museum, which was recently
dedicated in Washington, D.C. Allow me to read several words from
a Washington Post Article, describing it:
"Jame's Freed's severe, demanding building...is a
masterpiece. ...in the Holocaust Museum, the acute, unforgiving
angles, the sharp, forced turns, are a powerful pedagogical
device. This is the architecture of forced marches, of mechanized
cruelty, of industrialized death. The building's texture of raw
steel and brick and granite gives the feel of a factory, but its
calculated irrationalities - cracked lines, dead ends, blotted
windows, narrowing staircases - imply a machinery of
derangement."1
I would highly recommend that every American visit this
museum. To do so is to immerse oneself in a thought-provoking
emotional cauldron which is a testimony to a precious truth -
that, in the final analysis, governments of men will not be judged
on the merits of their economic productivity, but by the degree to
which they promulgated and protected eternal human values - or
failed to do so.
Several years ago, "Roundup," the monthly publication of the
Maricopa County Medical Society, published an article of mine
about this topic. I compared the demoralization of physicians
resulting from growing governmental control and interference with
the practice of Medicine to the psychological effects of
repressive techniques used by the Nazi regime as it attempted to
master a small segment of German society. Economic issues were
central to that dark event in human history, just as they are in
America's current "health care crisis."
1. Holocaust Museum - where infamy achieves
immortality, by Charles Krauthammer. The Washington Post, Friday,
April 23, 1993.
Although this analogy may seem extreme at first glance, I
would like to emphasize that I am only comparing the psychology
and effects of the methods employed in these two situations - not
the actual events themselves.
At the inception of the Holocaust, individual rights were
slowly abridged; minor ones at first. As Pat Robertson writes in
his book, "The New World order," "false propaganda, ridicule, and
demeaning comments" were all heaped upon the Jews by the Nazi's in
Hitler's Germany. "First they were ridiculed and blamed for the
economic collapse of Germany. Then they were denied a few rights
of citizenship. Then they were crowded into restricted ghettos.
And finally their property and their lives were taken from them."
As I wrote in Roundup in 1986: "The populace used denial to
explain away and minimize the importance of successive incursions
upon their Liberty and Freedom. As time wore on their dignity was
slowly stripped away; they coped, and survived, for a
time..."2 Eventually, all will and determination were
gone, and the controlling forces were easily able to shepherd the
subdued masses. By implementing regimentation slowly, step by
nefarious step, resistance had been effectively nullified.
It is all too clear that the federal government, in a
forcefully determined and progressive fashion, is artificially
fragmenting and dissolving the integrity of the medical
profession.
2. Roundup, Maricopa County Medical
Society News, Vol. 32, No. 11, November 1986, p.9.
Ever-burgeoning constraints are being levied upon
American physicians as they attempt to practice their craft while
the government steadfastly pursues its goal of the socialization
of our unique profession. For a short while we were saddled with
the "gag rule," which declared that a physician working for a
federal health clinic was forbidden to even discuss the option of
abortion. We have CLIA regulations proclaiming that a
dermatologist may no longer interpret skin biopsies
microscopically unless he pays a regulatory fee. We render
legitimate service only to find that payment is denied
retrospectively by third-party payors like Medicare. We are being
handled as if we are an industry, but we are forbidden to
unionize.
By passively permitting our government to arbitrarily abridge
our professional rights to discuss interrelated scientific medical
matters with our patients, or by allowing the government to
constrain us from making full use of our professional abilities in
any way, we are not only facilitating governmental control over
the House of Medicine, we are running the risk of destroying the
very basis of that profession. While physicians are well aware
that the federal government has been incrementally restricting
their ability to practice Medicine in a free market fashion, they
have made no concerted effort to halt the process. Why? I believe
the main reason can be explained by what I call "The Heinlein
Principle," in deference to the late science fiction author,
Robert A. Heinlein. In his inimitable way, he stated that "it is
socially unacceptable to be right too early." Another (and better
known) philosopher, George Santayana, stated that those who do not
study history will be condemned to repeat it.
Education notwithstanding, history usually does repeat
itself. I have formulated my "Heinlein Principle," a composite of
the thoughts of these two men, in order to try to explain why this
is so.
The "long version" of the Heinlein Principle states: History
usually repeats itself because those who would otherwise take
appropriate action and preventive measures in a timely fashion are
restrained by the knowledge that they would be stigmatized due to
the perception of the public and their peers that such actions
were at least premature - if not entirely inappropriate. Or, to
sum this up more succinctly: History usually repeats itself
because precocious prevention is scorned.
Passivity, coupled with the use of denial, is the
characteristic and expected response to the slow but steady
abridgment of freedom we are experiencing - this, even in the face
of death itself.
Thinking that I had indeed pushed an analogy to its limits
when I published my own article, it was most interesting to read a
paper in the April 25, 1990 Journal of the American Medical
Association bringing up the same historical issues during a
discussion about the possibility of active euthanasia in America
in the near future. Allow me to quote from the JAMA publication,
which reflects on the infamy of the Holocaust as it discusses what
it considers to be a growing threat to the longevity of our
nation's elderly:
"Not only has there been a movement to discriminate against
patients in a persistent vegetative state, but evidence of
discrimination against the aged in our population is becoming
apparent. It has been suggested that after a person has lived most
of his or her natural life span, medical care should not be
oriented to resisting death...
The greatest aberration of the physician occurred in Nazi
Germany, with direct medical killing and systematic genocide. How
could a physician be transformed into a being capable of such
heinous actions? First, there was the concept of lebensunwertes
leben ("a life unworthy of life"). Soon the unworthy life came to
be anyone considered undesirable or useless. Second, physicians
were no longer caretakers of an individual patient, but rather
promoters of the general health of the German people. Physicians
were servants of the state rather than independent practitioners
[italics, ed.]. These [undesirable] people were [deemed to be] a
tremendous economic burden on society, [and] there was a
distancing of the killer from the victim.
The beginnings [of those crimes perpetuated during the
Holocaust] at first were merely a subtle shift in emphasis of the
basic attitude of the physicians."
[You may find what I am next about to tell you unbelievable -
it may seem that I have made it up - but the next few words are
all too frighteningly true. The following statement appears in the
manifesto of the Arizona Affordable Health Care Coalition, the
group of citizens and corporations - including Cigna, Intergroup,
Blue Cross and Blue Shield - which is designing my own state's
managed care plan. I doubt these people fully realize how closely
one of their main policies mimics the paradigm shift in medicine
which occurred in Nazi Germany. Their so-called (confidential)
"Vision Statement" maintains that (and I quote):
"The physician gradually will need to accept a necessary
change of ethical focus from the biomedical mode (intervention
without regard to cost if there be any chance of success) to a
biosocial model that considers not only the health needs of
individuals, but also the health needs of populations, including
those members of the population who do not seek medical care."
As the saying goes, ideas do have consequences.
This same manifesto goes on to insist that "health care
quality and patient safety will never be compromised"!]
Joseph Goebbels, Hitler's propaganda minister, stated that if
you make the lie big enough it will be believable.
According to the 1990 JAMA article, "The parallels of what
happened in Germany and what is currently occurring in this
country...are striking. Physicians [are] becoming more concerned
with societal needs as opposed to the needs of an individual
patient as scarce resources decrease."3
3. Changes Attitudes and Practices in Forgoing
Life-Sustaining Treatments, Charles L. Sprung, M.D., J.D., JAMA.
1990;263:2211-2215.
I agree with JAMA about these changes and the parallels it
draws, but I maintain that the engine governing the new road along
which medical care is being guided is the federal government
rather than society per se, and this attitudinal shift is being
driven solely by the economic concerns of Bureaucracy and Big
Business - the "wealthy elite," as William Greidner says in his
book, "Who Will Tell the People". Societal and physician attitudes
are being molded by the approach which the government and the
managed care plans it has been fostering have decided to take.
Doctors are being straightjacketed, their autonomy and creativity
throttled. The methodology being used to successfully turn doctors
into servants of the state is designed to substantially decrease,
if not destroy, the ethical incentives intrinsic to the proper
practice of Medicine.
The subtleties of these ongoing events and their noxious
consequences should not be dismissed, and it must be appreciated
that it is in the government's fiscal interests to breach the wall
of physician advocacy. The physician's championship of his
patient, a key ingredient in the practice of Medicine, is the most
substantial - and critical - barrier to the goals of statist
medicine.
As the article in JAMA stated, ..."American medicine must
realize where it stands in its fundamental premises. There can be
no doubt that in a subtle way the Hegelian premise of "what is
useful is right" has infected society, including the medical
portion. Physicians must return to the older premises, which were
the emotional foundation and driving force of an amazingly
successful quest to increase powers of healing and which are bound
to carry them still farther if they are not held down to earth by
the pernicious attitudes of an overdone practical realism."
As you know too well, the attitude of many of our colleagues
is: "It is useless. There are too few of us with the will to
resist."
Well, resistance movements are generally never large. There
are very potent obstacles in the way of a large scale, concerted
physician rebellion against governmental control, especially vis a
vis Medicare: threats of civil and criminal penalties - for
example, fines of up to $10,000 a day for not completing certain
paperwork requirements. The government is quite an intimidating
opponent. Additionally, there is no question that doctors are
constantly in jeopardy of a severe public backlash at the merest
mention of the word "fees." (Any doctor realizes that "fee" is
really a four-letter word.) Knowing this, it is particularly
clever of the government to force physicians to ration care by
means of fee constraints. Our government is quite cognizant of how
difficult it is for doctors to win any points if this subject is
debated, and we realize that private contracts are of paramount
importance to the physician-patient relationship. Ironically,
while our government pompously declares health care a "Right" it
attempts to forbid Medicare patients from purchasing this "Right"
with their very own funds!
According to a 1992 issue of AAPS News, in 1949 Melchior
Palyi said - "In democracies the Welfare Sate is the beginning and
the Police State the end. The two merge sooner or later, in all
experience, and for obvious reasons...All modern dictators have at
least one thing in common. They all believe in social security,
especially into coercing people into governmentalized
medicine."4
Was Ayn Rand correct when she wrote that the difference
between a welfare state and a totalitarian state is only a matter
of time? If we allow ourselves an open mind to examine the issues
raised here, the parallels with Communism and all its pitfalls
should be obvious.
There are frighteningly accurate predictions of the present
government and corporate rape of Medicine in Ayn Rand's Atlas
Shrugged. In the novel, the government decides to control a
new, lightweight and exceedingly strong metal- symbolic of the
metal of one's mind, one's soul - one's productivity - and enacts
laws making ownership of Rearden Metal a virtual right. Then, in
order to determine what constitutes a fair share of this valuable
commodity, the government hires the equivalent of our own Dr.
Hsaio. Finally, Rearden is informed that he must sell his metal to
the government - that he has no choice. His response is
noteworthy:
"A sale," said Rearden, slowly, "requires the seller's
consent." He got up and walked to the window. "I'll tell you what
you can do."
4. AAPS News, August 1992, p.3.
He pointed to the siding where ingots of Rearden
Metal were being loaded onto freight cars. "There's Rearden Metal.
Drive down there with your trucks - like any other looter, but
without his risk, because I won't shoot you, as you know I can't -
take as much of the Metal as you wish and go. Don't try to send me
payment. I won't accept it. Don't print out a check to me. It
won't be cashed. If you want that Metal, you have the guns to
seize it. Go ahead...You need my help to make it look like a sale
- like a safe, just, moral transaction. I will not help you."
5
"...looters believe it is safe to rob defenseless men, once
they've passed a law to disarm them. But their loot becomes the
magnet for other looters, who get it from them as they got it.
Then the race goes, not to the ablest at production, but to those
most ruthless at brutality. When force is the standard, the
murderer wins over the pickpocket. And then that society vanishes,
in a spread of ruins and slaughter."
"When you see that trading is done, not by consent, but by
compulsion - when you see that in order to produce, you need to
obtain permission from men who produce nothing - when you see that
money is flowing to those who deal, not in goods but in favors -
when you see that men get richer by graft and by pull than by
work, and your laws don't protect you against them, but protect
them against you - when you see corruption being rewarded and
honesty becoming a self-sacrifice - you may know that your society
is doomed."
5. Ibid. pp. 346-7.
"Do not expect [men] to produce, when production is punished
and looting rewarded."
"If it is now believed that my fellow men may sacrifice me
in any manner they please for the sake of whatever they deem to be
their own good, if they believe they can seize my property simply
because they need it - well, so does any burglar. There is only
this difference: the burglar does not ask me to sanction his
act."6
Later in the novel, the State's new policy's result in
internal strife and decay. The leadership decides it must take
drastic action in order to safeguard the recently implemented new
order (I will be quoting several pages here, interjecting comments
along the way):
"The picture now is this," said Wesley Mouch. "The economic
condition of the country was better the year before last than it
was last year, and last year it was better than it is at present.
It's obvious that we would not be able to survive another year of
the same progression. Therefore, our sole objective must now be to
hold the line. To stand still in order to catch our stride. To
achieve total stability. Freedom has been given a chance and has
failed. Therefore, more stringent controls are necessary. Since
men are unwilling and unable to solve their problems voluntarily,
they must be forced to do it."7
6.. Ibid, p.449.
7. Ibid, p. 503.
"In the name of the general welfare," read Wesley Mouch, "to
protect the people's security, to achieve full equality and total
stability, it is decreed for the duration of the national
emergency that -"
"Point One. All workers, wage earners and employees of any
kind whatsoever shall henceforth be attached to their jobs and
shall not leave nor be dismissed nor change employment, under
penalty of a term in jail..." [When Canadian doctors threatened to
strike they were threatened with imprisonment. Our own government
has just established a protocol for a large scale doctor draft
even though general conscription ended long ago - ed.]
"Point Two. all industrial, commercial, manufacturing and
business establishments of any nature whatsoever shall henceforth
remain in operation, and the owners of such establishments shall
not quit nor leave nor retire, nor close, sell or transfer their
business, under penalty of the nationalization of their
establishment and of any and all of their property."
"Point Three. All patents and copyrights, pertaining to any
devices, inventions, formulas processes and works of any nature
whatsoever, shall be turned over to the nation as a patriotic
emergency gift by means of Gift Certificates to be signed
voluntarily by the owners of such patents and copyrights. The
Unification Board shall then license the use of such patents and
copyrights to all applicants, equally and without discrimination,
for the purpose of eliminating monopolistic practices, discarding
obsolete products and making the best available to the whole
nation. Every formerly patented product shall be known by a new
name and sold by all manufacturers under the same name, such name
to be selected by the Unification Board. All private trademarks
and brand names are hereby abolished." [As you know, our
government is planning a nationwide "formulary" of "approved"
pharmaceuticals for our medical care, and new laws have shortened
the duration of pharmaceutical patents - ed.]
"Point Four. No new devices, inventions, products, or goods
of any nature whatsoever, not now on the market, shall be
produced, invented, manufactured or sold after the date of this
directive. The Office of Patents and Copyrights is hereby
suspended." [It is financially beneficial for the government to
restrict the number of physicians - especially the more learned
specialists - in order to limit medical expenditures as well as
technological and pharmaceutical progress. The stage has been set
- ed.]
"Point Five. Every establishment, concern, corporation or
person engaged in production of any nature whatsoever shall
henceforth produce the same amount of goods per year as it, they
or he produced during the Basic Year, no more and no less. The
year to be known as the Basic or Yardstick Year is to be the year
ending on the date of this directive. Over or underproduction
shall be fined, such fines to be determined by the Unification
Board." [ Ponder the concept of "Volume Performance Standards" and
realize that Gail Wilensky, the former director of HCFA in the
Bush administration, was quoted as saying that "conservative"
doctors would be rewarded under the RBRVS, the implication being a
doctor will be paid more per piece if he generates less piecework
- ed.]
"Point Six. Every person of any age, sex, class or income,
shall henceforth spend the same amount of money on the purchase of
goods per year as he or she spent during the Basic Year, no more
and no less. Over or underpurchasing shall be fined, such fines to
be determined by the Unification Board." [Contemplate the position
HCFA is taking with respect to the private purchase of medical
services by Medicare recipients and think about the restrictive
possibilities inherent in the nebulous phrase, "Global Budgets."
The abolition of balance billing, coupled with the universal
institution of price controls, has been spelled out quite frankly
in the Clinton Health Plan - ed.]
"Point Seven. All wages, prices, salaries, dividends,
profits, interest rates and forms of income of any nature
whatsoever, shall be frozen at their present figures, as of the
date of this directive." [Governments repeatedly utilize price
controls as a "quick fix," even though they are proven failures,
and Clinton is about to try them again in spite of verbal denials
-ed.]
"Point Eight. All cases arising from and rules not
specifically provided for in this directive, shall be settled and
determined by the Unification Board, whose decisions will be
final."8 As you know, our government is establishing a
"national health care board" which would control all medical
services and expenditures, both public and private, and Clinton's
plan explicitly states that its directives are final, and not open
to discussion - ed.]
"We have the right to do it!" cried Taggart suddenly..."We
need it"..."We'll be safe for the first time in
centuries."9
I wish that I could read Ayn Rand's words and dismiss them as
sheer paranoid invention - but they were truly prophetic. It is
clear that the federal government has already injected policies
into the Medicare program which are all too evocative of the image
of the totalitarian state painted in Atlas Shrugged.
Clinton has converted Rand's nightmarish scenario into deadly
serious reality.
Radical changes are in store for American Medicine, which our
government is manipulating in a manner all too redolent of the
actions taken by Rand's fictitious Unification Board. One might
almost believe the federal government is using her book as a
template for its "health care reform" program. It is patently
absurd to believe that our government is primarily concerned about
the quality of medical care. We know it - but we must tell the
public.
We physicians realize that American politics are threatening
medical science, our profession, and the very quality of life in
our country.
8. Ibid, pp. 505-6.
9. Ibid, p. 509.
Interestingly, but perhaps not so surprisingly, the
politics of late twentieth century America are not so very
different from what they were when our nation was founded. The
parallels between America's past and present political climate are
truly astounding. A couple of years ago I discovered a book about
life in pre-Revolutionary New York by Edward Countryman. It
revealed that the political rhetoric of that era and the
complaints about New York's elected officials at that time were
rife with modern similarities. Some of the 200 year old quotations
in this book are particularly relevant to our own time. The
comparisons are so strong that some of the words might just as
well have been written by any one of today's political
commentators. For "New York," simply substitute "America:"
"The provincial political structure began to weaken in the
mid-1760's...Its problems came from its own internal
contradictions and corruption... As its power weakened, the
government itself became the subject of ridicule and criticism
that questioned not only the propriety of its actions but the
rightfulness of power's remaining any longer with the men and the
institutions that held it."10
"The real rulers of provincial New York believed that they
held their power virtually as a matter of right. But how, and in
whose interests, did they exercise that power?...the old order was
filled with contradictions. From those contradictions much else
flowed, for they had a significant part in the way that the
conjuncture of imperial issues and postwar depression generated a
massive internal political crisis for New York itself."
10. A People in Revolution. The American Revolution
and Political Society in New York 1760-1790, by Edward Countryman,
copyright 1981 by the Johns Hopkins University Press, p.3.
"...once in office, the provincial assemblymen could be as
imperious as any royal placeman...political commentators were
vilifying the assembly, rather than the British, as the
greatest single threat to New York's well-
being."11
"...though many factors stimulated the voters' interest,
there was no real popular control over politicians in office.
Electors were invited to think about issues and to choose among
competing candidates, but they were choosing among men who saw
their task in terms of ruling the public, not in terms of serving
its wishes."12
"Officials and men in positions of social and political
privilege regularly employed the public machinery to achieve their
private ends, sometimes with disastrous public results. Many
officials considered their office as their private possession,
that they held for their own good rather than for the service of
either king or country...."
"Lesser officials, too, considered office as private
property. [The] corrupt provincial treasurers Abraham De Peyster
and John Watts showed it by the way they diverted public funds to
their private businesses."13
..."the contradiction between a rhetoric of involvement,
virtue, and public liberty and a reality of exclusion [and]
corruption...was becoming increasingly visible."14
Some words by a gentleman named Justice Livingston are
especially poignant: ""It is well known," he said, "that every Man
and Body of Men, are desirous of Power; this is natural to
humanity, for none fear the abuse of Power in their own Hands." He
described how the Commons took more and more power to itself,
until "at last, we find the Commons assuming all Power, turning
the Government into what was called a Common Wealth, though it was
a real Tyranny.""15
11. Ibid, p.73.
12. Ibid, p.76.
13. Ibid, pp. 80-98.
14. Ibid, p.85.
15. Ibid, p.92.
"New Yorkers were as worried about uncontrolled power in 1775
as they had been in 1765. But in 1765 their intellectuals had been
telling them that the danger posed by power came from outside,
from the British government [read "Russia" - ed.]....By 1775, in
contrast, the assembly had been exposed to years of blistering
criticism. The men who made it up, the things they did, the ways
they did them, and the principles on which they operated had been
analyzed, mocked, and held up as inimical to New York's
welfare....New Yorkers were being told that liberty's best defense
was no longer to be found in a virtuous elite operating as the
people's representatives. Rather, it lay in the people's taking as
direct a part in politics as they could."
"The power of the old order decayed. [B]y 1774 and 1775 the
old institutions had very little moral claim to authority, their
power rest[ing] on little more than whatever physical force they
could command."16
"The problem... sprang from contradictions that were inherent
in the political structure and the political culture of provincial
New York. Those contradictions came to a head during the imperial
crisis, as the opposition writers of that decade realized and
explained. Their maturation meant that independence would require
both angry conflict among New Yorkers and a sharp change from the
old ways."17
There is but one conclusion to be drawn from all this. We
must study history, learn from it, and then act upon our
knowledge. To do otherwise is to deny the heritage of our great
country and its magnificent Constitution. We physicians must take
the lead. There is no one else to turn to. We must fight for the
survival of private practice and our autonomy. To lose this battle
is to lose the fight for the profession of Medicine itself. We
must educate our public, our politicians, and our peers. Tell them
about Medical Savings accounts, inform them of organizations like
the AAPS that are fighting for their preservation, and urge them
to join - to be pro-active. Convince them that government
domination of the medical profession will spell disaster for all
concerned. Tell them that if medical care has to be limited due to
costs - and it does - that it is preferable for the patient rather
than the state or federal government to be the arbiter of
decisions related to medical expenditures. Listen to what former
Arizona Senator Barry Goldwater has to say about socialism and
socialized medicine:
"I'm not afraid of my country losing its freedom to any force
from the outside. What I am afraid of is that we are losing our
freedom because of the politics of men who don't know and men who
don't care. And that's a very evil combination. [S]ocialized
medicine is a step toward the downfall of a free government."
It is clear that our government knows full well what it is up
to, but at the same time it may not realize all the consequences
of its manipulation of our profession. As I wrote in my poem,
"Cancer Ward,"
"We have become actuaries of the soul
Who have failed to learn the principle
Of Heisenberg's uncertainty -
Our measurements must alter what we measure."18
We, here, have a charge. Although our professional autonomy
may be compromised for the rest of our careers, and even though
our government and the public at large may not support us, we must
retain the ardent dreams and aspirations which molded us into
physicians years ago, and keep fighting - for ourselves, our
patients, and our very country. We physicians have the strength
and the will requisite for this task. Let us dare to articulate
and be empowered by the message voiced in the Broadway play, "I'm
Not Rappaport," when an ageing white Jew turns to his black
counterpart, and says, "Who needs sight when we've got vision?"
May God grant us the will to persist.
16. Ibid, pp.96-7.
17. Ibid, p.98.
18. "Cancer Ward, 11th Hour," by Joseph M. Scherzer,
M.D. Journal of the American Academy of Dermatology, vol. 21,
no.4, Part 1, p. 23A, October, 1989.
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