While the health of
a nation’s leader can have an outsized role on a country, more important to a
nation’s strength and wellbeing is the health of the general population. It is
from this population that government officials, soldiers, technicians, and farmers
are drawn, and if the health of the people is poor, it will be reflected up
and down economic, government, and military institutions.
For North Korea, the
general state of the healthcare system and the presence of poor health in large segments of
society has affected a poorer educational performance, led to higher rates of
work-related disability, and has even influenced national security as the
military has had to lower recruitment criteria in a reflection of the impacts
of long-term malnourishment.
marginal attempts by Kim Jong-un at improving healthcare (such as the
construction of the Pyongyang General Hospital and modernizing the Myohyangsan
Medical Equipment Factory) and attempts to improve the food supply, illnesses
like tuberculosis still rage through the country and over 42% of the population
suffers from undernourishment.
problems associated with limited healthcare, food production, and endemic
disease has been the arrival of the COVID-19 pandemic and the regime’s response
to it. Closing the border has all but ended foreign trade, expelling foreign
aid workers has prevented medical and food aid from being distributed, and Kim
Jong-un has rejected offers by the international community to provide millions
of COVID vaccine doses.
As such, while Kim
Jong-un can boast some legitimate accomplishments in other sectors, the efforts to better the health of the people must be seen as
Health of the Nation
“The State shall
protect the people’s lives and improve the working people’s health by
consolidating and developing the system of universal free medical service
and improving the district doctor system and the system of preventative
medicine.” - Article 56 of the Democratic Peoples’ Republic of Korea’s
version. Emphasis added.
paper, one might suspect that North Korea has a fairly robust healthcare
system. With 133 provincial-level hospitals, 1,608 county-level hospitals, and
6,233 primary care clinics, there are almost 37
doctors per 10,000 people: a ratio on par with Australia. However, despite
impressive gains in life expectancy and the proliferation of medical clinics
into small villages around the country during the 1960s and 1970s, North Korea currently
has some of the worst healthcare infrastructure in the world.
Most clinics are capable of diagnosing basic diseases and
setting broken bones, but everything from sterile needles to
antibiotics and anesthesia is in short supply. In Kim Jong-un’s North
Korea, there still remains no national
emergency number (like 119 in South Korea or 911 in the U.S.) and patients
must arrange transportation directly with their local hospital. As there are
not enough ambulances in the country, private taxis may be required or even
asking for transport on a passing tractor.
Despite the constitution guaranteeing free healthcare,
people are often required to pay for supplies and medicine prior to receiving
any care (including emergency care), and there have been reports of patients
needing to provide their own blankets as well as meals for the nursing
staff and doctors.
Hospitals capable of providing more complicated services are
limited to Pyongyang and provincial capitals, but electricity shortages and
shortages of everything from IV bags to modern medical beds hamper even these
The constitution’s guarantee of preventative medicine has
likewise gone unfilled under the rule of Kim Jong-un.
71,300 North Korean die each year from smoking-related causes. These represent
31% of the total deaths in the country. Although the rate of smoking has gone
down, deaths caused by tobacco use are compounded due to a lack of early
detection and available treatment options.
To tackle this problem, all three Kim’s have instituted various
anti-smoking initiatives, but they have only met with moderate success. Under
Kim Jong-un, such initiatives have been seen in 2016
which included bans on smoking in certain public buildings.
However, Kim Jong-un continues to smoke in public,
undermining efforts to curb smoking among the people.
a self-inflicted disease the way lung cancer can be, but it is still an illness
that has been controlled in many parts of the world thanks to antibiotics and
routine screenings (86% of all
new cases can be found in just 30 countries). North Korea has the highest
rate of TB among its neighboring countries, and it has been reliant on
international aid to keep its spread in check. However, the regime hasn’t
always been fully cooperative, and international sanctions have hampered efforts
But while these joint efforts between Pyongyang and NGOs had
produced consistent positive results in the decline of TB deaths since 2000,
that trend began to reverse
in 2016. North Korea’s expulsion of foreign aid workers and border closures
in response to COVID-19 also means that the country has been left for over a
year with almost no assistance fighting this highly contagious disease.
By December 2020, experts and aid workers who had worked in
combating TB in North Korea warned that North Korea would soon run out of the
life-saving drug supplies it had acquired in the run-up to the country’s
lockdown. One U.S.-based humanitarian official said,
"Every untreated TB patient could infect 10 to 15 other people. We
could be looking at a much bigger epidemic [in North Korea]”.
Organizations were able to send 918,000 doses of the Bacillus
Calmette–Guérin (BCG) vaccine, but the usage rate is over 300,000 doses a year
as every newborn is given it. This left North Korea with only a three years’
supply in the best of circumstances.
A further shipment of TB-related treatments was stuck in a
Chinese port for months
as North Korea worked through their extreme quarantine measures (which extends
to both people and products). Lapsed TB treatment plays a role in the
development of antibiotic-resistant strains. These ‘super strains’ already account for 21% of new TB cases in North Korea and the country has run out of the drugs
needed to fight them.
If Kim Jong-un doesn’t end the lockdowns soon, whatever
progress had been made in fighting TB (and drug-resistant TB in particular) could
largely be undone. With an estimated
135,000 people currently infected, without treatment, each of those individuals
could infect a further 10 to 15 people as stated above.
It must also be said that in the case of North Korea, of
five main risk factors, over 65% of TB cases are attributable to
undernourishment according to the WHO “Global
Tuberculosis Report 2020”; a problem that has only increased due to the
extreme nature of the country’s lockdowns.
In terms of being
able to provide services and access, North Korea’s healthcare system is
deficient in multiple areas.
to the article “Surgical Diseases in North Korea: An Overview of North
Korean Medical Journals” published in the International Journal of
Environmental Research and Public Health in 2020, North Korea’s healthcare
infrastructure seems to be unable to provide complex surgical procedures like
Based on a review of medical literature from hundreds of
DPRK-specific reports, the 2019 study “Systematic
review of evidence on public health in the Democratic People’s Republic of
Korea” found that cancer screenings appear lacking, particularly for cervical and
breast cancers. While both rural and urban women are aware of diseases like
cervical cancer, only 6% of women reported having a cervical cytology smear
test and 62% of rural women said that travel distances were a barrier to getting
It is this lack of access and loss of faith in the medical
system (due to distance, medical costs, and shortages of medicine) that leads
many patients to forego visiting hospitals and instead seek medications on the
black market and herbal/folk remedies for self-treatment
for a wide range of illnesses.
Unfortunately, this has helped to fuel drug addiction in the
country as upwards of 61% of patients end up buying
opioids on the black market. Without adequate monitoring, both addiction and
physical dependence can quickly develop, leading to a host of other problems.
Attempts to limit or
ban drug abuse and alcoholism have occurred for decades. Although drug
addiction is not as widespread as some suggest, the lack of proper medicine and
treatment options requires that people seek help elsewhere. The state doesn’t help
matters by being behind the manufacture of drugs like methamphetamine
and heroin. In fact, for a time in the 1990s, most of the methamphetamine
being abused in northern China came from North Korea.
Despite crackdowns on domestic drug use, abuses of
amphetamines and opioid narcotics remain more than a passing fad among the
country’s youth. Occasionally reaching epidemic proportions within the northern
provinces of the country, the drugs aren’t merely being used for people to get
high, but are used to cope with never-ending demands for labor, long working
exhaustion, and to try to address health problems like chronic pain from
injury, disability, and even end-stage cancers.
As briefly mentioned above, compounding the spread of drug
use is also its state-sponsored manufacture. With sanctions cutting into the
regime’s finances and China taking a harsher view toward drug sellers, domestic
drug sellers and criminal gangs have had to find local buyers for their
highly potent drugs.
No proper study has been conducted on drug abuse within the
country, and the regime often claims it doesn’t even exist, but the reports
from defectors are consistent in that drug abuse exists and has reached what
could be described as an epidemic at different points since the 1990s, with
drug addiction being almost unheard of prior to the famine.
In the field of
mental health, competent institutional support for psychiatric problems is almost
completely lacking. While some facilities exist, named No.
49 Hospitals, they are described by defectors as little more than prisons
for the mentally unwell.
Words like “psychiatrist” and “mental health” are rarely
known of by the average person, and the most common way to address mental
illnesses of all sorts, it would seem, is for people to either ignore it or try
to treat it (as though it were a regular disease) with herbal medicines.
In general, mental health disorders are simply not
recognized as such and there is little in the way of research or treatment.
Additionally, people can be accused of anti-state activities because they are
non-conforming and don’t simply “snap out of it” after being subjected to greater
ideological indoctrination. To summarize defector sentiment
about the state of mental health in the country, in North Korea, only the
mentally sound exist. A sentiment underpinned by the general view that,
disorders should not exist in an ideal socialist society.”
Undiagnosed and untreated mental illnesses are also
associated with higher rates of suicide, alcohol and drug abuse, and can even express
itself through violence in a country where domestic
abuse and abuse
against women outside the home are already common.
and maternal mortality, North Korea has made continued improvements in infant
mortality with the mortality rate per 1,000 live births dropping from 55
deaths per 1,000 in 2000 to just 20 in the year 2020. On the other hand,
maternal fatalities are on the rise.
According to the “Report
of the detailed findings of the commission of inquiry on human rights in the
Democratic People’s Republic of Korea” by the UN Human Rights Council and
published in 2014, “almost half of the women surveyed did not see a doctor
throughout their pregnancy and almost half delivered their babies at home
regardless of whether they were from a major city or village. Women also
reported that the death of the mother or baby during or after childbirth was
not uncommon. Maternal mortality rates almost doubled in the decade from 1993
to 2003, largely due to inadequacies in emergency obstetric care. The maternal mortality rate in 2010 was estimated
to be 81/100,000 live births.”
Maternal mortality has thankfully dropped from 81 deaths
down to 66 deaths per 100,000
live births as of 2014, but it is still six times as high as in South Korea,
over twice as high as in China, and higher than Cuba’s, another country who has
held on to a strict command economy and has been the subject of sanctions for
In particular, the high level of maternal mortality is due
to the fact “that many hospitals were unable to provide adequate obstetrical
emergency care such as anticonvulsants, antibiotics, and blood products.” Such
inadequacies can be seen throughout the whole of North Korea’s medical system.
Korea’s healthcare system has several severe deficiencies, there are areas in
which the system is not only competent but has the resources required to
provide care such as in basic dental and eye health, and as mentioned above, the
system has been able to make strides in infant mortality.
The problem is that these improvements aren’t equally
distributed. The most modern equipment and best medicines are first reserved
for a handful of elite hospitals that are allowed to work on Kim Jong-un, the
rest are distributed throughout Pyongyang. Finally, the main provincial
hospitals can expect to receive occasional modernization efforts; although,
medicines are often diverted into the black markets or given to the military.
Kim Jong-un has mentioned healthcare in five of his New
Year’s speeches, but they were simply token remarks with the exception of 2018. That year he moderately expounded
upon the state’s goals saying the state should “apply the
people-oriented character in public health service in a thoroughgoing way, and
boost the production of medical equipment and appliances and different kinds of
Interestingly, “anti-epidemic” work was expressly mentioned
in his 2015 speech, but what
concrete measures were implemented is hard to say.
Over the last decade, there have been a few large
construction projects related to medical infrastructure. One of the earliest
was the opening of a new breast cancer research center at the Pyongyang
Maternity Hospital in 2012. Although it is reported to be the cutting-edge research
and treatment center for breast cancer in the country, as discussed above,
travel difficulties remain a major barrier to accessing treatment.
Additionally, as entry into Pyongyang itself is restricted, rural women
being able to get emergency treatment is even more precarious.
Following that, the nearby Okryu Children's Hospital was
opened in 2013. Billed as the best children’s hospital in North Korea, it is
where the bulk of pediatric specialists can be found.
North Korea has a high incidence of cataracts and other eye
conditions. To combat this, foreign specialists have been allowed to
occasionally enter the country and direct mass evaluations of patients and to conduct procedures. However, in 2016 Kim Jong-un order the construction
of the Ryugyong General Ophthalmic Hospital. It is the second of two identified
eye-specific hospitals in the capital.
In late 2018 Kim Jong-un ordered the modernization of the Myohyangsan
Medical Appliances Factory which he found lacking during a visit that
October. The factory is responsible for the manufacture of medical beds, dental
chairs, and a wide range of other equipment.
A year later in 2019, a medical
oxygen plant was constructed. As we have seen in India
and elsewhere during the COVID-19 pandemic, having the capacity to domestically
produce enough medical oxygen is an essential part of the medical supply chain
and is a requirement for the treatment of scores of diseases.
The most recent major medical construction project has been the Pyongyang General Hospital. Slated for completion in October 2020, it sits unopened today. Causes for the delay have been numerous including poorly manufactured electrical insulators and Pyongyang’s inability to import needed equipment. Located in the heart of Pyongyang, right next to the WPK Founding monument, the hospital must be viewed through the lens of being a personal prestige project for Kim Jong-un and the regime; one that is now 15 months overdue.
A kind of long-distance
medical system was also introduced in recent years, with a drive to expand
the system in 2021, but accessing it still requires patients to travel to their
local clinic or hospital, and as personal computers and smartphones are banned
for most of the population, patients can’t directly access the system at home.
to senior researcher Kim Young Hui of the Korean Peninsula New Economy Center,
this remote medicine system has allowed provincial doctors to learn new skills
and improve their treatments as they are monitored by doctors at more advanced
medical facilities around the country.
Worker health and
safety is another key indicator of a government’s commitment to its people, as
well as the strength of workers’ rights and labor laws. In a ‘worker’s
paradise’ like North Korea, one would expect that labor laws and safety
requirements are rigidly adhered to, with tough repercussions for neglectful
However, as there are no independent labor organizations,
lobbying or pressure groups, and no independent enforcement agencies, the North
Korean state has a monopoly over the entire labor market and set standards as
they see fit, and ignore them with impunity.
The constitution guarantees an eight-hour workday and
prohibits child labor, but these regulations are routinely ignored. Grade school students,
college students, and soldiers alike are all required to work on farms for portions
of each year. Teenagers and the adult population are also often called upon to
engage in ‘speed campaigns’ of mass, manual labor to build the regime’s latest
megaproject. Hundreds of thousands of others are called to duty to perform mass
games and serve in military parades.
The labor activities and the training for things like the
mass games and parades place a tremendous burden on the body,
with injuries being very common and with participants unable to take time off
for sickness, to use
the bathroom at will, and are rarely provided with enough calories to meet
the increased activity level.
A lack of robust occupational safety regulations means that
injuries and disabilities in the mining, timber, and construction industries are
common. Repetitive stress injuries and the development of chronic conditions
within agriculture (which is still largely a feudal activity involving
significant human labor) are also routinely found.
All of this means that North Korea has been ranked by the
World Health Organization as having the third-worst worker-related death and
injury rate in the world.
Based on the “WHO/ILO
Joint Estimates of the Work-related Burden of Disease and Injury, 2000–2016”
report (published in 2021), North Korea had 76.9 work-related deaths per
100,000 workers in 2016. That's an increase from 56.2 in the year 2000.
For comparison, in 2016 South Korea had 20.6 work-related deaths per 100,000
workers, China had 39.7, and the United States had 25.7.
Despite alleged worker protections limiting the workday to
eight hours, North Korea also had among the worst rates of “stroke attributable
to exposure to long working hours.” Long working hours is defined as more than
55 hours a week. North Korea had 28.1 work-related stroke deaths per 100,000
workers in 2016. South Korea and Japan, both countries well-known for their stressful
working conditions and long hours had significantly fewer stroke-death rates at
3.9 and 4.9 respectively.
All of this has a significant impact on the North Korean
economy, with the country losing an estimated $1.5 billion
each year due to work-related injuries, disabilities, and death.
Although North Korea has enacted numerous domestic laws and
multi-year plans stated to protect workers and bolster healthcare, and despite
voting in favor of multiple international resolutions calling for improved
access to trauma medicine, surgical care, and increasing access to basic
medicine in rural areas, the lack of implementation means they currently have
not made a measurable impact on people’s lives.
North Korea’s Ministry of Public Health announced in their
2016-2020 plan to modernize 200 local hospitals outside of Pyongyang. Yet, the
regime has failed to even complete the flagship project of North Korea’s
medical sector, the Pyongyang General Hospital, despite it being slated for
completion in October 2020 – let alone hundreds of smaller facilities. And a
review of satellite imagery indeed shows only a handful of provincial hospitals
that have been upgraded.
Also affecting both civilian workers and those in the military
is North Korea’s nuclear program. From mining and milling uranium to producing
plutonium and testing the finished bombs, the process is fraught with physical
dangers and toxic chemicals. In 2019 I wrote two articles detailing the health
consequences of Pyongyang’s nuclear program (Part
In short, pollution
leaking into the environment from the mining and milling process affects
the drinking and irrigation water for thousands downriver. Former workers of
the Pakchon Uranium Concentration Plant and from the Yongbyon Scientific
Nuclear Research Center have all reported on a number of diseases consistent
with both acute and long-term radiation exposure. And, defectors who lived in
the areas downwind of the Punggye-ri Underground Nuclear Test Site have
reported spikes in illness following the nuclear tests, describing the illness
as the “ghost
disease” as it comes and goes (following the tests) and causes its victims
to become very weak (also consistent with radiation exposure).
The state of health in North Korea is also having substantial impacts on arguably its most important institution, the military.
The health of KPA military personnel received a lot of
international attention in 2017 when a soldier defected across the DMZ. He was
shot multiple times by fellow DPRK soldiers and required intensive medical care
in South Korea. During his treatment, it was revealed that he had large intestinal
This discovery was not surprising. As many as 47% of North
Koreans have helminthiasis, parasitic worm infections. What is
surprising is its existence within a soldier who was serving in a relatively
elite KPA unit as a frontline soldier of the DMZ.
Food rations in North Korea have long been based on one’s
social and political standing, with the military receiving better rations and
other supplies as part of the Songun Policy. Thus, one would expect to
see fewer infections and other health problems among the military. Yet, this
does not seem to be the case ever since the collapse of the economy in the
Exposure to these parasites is predominantly due to poor
hygiene (only 59% of the population has access to flush toilets), the use of
improperly prepared “night soil” (a euphemism for fertilizer made from human
waste), and eating food that hasn’t been properly cleaned.
strata of society, from soldiers to farmers to students, are required to
collect night soil and are also required to engage in farming activities. This
creates a large level of exposure to parasites and other pathogens.
Chronic parasitic infections are associated with everything
from poor cognitive development in children to liver damage. They can also
exacerbate malnutrition and make one more susceptible to tuberculosis
Although the levels of malnourishment have fallen since the
days of the famine, most soldiers still do
not receive their full dietary requirements, leading to soldiers robbing
civilians of their food in some instances.
This multigenerational experience of malnutrition has been
reflected in the military changing some of its recruitment criteria. Among
them, the acceptable shortest height for new recruits was lowered
in 2012 to 142 cm (4’ 6”). This change remains today and is not always enforced
as the military struggles to maintain recruitment quotas.
Malnourishment and chronic disease can only have one impact
– lowering the soldier’s readiness and endurance, regardless of their
ideological fervor. Repeated injuries are also common in basic training, while
taking part in labor activities, as well as for those who are called up to be
part of mass parades. This lack of caring on behalf of the state has been discussed
by multiple former KPA defectors, some of whom have taken to YouTube to describe the
difficulties associated with military parades.
While the state is
ultimately responsible for the general welfare of its people, the inescapable role
of international sanctions, levied as a result of North Korea’s nuclear and
ballistic missile programs, on the country’s healthcare system cannot be
Overbroad sanctions and bureaucracies that move with the
speed of pitch have created a complex web of import controls and trade barriers
that even make it illegal for North Korea to acquire computer monitors for
hospitals and many medicines. Getting specialized equipment into the country is
In the wake of the COVID-19 pandemic, aid organizations have
had to seek
exemptions from the United Nations to send even the simplest of medical
goods. Gloves, masks, and thermometers are all tightly regulated by
Of course, the regime in Pyongyang has not been helpful in
this regard, either. Ignoring their continued development of nuclear bombs which
lead to the sanctions being put in place to begin with, Kim Jong-un’s
actions to combat COVID-19 can only be seen as criminal.
Kim closed down the country’s borders in January 2020 and put an end to tourism as well. Soon
after, foreign diplomats and aid workers were being sent out of the country,
group by group. By March 2021, not
a single foreign aid worker was left in the country.
This ‘border blockade’ has had multiple effects. It prevents
goods and medical supplies from entering the country through legitimate trade
and it keeps international groups from being able to bring in and distribute
The regime’s extreme stance is underpinned by the mistaken
belief that the surface of products can be a major source of COVID infections. Everything
from visitors to Pyongyang to bus seats has been disinfected more than once,
and the government issued shoot-to-kill orders regarding any foreigner who may
wash up on their shores (for instance, a wayward fisheries official
from South Korea in need of help).
COVID’s threat to North Korea is very real. Although the
country is perhaps better equipped than most to enforce local and regional
lockdowns to stop any spread of the virus, the country’s medical infrastructure
is incapable of dealing with numerous severe cases at once.
To that end, the regime has taken strict measures to
quarantine people with COVID-like symptoms and increased legal penalties for
those who disobey lockdown orders. North Korea has also tested roughly 50,000
people for COVID-19 and reported zero positive cases. While this has raised
a number of doubts
(particularly as small outbreaks of COVID-like illnesses have occurred), it
does seem that North Korea’s extreme measures have prevented any widespread
However, there have been major consequences to the country’s
lockdown measures. Food supplies are running low, people are unable to find daily
hygienic items in the marketplace, medications for tuberculosis are running
out, and the government can’t import the vast majority of things they need to
keep hospitals operating because the border has basically been hermetically
Although UN medical
supplies were sent to North Korea in October 2021, the lack of personnel to
distribute the supplies and to independently monitor that distribution means
the supplies could easily be diverted elsewhere, as has happened with various
other aid and food shipments in the past.
Making matters even worse is Kim Jong-un has the power to
end this suffering while also combating the virus. As NK News reported,
“North Korea is one of only two countries that has yet to administer any
COVID vaccines, despite being promised over 8.12 million doses from COVAX and
rejecting another 3 million Sinovac doses.”
Instead, he has taken the opportunities afforded by having a
sealed border and almost no foreigners at all in the country for the first
time in a generation to crackdown on everything from market activity to going
after people wearing skinny
jeans (something viewed as being foreign and anti-socialist).
While the war on pants endures, mothers can’t get the help
they need during childbirth.
There has been a recent glimmer of hope, however. At least one
train has recently been granted permission to enter the country from China
to test out North Korea’s new disinfection center at Uiju. If the process goes
well, this may open up opportunities for cargo to once again regularly enter
Additionally, the state-party newspaper Rodong Sinmun
on January 10, 2022, that the regime is modifying its anti-epidemic policies to
be more “people-oriented”, suggesting that some restrictions may be lightened
up. While no specific changes were announced, it is clear that two years of
total shutdown have wrecked both the economy and the country’s healthcare
system, all without a single COVID case ever (officially) being reported.
The current state
of healthcare in North Korea is due to multiple factors. From economic
mismanagement to diverting products away from hospitals and clinics to sell for
foreign currency to the cumulative effects of years of sanctions. But Kim
Jong-un has had a chance to address each one of these major factors and has
opted not to.
His anti-pandemic measures have only served to make matters
The construction and modernization of select medical
facilities in the country reflect the regime’s “our way” attitude and are an
attempt at self-sufficiency, but the country lacks the indigenous manufacturing
capacity to adequately supply itself with even the most basic of supplies. In
2017 the last WHO-certified drug manufacturer in the country was closed down,
leaving citizens with only folk remedies and highly dubious “Koryo-medicine cures”
made of everything from ginseng
to rare earth minerals.
While there have been some statistical improvements, the
lack of reliable sources of medicine and equipment, along with constant
electricity shortages, has meant that the North Korean healthcare industry is
moribund and unable to right itself.
Patients dealing with advanced cancer, mental health
problems, or work-related trauma face a medical system that can’t cope due to
its inherent structural inefficacies, and that may often actually be
detrimental to the patient.
The rapidly declining availability of everything from food
to hygienic supplies to antibiotics as a direct result of Pyongyang’s
anti-COVID measures does not inspire confidence that the state of North Korean
healthcare will improve in the near term, particularly as UN food aid has not
been able to enter the country since March 2021 and the regime refuses to
accept COVID vaccines that could help them end the lockdown.
And while Kim Jong-un has recently directed that future
COVID measures be more tailored and “people-oriented” perhaps hinting at a
loosening of some controls, only time will tell if these new policies will have
any real impact at all. Currently, all that can be said is that the average
North Korean has fewer medical options today than just a few years ago.
~ ~ ~ ~
I have scheduled this
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I would like to thank my current Patreon supporters: Amanda O.,
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--Jacob Bogle, 1/17/2022