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Archive for the ‘health’ Category

I recently visited the Chateau de Clos Lucé in Amboise, in the Loire valley. This is where Leonardo da Vinci spent the last years of his life. He was invited to live there by François I in 1516. The king provided Leonardo with a place to live, 700 gold ecus a year, and financed his works, in turn for the pleasure of his company and daily discussions with him. Leonardo only lived three more years, dying in 1519, which is why, on this 500th anniversary year of his death, the chateau is hosting a major exhibition of his work. (As an aside I find it fascinating and inspiring that Leonardo was given free range “to dream and work” – what kind of society could we have if we funded creatives and academics to “dream and work” together, without goals, funding applications or publication demands?)

There are a number of Leonardo quotations around the chateau and the gardens. This one caught my eye –

You know that medicines when well used restore health to the sick: they will be well used when the doctor together with his understanding of their nature shall understand also what man is, what life is, and what constitution and health are. Know these well and you will know their opposites; and when this is the case you will know well how to devise a remedy.

After a lifetime career in Medicine, I’m less sure now that medicines do “restore health to the sick”. I think it’s biology which restores health. Human beings are complex adaptive systems, and all such organisms have both “self-healing” and “self-making” capacities. The best medicines stimulate those natural processes of healing. The next best support the processes. Many of the ones we use reduce symptoms, or reverse an imbalance in the body, both of which are reasonable goals and acts, but are they directly involved in restoring health to the sick? Do you think that’s just semantics? I don’t. I’d have a hope for the future that we’d develop the treatments which really do support and stimulate the natural processes of healing, and that’s what Leonardo says, in other language, at the end of that quotation – “when this is the case you will know well how to devise a remedy”.

When what’s the case?

Oh, yes, understand “what man is, what life is, and what constitution and health are”.

Ah! Well, there lies both the problem and the signposts to the solutions…..

A couple of years into my work as a General Practitioner I started to wonder what health is. Nobody taught us what health is at university, and the clinical training of a young doctor focuses on learning diagnostic and therapeutic techniques – identifying pathologies and treating disease states. I went back and looked at my Clinical Medicine textbooks. I searched the index for “health” – no entries. Nope, not one. That set me off on an exploration, looking for an understanding of what health is. The medical school textbooks were no help. Oh yes, there was that old World Health Organisation definition –

“a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”

But all that really does is substitute the word “well-being” for “health”. It does suggest health is multidimensional – physical, mental and social – and it does suggest health is something positive, not just the absence of disease or infirmity. But does it really take us much further that irritating “Brexit means Brexit”?

While researching the issue of the absence of health in medical textbooks, I discovered there was a kind of parallel anomaly….biology textbooks didn’t have a definition of life. Really? Well, yes, it wasn’t uncommon to find a biology textbook without the word life appearing in the index.

So what is life?

One of the more satisfying descriptions I read was from Maturana and Varela’s, living organisms demonstrate a “self-making” capacity, which they termed “autopoiesis” and that lead me down the path of the complexity scientists and their definition of “complex adaptive systems”. I still find that a good starting place.

That leaves us with two more areas to explore, according to Leonardo. What is man? and What is a constitution? Remember he was writing 500 years ago, and we would probably now say “What is a human?”, rather than “what is man?”. Let’s leave constitution aside for just now, as it’s pretty embedded in the issues of what is a human and what is health?

What is a human being?

There have been a couple of books published recently which put this question centre stage again. Douglas Rushkoff’s “Team Human“, and Paul Mason’s “Clear Bright Future“. Both of these books are concerned about the impact of technology on human beings and on our societies. Rushkoff says –

being human is a team sport. We cannot be fully human, alone. Anything that brings us together fosters our humanity. Likewise, anything that separates us makes us less human, and less able to exercise our will.

In other words, he focuses on the innate sociability and need to act co-operatively in human beings. I’ve heard Paul Mason say at least two interesting definitions of what is a human – human beings “use energy to counter entropy” – in other words we are a creative species. And human beings are “co-operative, imaginative and linguistic” – the combination of which makes us a unique species.

All of these ideas are interesting to me. And I find it refreshing that these questions are coming to the fore now. Surely this is a timely and positive response to the mechanical, data and statistics driven reductionism which is so utterly de-humanising.

I continue to explore what it means to be human, and I find some of the more impressive answers in the works of philosophers, from the classical schools to Spinoza, Bergson and Deleuze (to name just a few!)

Of course, I could write about this for hours! Ha! Ha! But I’ll stop here and leave the possibility that these are questions you might like to pursue for yourself.

Let me summarise – because I think this is a lifetime project as well as potentially the basis for a whole curriculum –

  • What is Life?
  • What is a human being?
  • What is health?

The answers which appear from those studies could, possibly, give us the remedies of the future – the ones which actually do “restore health to the sick” – and, yes, more than that, allow us to create healthier societies filled with people who fulfil their potentials, creatively, co-operatively, and artistically…..can I even say “spiritually?”

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I was reading an interview with Harvard historian, Anne Harrington, who has written “Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness”.

When I was at university I was taught there were two types of depression – reactive and endogenous – the former occurring in response to specific events, and the latter seen as an illness of internal origin. It was thought that talking therapies, as they’ve come to be called, were the best way of dealing with reactive depression but that endogenous was a biological problem which required drugs. One of the main themes which emerged from that thinking was the serotonin theory of depression which was the basis for the great commercial success of Prozac, a drug which influenced the levels of serotonin in the brain.

Well, it all changed. Psychiatrists stopped distinguishing between “reactive” and “endogenous” and moved to thinking of all depression as biological and, hence, all requiring treatment with drugs.

But that didn’t last. As Anne Harrington describes, in the late 90s, “a range of of different studies increasingly seemed to suggest that these antidepressants – although they’re helping a lot of people – when compared to placebo versions of themselves, don’t seem to do much better.” As the “gold standard” of drug effect is its performance over that of placebo, and drug after drug was shown not to be that much better, it got harder and harder to bring new drugs onto the market. She says –

“But it doesn’t mean that the drugs don’t work. It just means that the placebo effect is really strong. But the logic of clinical trials is that the placebo effect is nothing, and you have to be able to better than nothing. But of course if the placebo effect isn’t just nothing, then maybe you need to rethink what it means to test a drug”

This is the same observation as Irving Kirsch made in his “Emperor’s New Drugs”. In that book he drew a graph which I found very impressive –

 

 

The point he was at pains to make was the same as Anne Harrington’s – well, actually, he was trying to emphasise that just because the drugs didn’t seem much more effective than placebo didn’t mean that doctors should stop prescribing them. But the main point, I think, is –

Placebo is not nothing

It seems crazy to me that people make decisions about whether or not a treatment should be offered to patients solely on the basis of its statistical difference to placebo if those decisions then lead to the withdrawal of treatments which were helping thousands of patients.

If the placebo effect is not the same as doing nothing (and it is clear that it is NOT the equivalent of doing nothing) then we should be exploring just what it is. That will involve moving on from the stigma of trickery, because that’s how the placebo effect has been portrayed. “Dummy pills”, “inactive pills”, “mock treatments” producing real life changes in the patients who receive them, only to reveal to them that, ha! ha! you got nothing!

I think it’s interesting that it is in the area of psychiatry that this debate has emerged. Because we know something of the power of placebo on our mental states. But as we are whole, body/mind, non-dual beings. What influences our mental states, influences our bodily functions too. Placebo effects are not restricted to changes in mental states, they are seen throughout the body, influencing organs, cells and circulating levels of natural chemicals.

Here’s the other thing – if placebo is NOT the same as doing nothing but a drug doesn’t show a substantial and significant benefit over placebo, then what else can we offer the patient? What else will be at least as powerful as placebo, but less harmful than the drug?

What about exercise, nutrition, the creation of significant social relationships, engagement with natural environments, meditation, learning how to handle our emotions for starters? And not forgetting demanding that we do something about the conditions in which more and more chronic illnesses are emerging – both mental and physical – poverty, poor housing, inequality, polluted environments, industrial, chemical methods of agriculture and food production and so on – have a look at the perspective I described in “There still aren’t enough”, and in “Inequality and health”.

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cordes sur ciel

There’s a lot of talk about the increasing strain on health services, something I’ve addressed here.

One of things that bothers me about these discussions is the assumption that increasing funding and resources to the health care system will result in a healthier population, which will, in turn, reduce the demand on the health services. This has never happened. And it’s not likely to happen.
The health of a population mainly comes down to how we live, not to the medicines we swallow or how quickly we can get an operation. Let me just clarify that I’m not arguing against more resources and funds for the health service, we need that to improve them. It’s just that this isn’t a way to create a healthier population and so reduce demand.
To create a healthier population we need to invest in what creates better lives. Better lives for as many people as we can.
There are many ways to do this. But let’s start with housing. Because decent housing, warm, weather-proof, houses with enough living space, clean, running water, an efficient sanitation system, and affordable, reliable power, is a foundation for healthier lives.
Would anyone argue otherwise?
If people are homeless, or living in insanitary, unsafe, overcrowded conditions, then they are more likely to get sick – both in the short term, with infections, and in the longer terms, with chronic, inflammatory conditions. I’m not going to list references here. Google these issues for yourself. But I am going to claim that adequate shelter is a necessary first step to better health for a population.

There are many factors and problems to consider here, but I just want to focus on one – waste – the number of abandoned and/or unused dwellings in every town and city.
When I think about this I can’t help also becoming aware of “high streets” full of empty, abandoned shops and offices. So, let’s take that into consideration too. Because when the town centres empty of commerce they aren’t only dying, depressing and, possibly, dangerous, but they represent a huge waste of opportunity for people to work and live together. We need shops, offices, workshops, cafés, restaurants, exhibition and performance venues, to have a healthy community. It’s no good just building lots of apartments in streets which are devoid of the possibilities for people to meet, share, and work together.

Take a walk around the streets where you live, both the residential streets where you dwell, and the town streets you visit most often for shops, offices, cafés, restaurants, and so on.
How many properties are sitting closed up and seemingly abandoned?
At the same time, are there homeless people in your locality? The homeless might be obvious sitting or lying on the pavements, in the doorways of closed shops, or they might be invisible to you, struggling to get by in bedsits, guest houses or hostels. What about decent housing? Is there anyone living in sub-standard, even unsafe properties? Is there anyone housed in overcrowded conditions with landlords maximising their income by minimising the personal living space of their tenants? Are the streets of your town vibrant, filled with people socialising and satisfying their daily needs and desires, for material , social and cultural goods?

I’m asking because it seems to me that it’s very common to find so many shops, offices and houses that look abandoned that a whole area feels either unsafe or unhealthy. The French have a word for it – désertification…..where a once vibrant locality becomes a desert. What could we do to turn this around? Here’s one idea.

A policy of compulsory purchase and leasing.

What if the local authority, the Council, or the Commune, had the right to compulsorily purchase, in its area of jurisdiction, any property which was uninhabited or unused for at least five years? What if all such properties could be compulsorily purchased for the current independent valuation price, then leased out to new tenants?
Residential properties could be rented out to those on housing benefit, paid for directly from the tenants’ housing benefit, instead of the current situation where these benefits go straight into the pockets of private landlords. Some properties could also be rented at commercial rates to either individuals or groups of individuals, encouraging a healthy social mix in the community.
Additionally some could be offered for sale, either directly at market rates, or using co-ownership schemes, where part of each month’s rent is allocated towards the final purchase of the property by the tenants. In a co-ownership scheme, an additional idea could be to agree a contract of improvement and renovations of the properties which would be paid for by the initial rental payments. For example, a property requiring £50,000 of work, and valued at a monthly rental of £1000, could have the works paid for by the first 50 rental payments.
Commercial properties, shops, workshops and offices could be offered rent-free for new tenant businesses. Instead of paying rent, the Council or Commune could be empowered to collect the VAT generated by these businesses, keeping that element of taxation for local use, instead of it disappearing into national funds.
The income streams to the councils from the housing benefits, domestic rents, co-ownership contracts, sales and locally ring-fenced VAT could then be used to make more compulsory purchases.
I’m sure somebody else will be able to take this idea and refine it considerably, but the basic idea is to favour circulation of property and wealth in the local economy and environment, instead of the current picture of stasis and decline.
Community associations, and co-operatives could be included in such schemes. In other words, it’s not just something for independent businesses and entrepreneurs, but something which could also encourage community led activities. Workshops, recycling services, training and education courses, as well as libraries, galleries, theatres and music venues.

Bringing life back to our existing communities by prioritising decent housing for everyone and supporting the daily opportunities for people to live, work and play together, would be a good beginning, if we want healthier populations who have less need of health services.

I’ll explore some other factors in later articles, including food, education and inequality. But maybe you’d like to share your own ideas? If you do, on your blog, your youtube channel, your instagram feed, or wherever you express yourself, please let me know. I’ll include links to your ideas in my posts.

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bandanaEvery day in the UK, we hear stories of ambulances waiting in queues at hospitals. Patients waiting hours to receive attention. Patients waiting hours on trolleys in hospital corridors.

What’s the problem?

Much of the media coverage focuses on the “demand”, by which they mean the sheer numbers of people coming to hospital for health care.

Let me return to the issue of demand in a minute, but let’s start with waiting times. Let’s set targets aside for a moment as well, because targets can be arbitrary and unhelpful.

Why are there queues of ambulances at hospitals?

Part of the answer is there aren’t enough doctors and nurses to attend to the patients’ needs.

There aren’t enough, because if there were, they would be able to devote all the time necessary to each patient but there wouldn’t be a huge queue.

Part of the answer is the staff can’t move patients through from A&E for inpatient care because there aren’t enough inpatient beds.

There aren’t enough inpatient beds.

There are more patients needing inpatient care than there are beds to put them in.

Beds aren’t enough.

Once a patient is in a bed, they need to be cared for….by staff to keep the ward clean, staff to make food for them and feed them, staff to care for their daily needs and staff to manage their diseases and get them well enough again to go home.

So can we fix that first?

  • Increase the numbers of beds available in the NHS to cater for the needs of sick people.
  • Increase the numbers of NHS staff to the level where there are enough of them to meet the needs of sick people.

Wasn’t that the whole point of the NHS in the first place?

To meet the needs of the sick in society.

Let’s turn to demand.

It’s going up.

And there’s absolutely not a shred of evidence to suggest it’s going to do anything other than continue to go up.

The proportions of the population over 60, over 70, over 80, and, yes, over 90 are all rising. All the evidence shows that older people have greater health needs. The demographics of the country tell us that demand will increase.

Life expectancy might be going up, but disease isn’t going down. There are more people suffering from a chronic illness every year. There are more people suffering from two or more chronic illnesses every year. This is what doctors are referring to when they talk about increases in “complex problems and needs”.

All those patients waiting on trolleys for a hospital bed have been assessed as needing the complex care of a hospital to cater for their complex needs.

Not all those patients already in the hospital need the complex care of the hospital. Some of them are elderly, and/or disabled people who are not able to look after themselves at home. They need to be looked after somewhere else.

Here’s the next item on the list.

There are not enough places available in care facilities which are not hospitals.

Places in care facilities, (nursing homes, residential homes etc), need sufficient numbers of trained and support staff to provide the care for their residents. We don’t have enough care facilities.

Let’s think about another aspect of demand. Time and again we hear that many people pitch up at A&E because they can’t get to see their local GP. They are told they have to wait several days, or even weeks, for an appointment so they go to the local hospital instead – with problems which could be, and should be, managed by GPs in the community.

Why can’t people get to see a GP in a more timely manner?

There aren’t enough GPs.

There never have been.

The scourge of General Practice is not having enough time to treat each patient as well as the doctors would like to. Were five minute appointments ever adequate? Are ten minute appointments adequate? Do they give the patient enough time to say what they want to say? Do they give the doctor enough time to listen, to examine, to diagnose, to offer treatment, to give the patient enough information to give informed consent to the treatment, to allow enough time to discuss options and alternatives?

You’ll have a hard time finding someone who can answer yes to that.

There aren’t enough GPs.

And there aren’t enough staff in the GPs’ teams either.

A healthier society

The biggest delusion suffered by those who created the NHS was that the NHS would make the population so much more healthy that eventually demand for it would shrink. That’s never happened. And it’s not likely to happen.

Health care isn’t the biggest contributor to the health of the population.

We need to address the causes of illness if we want to reduce demand. The causes of illness are primarily social, economic and environmental.

  • We need to tackle the isolation of people in our society.
  • We need to tackle poverty.
  • We need to tackle the constant stress of the “precariat” – all those without secure incomes, those on zero hour contracts, short term contracts, those employed for insufficient hours at insufficient levels of pay to meet their daily needs.
  • We need to tackle the food industry, from farming methods, to factory production of foodstuffs, to marketing and sales of food.
  • We need to tackle the chemical industry, to reduce the amount of CO2 in the atmosphere, the amount of plastic in the sea, the number of chemicals found in the blood of every newborn child, the number of chemicals found in drinking water, the number of chemicals in every household.
  • We need to tackle inequality which is rising fast and has been shown time and time again to inflict pain and suffering on millions.
  • We need to tackle conflict, to be able to direct resources towards healthy lives instead of war.
  • We need to tackle our political systems which leave so many feeling disempowered and forgotten. Democracy might be a great idea. Maybe we should try it. Not the pretend democracy of a vote every few years for someone to work in government, but real, relevant, responsive democracy which increases the engagement and autonomy of citizens.
  • We need to find different ways to live together.
  • We also need to tackle the Pharmaceutical industry. That industry which doesn’t exist to produce cures, but profits. There isn’t a drug on the market which increases health. At the very best a drug will support the body’s natural systems of repair and recovery. At worst drugs diminish symptoms without making any impact on the underlying disease.

We need a different philosophy of health care, one focused on health not taking drugs.

That’s an awful lot. Daunting perhaps. But are there better answers?

In summary

This is a toe in the water. There is no way to cover the complexity and extent of the issues in one short article. But can we make a start?

  1. We need more hospital beds, more care facilities, more GPs, more doctors, more nurses and more support and care staff.
  2. At the same time, we need to tackle the causes of the increase in demand – the social, economic and environmental causes.

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Every year I’m amazed to watch the butterflies appear in the garden the very same day the buddleia bushes flower. I’m convinced they both appear at exactly the same moment. No idea how that happens! Are the butterflies just hanging out around the corner somewhere waiting for the blossoms to appear, then zip round as fast as they can the moment that happens?

However it happens, it’s a delight to see so many varieties of butterfly (and the hummingbird moths, which are incredible creatures!), to watch how they fly in such utterly unpredictable directions, how they spread their wings in the sunlight, or close them up so they look like little leaves.

But here’s one thought which comes up for me time and time again when I see butterflies….they make me more aware of the cyclical nature of life. These little creatures have such different life stages, so different you wouldn’t realise they were stages of the same life. Do we think of them as having a beginning and an end? Starting with an egg, progressing through their caterpillar stages, becoming a chrysalis, then emerging as a butterfly which lays eggs, then dies. Is that the life?

I suppose we do all think of ourselves as having a beginning and an end. But where do we begin, and where do we end?

It depends on whether or not you want to reduce a person to just a physical body. My physical body began with a single fertilised egg and this body will die.

But what about ME?

Do I really think I’m only a physical body? Don’t I have a sense of something immaterial too? A consciousness? A sense of Self? A personality? Characteristics, behaviours, values, beliefs, creative acts, destructive acts? Is there anything I can do which doesn’t ripple out into the world beyond me?

When I look at Rodin’s “The Kiss”, or “The Thinker”, what do I see? The product of the imagination and creative skill of the man called Auguste Rodin. When I listen to music composed and performed by people who are long since dead, isn’t there something I’m sharing there which only they could have created? Aren’t these great works of art the ongoing ripples of unique human beings? Or do you think these are just their footprints? (It doesn’t seem that way to me….these works seem full of life and the potential to continue to create and send out ripples into the universe)

And what about those characteristics, quirks or tendencies that I have which others in my “family tree” also exhibited, even perhaps before I was born? Anyone who explores their genealogy encounters remarkable “coincidences”, talents, life events, behaviours which echo down through the generations. Weren’t those threads present even before the egg which became me even existed?

I think it’s inadequate to narrow a person down to a physical body.

But even if we did, there is still the fact that the body changes continually. It never stops. There is a constant turnover of cells, new beginnings, new endings, every hour of every day. There is a continuous exchange of energy, materials and information between my body and my environment, and we all share the same environment, the same atmosphere, the same air, water…..we are all made from the same molecules, all created from the same “star stuff”.

So it seems to me that beginnings and endings are everywhere……wherever, and whenever, we happen to look.

But it also seems to me that they are nowhere. They just don’t exist. We all emerge from, and dissolve into, the great cycles of the universe.

Beginnings and endings are just where we choose them to be. But we can always make a different choice. We can always take a broader view, a bigger view, a longer view, a more holistic view.

I’m reminded of a song from my school days….it’s by Jeff Beck, and it’s called “Hi Ho Silver Lining” – he sang this truth right there in the opening line of this song…in the first five words……

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I see this sort of thing a lot when I look at old buildings in either France or Spain. This one is in Segovia.

What’s the first thing you notice?

The window?

Or the window in an arch?

See, when I look at something like this I really get to wondering….how did this come about? Did the original builders build a nice big entrance way, two verticals and a horizontal? Building a frame like a picture frame for an entrance? Maybe not….well, maybe not exactly anyway, because it looks like exactly the same bricks have been used to make the archway and some of the bricks seem to run between the two frames….the square frame and the arched frame. So maybe the original builders built an arched entrance and surrounded the arch with a frame?

But then it looks like somebody decided not to have an entrance there after all and filled in the space.

Then somebody else thought, hey, wait a minute, I’d like a window here and put in the window….but did they fit bars around the window at the same time?

So, has this window, this barred window, emerged over many years from a wall which was built in the space formed by an arched doorway?

And what was the thinking behind each of those steps in the development?

Make an entrance, an attractive, obvious entrance…..then block it up…..then make a window, but not one for letting that much light in, and certainly not one somebody might climb into, or out of…..was that, is that, a problem around here? People climbing in and out of windows?

Bear with me here but because I worked as a doctor for almost forty years this image sparks my thinking about patients and the problems they talked about in the consulting room. They’d bring the equivalent of this window….let’s say they’d talk about a pain (instead of a pane….ha! ha! sorry!)…..and I’d ask about the pain, asking them to describe it….its features, its characteristics, its exact location, what surrounded it, or accompanied it……and then I’d want to know how it arose. Tell me when it wasn’t there. What was there before it? What was happening when it began? And so, gradually, what a first glance might be a simple symptom turned into a unique, never before told, story…..and that’s where I began to understand what the problem might be.

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I was in Segovia last week and I noticed quite a few towers had stork nests on them, and the nests had adult storks as well as chicks

Then as I looked one of the adults (the mother?) brought home some food

Wow! Amazing, huh?

There’s been something rattling around in my head for a while. It’s related to the ideas of the left and right hemisphere ways of engaging with the world, as described by Iain McGilchrist, but also to the ancient traditions of yin and yang, of the divine masculine and the divine feminine, of the Emperor and the Empress in the Tarot Majors, of alchemical and spiritual practices of bringing together two halves to make a whole…..and to my thoughts about two fundamental forces of the universe.

Here’s what’s been cropping up – (NB this is thinking about the psyche not about gender…..whilst our societies might ascribe clearly different tasks and roles to men and women I believe for each of us to be whole we need to integrate the male and female within us all – the anima and animus if you wish (I know that’s not quite the same) )

There are two pairs of behaviours, functions, activities which we ALL need to access….not just farm out one pair to someone of the opposite sex while keeping the first pair for ourselves!

The two pairs are –

Provide and Protect

and

Nourish and Nurture

I think we all need all of these behaviours in the adults around us or we won’t grow into healthy adults ourselves. And when I look at these storks in Segovia I see the incredible, huge structures of the nests, built to provide a home and shelter, built up high to protect from predators. And I see this adult feeding the chick directly – providing nourishment and nurture both at the same time (food and loving attention)

Maybe each of us specialise in, or concentrate on, one of these pairs – we are the providers and protectors OR we are the nourishers and nurturers – but I feel it’s becoming clearer to me that all of us need to develop both of these pairs….that with only one, we are not whole.

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