Commentary

International Reproductive Health Still Worth the Investment

Wayne Shields & Suzanne Petroni

United States investments in maternal, reproductive and sexual health programs have been a tremendous success but challenges remain, which the sexual and reproductive health community must help overcome.

Editor’s Note:  This editorial is reprinted from the June 2011 issue of the Association of Reproductive Health Professionals’ Contraception: An International Reproductive Health Journal.

The United States has been a global leader in the international population arena for nearly 50 years. United States investments in maternal, reproductive and sexual health programs have been a tremendous success, saving and improving many millions of lives. But many challenges remain, and the collective education and advocacy efforts of the sexual and reproductive health community can help overcome them.

The world’s population continues to grow at a rate of nearly 80 million people a year.1 An estimated 215 million women throughout the developing world want, but do not have access to, modern methods of contraception, which contributes to some 76 million unintended pregnancies and 20 million unsafe abortions each year.2 The number of women who die during childbirth remains unacceptably high, with hundreds of thousands still succumbing to mostly preventable maternal deaths each year.3 Hundreds of thousands more women are injured during pregnancy, with tens of thousands facing the tragedies of obstetric fistulae or unsafe abortions.3 AIDS is now the leading cause of death among women of reproductive age, and maternal mortality is the leading killer of women aged 15–19 years throughout the world.4 Because of gender discrimination and sociocultural beliefs, young women are particularly ill-equipped to negotiate safer sex practices with their typically much older partners.

Access to comprehensive sexual and reproductive health services can solve many of these grave challenges, and for many decades, the United States has supported the provision of such services for women and men in the developing world. At the International Conference on Population and Development (ICPD), held in Cairo, Egypt in 1994, the United States led the world — and joined leaders in health, science, medicine, women’s rights and the environment — in committing to provide the funding and support needed to meet the world’s reproductive health needs.5

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In recent years, however, US policies around these issues have become increasingly divisive and politicized, contributing to insufficient funding and constrained programs. Indeed, while not all programs supported by the US government are as efficient as they might otherwise be — operating as they do in silos, with ideologically driven restrictions, and sometimes in competition with each other — the assistance that the US provides to address the sexual and reproductive health needs of the world’s poorest people is absolutely critical and lifesaving. These investments must be protected from a new Congress, which seeks to curtail funding for development assistance, and they must be supported by an Administration that has made promising initial steps toward breaking down barriers and meeting the commitments made by the United States.

The significant progress that has been made in the past half century will be lost unless the United States and other nations reinforce their commitment to the ICPD agenda and to the notion that women’s health is worth protecting.

What Did the World Agree to in Cairo?
The ICPD Programme of Action, arduously negotiated over many months, was a comprehensive document that reached across a broad range of issues associated with population and development, including, but not limited to, education; infant, child and maternal mortality; population dynamics; the environment and consumption; migration; HIV/AIDS; and technology, research and development.5

While far-reaching in scope, the core of the ICPD was recognition that a sustainable world was not about numbers, but about people, and that all people, particularly women, must have access to reproductive health. This worldwide consensus recognized that achieving universal access to reproductive health is critical for individual health, family well-being, economic development and a healthy planet.

Reproductive health was defined at Cairo in more comprehensive terms than ever before, namely, as “a state of complete physical, mental and social well-being … in all matters relating to the reproductive system.” This meant expanding the definition beyond family planning — long the mainstay of population programs — to include maternal and neonatal health; prevention and treatment of sexually transmitted infections, including HIV/AIDS; and prevention and response to gender-based violence — all-critical elements of achieving universal access. Women’s empowerment, including their right to determine the number, timing and spacing of childbearing, was given paramount importance at Cairo.

The ICPD also encouraged breaking down the silos in which sexual and reproductive health programs had traditionally been divided, an innovative way to advance a more holistic— and realistic — view of health.

The ICPD Agenda Is as Needed as Ever
The United States was one of 179 nations that made a commitment in Cairo to help advance the health and welfare of women, men and young people around the world. This commitment was made out of a moral obligation to ensure that individuals can rise out of desperate poverty, a conviction that women and children should not suffer and die needlessly, and as a practical investment in our shared future. Some 17 years later, the principles and goals of Cairo are as relevant and needed as ever.

As health care researchers and providers know, sexual and reproductive health care is a critical component of the overall health and welfare of women, men and young people. Individuals’ welfare contribute to the welfare of communities, nations and ultimately the world. Their sexual and reproductive health status impinges greatly on the decisions of women, men and young people, and impacts their access to needed information, care and services.

Even as we face a global population that will soon number an historic seven billion, we can continue to advance toward a healthier, more equitable and sustainable world.6 Working in partnership with other nations around the world, we have a responsibility to do so.

We Know What Works
Despite the many challenges, we know from successful investments in global health that solutions are within reach.

Supporting the comprehensive package of simultaneous interventions recommended by the ICPD will ensure that voluntary contraception is affordable and safe; that women are empowered to decide whether and when they want to have a baby; that evidence-based sexuality education programs reach all those in need, so that unintended pregnancies and sexually transmitted diseases are prevented. These interventions will ensure that pregnant women have access to lifesaving information for themselves and their children, and that they give birth with skilled assistance. They will ensure that young women are not subject to sexual violence, including culturally driven practices, like female genital circumcision, that impair their rights and their sexual health.

What has been proven NOT to work are siloed programs and ideologically driven policy restrictions — such as the Mexico City Policy or “Global Gag Rule” that restricts family planning funding from organizations that provide — with their own funds — abortion counseling, lobbying or services.7

Comprehensive solutions are effective. Maternal mortality rates in Egypt have dropped by more than 50%, as contraceptive usage increased from 23% in 1980 to 57% in 2005. In Mexico, the infant mortality rate fell by 70% between 1970 and 2005, as the use of modern contraceptives and access to prenatal care increased.8 In the past 3 years alone, more than 6000 communities in eight sub-Saharan African nations have abandoned female genital mutilation.9 The number of people infected with HIV/AIDS in Zimbabwe nearly halved in a 10-year period: from 29% of the population in 1997 to 16% in 2007, as awareness about prevention methods increased.10 Similar successes appear in every corner of the world.

Fortunately, What Works Is Supported by the American Public
These are cost-effective elements of US foreign policy, and they are supported by an overwhelming majority of Americans across the political spectrum. According to American Public Opinion and Global Health (May, 2009), 68 percent of Americans said they support “helping poor countries provide family planning and reproductive health services to its citizens.” Some 78 percent support “improving the health of mothers and children in poor countries”.11 And according to the Kaiser Family Foundation, 85 percent of Americans think “promoting the rights of women” should be a top priority for the US government.12

The Obama Administration Is on Board…Mostly
The Obama Administration has recognized that we must not roll back the significant progress that has been achieved thus far, and has taken specific, concrete steps to advance more comprehensive, integrated, evidence-based approaches to sexual and reproductive health and women’s rights. The Global Health Initiative (GHI), a hallmark of the Administration’s international development policy, would institutionalize a cross-disciplinary and cross-agency approach to the challenges laid out in Cairo, breaking down the silos that have long hampered effective development assistance.13 Based on years of successes and understanding that women’s health and rights are absolutely essential to ensuring the health of communities and the world, the GHI is powerfully focused on interventions to prevent unintended pregnancy, promote women’s health and save women’s lives.

The GHI also recognizes the importance of innovation in achieving global health solutions. We hope that this recognition will lead to increased support by the Administration of new innovations to advance sexual and reproductive health, such as multipurpose prevention technologies that would allow women to simultaneously prevent unintended pregnancy and a range of sexually transmitted infections.14 Multipurpose prevention technologies represent the ideal illustration of working across issue silos to address the holistic health needs of women.

The creation of an Office of Global Women’s Issues, led by an ambassadorial-level appointment and reporting directly to the Secretary of State, and whose staff has been intimately engaged in advancing the GHI, is yet another indication of the prioritization of women and women’s health in US foreign policy and assistance.

And while we would argue that it does not go nearly far enough, President Obama’s budget request for Fiscal Year 2012 included necessary increases in funding for international reproductive and maternal health programs.

Call to Action
In more cases than not, the smartest long-term strategies build on what is proven to work with an infusion of fresh data and a dash of creativity. The Cairo principles have proven to work and serve to inform specific strategies to raise the standards of health and quality of life for women and their families in all nations.

It is important for all nations to show global leadership by continuing to break down barriers between disciplines, specialties, agencies and interest groups to address common public health goals. A sustained, long-term US commitment to advancing reproductive health is the way to make progress. Some countries are meeting their commitments to advance reproductive health, but the United States is not. In order to meet its fair share of the Cairo agenda and keep its promise to the world’s women, the US government should provide $3.2 billion for maternal, newborn, child and reproductive health programs and advance policies that ensure these funds are used effectively to meet the health needs of individuals. With adequate funding and appropriate policies, the United States can help to prevent the deaths of hundreds of thousands of women and children, reduce the spread of HIV/AIDS, grow economies, make poverty history and preserve natural resources the world over.

Cairo represented a watershed moment for the development and implementation of global health strategies, and we are on the right path — but the huge potential of these basic principles to create monumental changes in reproductive health globally has yet to be realized.

What You Can Do
To be most effective, policies should be evidence based and meet real-life needs. As reproductive health professionals, you rely on this approach to ensure the greatest likelihood of public health success. Your professional voice holds more sway than you might think.

Here is what you can do:

  1. Include information about the Cairo principles and our global progress when developing any relevant curriculum, continuing medical education program, speech, interview or other outreach platform.
  2. Initiate conversations with professional colleagues, policymakers, educators, religious leaders, members of the media and others to advocate for basing policy decisions on evidence — not ideology — and to support necessary national funding to reach the Cairo goals.
  3. Show your support for evidence-based policies and the Cairo principles by encouraging policymakers to provide support to the world’s women and increase funding levels to meet the commitments of support.
  4. Sign up for professional updates and helpful links to vetted information resources (government agencies, nongovernmental organizations, global health advocacy groups and donors, and others): www.arhp.org/supportglobalhealth. We encourage your support, advocacy and constructive comments.

References

  1. Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat . World population prospects: the 2008 revision. United Nations. http://esa.un.org/unpp Last accessed February 17, 2011.
  2. Susheela S, Darroch JE, Ashford LS, Vlassoff M. Adding it up: the benefits of investing in family planning and newborn and maternal health. Guttmacher Institute and United Nations Population Fund, 2009. http://www.guttmacher.org/pubs/AddingItUp2009.pdf Last accessed February 22, 2011..
  3. In: WHO , UNICEF , UNFPA , World Bank  editor. Maternal mortality in 2005. Geneva: World Health Organization; 2007;p. xiv, 10;http://www.who.int/making_pregnancy_safer/topics/maternal_mortality/en/index.html Last accessed February 17, 2011.
  4. World Health Organization . Women and health: today’s evidence tomorrow’s agenda. Geneva: WHO Press; 2009;http://www.who.int/gender/women_health_report/en/index.html Last accessed February 22, 2011.
  5. International Conference on Population and Development: summary of the programme of action . United Nations Department of Public Information. http://www.un.org/ecosocdev/geninfo/populatin/icpd.htm Last accessed February 17, 2011.
  6. Development Data Group, World Bank. In: 2009 World development indicators. Washington, DC: International Bank for Reconstruction and Development/The World Bank; 2009;p. 43.
  7. Cincotta RP, Crane BB. Public Health. The Mexico City policy and U.S. family planning assistance. Science. 2001;294(5542):525–526.
  8. Mortality country fact sheet, 2006. World Health Organization. 2006. Available at: http://www.who.int/whosis/mort/profiles/mort_emro_egy_egypt.pdf. Last accessed February 17, 2011.
  9. UNFPA, UNICEF. The end is in sight: annual report 2009 for the UNFPA/UNICEF Joint Programme on Female Genital Mutilation/cutting. 2010;http://www.unfpa.org/public/home/publications/pid/6435 Last accessed February 17, 2011.
  10. Halperin DT, Mugurungi O, Hallett TB, et al. A surprising prevention success: why did the HIV epidemic decline in Zimbabwe?. PLoS Med. 2011;8:e1000414.
  11. Ramsey C, Weber S, Kull S, Lewis E. Americans support US working to improve health in developing countries. World Public Opinion, Inc. (May 20, 2009). http://www.worldpublicopinion.org/pipa/articles/brunitedstatescanadara/610.php Last accessed February 17, 2011.
  12. Survey about U.S. role in global health reports that Americans want to take care of problems at home first in a recession, but say don’t cut funding for global health and development. Public Opinion and Research Program, Henry J. Kaiser Family Foundation (May 6, 2009). http://www.kff.org/kaiserpolls/posr05609pkg.cfm Last accessed February 17, 2011.
  13. The US Government’s Global Health Initiative. PEPFAR, United States Department of State. Available at: http://www.pepfar.gov/ghi/index.htm. Last accessed February 17, 2011.
  14. Initiative for Multipurpose Prevention Technologies (MPT) . Coalition advancing multipurpose innovations. http://www.cami-health.org/Initiatives.html Last accessed February 17, 2011.

News Health Systems

The Crackdown on L.A.’s Fake Clinics Is Working

Nicole Knight

"Why did we take those steps? Because every day is a day where some number of women could potentially be misinformed about [their] reproductive options," Feuer said. "And therefore every day is a day that a woman's health could be jeopardized."

Three Los Angeles area fake clinics, which were warned last month they were breaking a new state reproductive transparency law, are now in compliance, the city attorney announced Thursday.

Los Angeles City Attorney Mike Feuer said in a press briefing that two of the fake clinics, also known as crisis pregnancy centers, began complying with the law after his office issued notices of violation last month. But it wasn’t until this week, when Feuer’s office threatened court action against the third facility, that it agreed to display the reproductive health information that the law requires.

“Why did we take those steps? Because every day is a day where some number of women could potentially be misinformed about [their] reproductive options,” Feuer said. “And therefore every day is a day that a woman’s health could be jeopardized.”

The facilities, two unlicensed and one licensed fake clinic, are Harbor Pregnancy Help CenterLos Angeles Pregnancy Services, and Pregnancy Counseling Center.

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Feuer said the lawsuit could have carried fines of up to $2,500 each day the facility continued to break the law.

The Reproductive Freedom, Accountability, Comprehensive Care, and Transparency (FACT) Act requires the state’s licensed pregnancy-related centers to display a brief statement with a number to call for access to free and low-cost birth control and abortion care. Unlicensed centers must disclose that they are not medical facilities.

Feuer’s office in May launched a campaign to crack down on violators of the law. His action marked a sharp contrast to some jurisdictions, which are reportedly taking a wait-and-see approach as fake clinics’ challenges to the law wind through the courts.

Federal and state courts have denied requests to temporarily block the law, although appeals are pending before the U.S. Court of Appeals for the Ninth Circuit.

Some 25 fake clinics operate in Los Angeles County, according to a representative of NARAL Pro-Choice California, though firm numbers are hard to come by. Feuer initially issued notices to six Los Angeles area fake clinics in May. Following an investigation, his office warned three clinics last month that they’re breaking the law.

Those three clinics are now complying, Feuer told reporters Thursday. Feuer said his office is still determining whether another fake clinic, Avenues Pregnancy Clinic, is complying with the law.

Fake clinic owners and staffers have slammed the FACT Act, saying they’d rather shut down than refer clients to services they find “morally and ethically objectionable.”

“If you’re a pro-life organization, you’re offering free healthcare to women so the women have a choice other than abortion,” said Matt Bowman, senior counsel with Alliance Defending Freedom, which represents several Los Angeles fake clinics fighting the law in court.

Asked why the clinics have agreed to comply, Bowman reiterated an earlier statement, saying the FACT Act violates his clients’ free speech rights. Forcing faith-based clinics to “communicate messages or promote ideas they disagree with, especially on life-and-death issues like abortion,” violates their “core beliefs,” Bowman said.

Reports of deceit by 91 percent of fake clinics surveyed by NARAL Pro-Choice California helped spur the passage of the FACT Act last October. Until recently, Googling “abortion clinic” might turn up results for a fake clinic that discourages abortion care.

“Put yourself in the position of a young woman who is going to one of these centers … and she comes into this center and she is less than fully informed … of what her choices are,” Feuer said Thursday. “In that state of mind, is she going to make the kind of choice that you’d want your loved one to make?

Rewire last month visited Lost Angeles area fake clinics that are abiding by the FACT Act. Claris Health in West Los Angeles includes the reproductive notice with patient intake forms, while Open Arms Pregnancy Center in the San Fernando Valley has posted the notice in the waiting room.

“To us, it’s a non-issue,” Debi Harvey, the center’s executive director, told Rewire. “We don’t provide abortion, we’re an abortion-alternative organization, we’re very clear on that. But we educate on all options.”

Analysis Law and Policy

California Bill Aimed at Anti-Choice Videos Draws Free Speech Concerns

Amy Littlefield

“We wanted to make sure that we updated ... laws to kind of reflect a changing world and to make sure that we actually protect the doctors who provide these important services to women,” California Assemblymember Jimmy Gomez said, adding that his legislation would also protect patient safety and access to abortion.

A California bill that would make it a crime to distribute secret recordings of health-care providers—like the ones David Daleiden used in his smear campaign against Planned Parenthood—has cleared a legislative hurdle, but faces opposition from media groups and civil liberties advocates, who say the legislation is overly broad.

It is already illegal in California to record, whether in audio or video form, a confidential communication without the consent of all parties involved. But California Assemblymember Jimmy Gomez, who introduced AB 1671, told Rewire that while current law specifically forbids the distribution of illegally recorded telephone calls, there is no similar protection for videos.

“We wanted to make sure that we updated those laws to kind of reflect a changing world and to make sure that we actually protect the doctors who provide these important services to women,” Gomez said, adding that his legislation would also protect patient safety and access to abortion.

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AB 1671 makes it a crime if someone who violates California’s existing law against secret recordings “intentionally discloses or distributes, in any manner, in any forum, including, but not limited to, Internet [websites] and social media, or for any purpose, the contents of a confidential communication with a health care provider that is obtained by that person.”

Violators could be jailed for up to a year and fined up to $2,500, penalties similar to those already in place for making illegal recordings. But the new measure specifies that for both recording and distribution, the fines apply to each violation; that means someone like Daleiden, who circulated his videos widely, could quickly rack up heavy fines. Repeat offenders could face fines of up to $10,000 per violation.

The effort to pass the bill comes as abortion providers face a rising tide of threats and secret recordings. Besides Daleiden’s efforts, covertly recorded footage of clinic staff has cropped up in the documentary HUSH and in videos released by the anti-choice group Live Action. Planned Parenthood reported a ninefold increase in harassment at its health centers in July last year, when Daleiden began releasing the deceptively edited videos he claimed showed the organization was illegally profiting from fetal tissue donation. (Multiple federal and state investigations have found no wrongdoing by Planned Parenthood.) The National Abortion Federation recorded an “unprecedented” spike in hate speech and threats against abortion providers last year, peaking with the fatal shooting of three people at a Colorado Springs Planned Parenthood.

Increased Threats

“It was so alarming and so extensive that our staff that normally tracks threats and violence against providers could not keep up,” NAF President and CEO Vicki Saporta told Rewire. The organization was forced to hire an outside security firm.

Beth Parker, chief legal counsel for Planned Parenthood Affiliates of California, told Rewire the new legislation is needed to protect the safety of abortion providers.

“If our providers aren’t safe, then they won’t provide, and we won’t have access to reproductive health care,” Parker said in a phone interview.

Daleiden’s group, the Center for Medical Progress, is based in California, and much of his covert recording took place there. Of the four lawsuits he and his group face over the recordings, three have been filed in federal court in California. Yet so far, the only criminal charges against Daleiden have been lodged in Texas, where a grand jury tasked with investigating Planned Parenthood instead indicted Daleiden and fellow anti-choice activist Sandra Merritt for purportedly using fake California driver’s licenses as part of their covert operation. The charges were later dropped for procedural reasons.

Last summer, California Attorney General Kamala Harris announced plans to review whether the Center for Medical Progress violated any laws, and in April, state investigators raided Daleiden’s apartment. Harris has not yet announced any charges. Daleiden has accused officials of seizing privileged information, a claim the attorney general’s office told Rewire it is working on resolving in court.

Harris, meanwhile is running for Senate; her campaign website describes her as “a champion for a woman’s right to choose.”

“We think there is an excellent case and the attorney general should have prosecuted,” Beth Parker of Planned Parenthood Affiliates of California told Rewire. “Daleiden did more than just publish the videos, as we know, I mean he falsified driver’s licenses, he falsified credit cards, he set up a fake company. I mean, we have, as you know, a major civil litigation against him and his conspirators. I just can’t answer to why the attorney general hasn’t prosecuted.”

Parker said AB 1671 could increase incentives for law enforcement to prosecute such cases.

“What we’ve heard as we’ve been working [on] the bill is that criminal law enforcement almost never prosecutes for the violation of illegal recording,” Parker said. “It’s just too small a crime in their view.”

Assemblymember Gomez also said he hopes his bill will facilitate the prosecution of people like Daleiden, and serve as a deterrent against people who want to use illegal recordings to “undermine the fact that people have this right to have control over their bodies.”

“That’s the hope, is that it actually does change that landscape, that DAs will be able to make a better case against individuals who illegally record and distribute,” Gomez said.

Vicki Saporta of the National Abortion Federation says the actions of law enforcement matter when it comes to the safety of abortion providers.

“There’s certainly a correlation between law enforcement’s response to criminal activity aimed at abortion providers and the escalation or de-escalation of that activity,” Saporta said, citing the federal government’s response to the murders of abortion providers in the 1990s, which included the deployment of federal marshals to guard providers and the formation of a task force by then-Attorney General Janet Reno. “We had more than a decade of decreases in extreme violence aimed at abortion providers, and that ended in 2009 with the murder of Dr. [George] Tiller.”

But media and civil liberties groups, including the Electronic Frontier Foundation and American Civil Liberties Union of California, have expressed concerns the bill could sweep up journalists and whistleblowers.

“The passing of this law is meant to chill speech, right, so that’s what they want to do,” Nikki Moore, legal counsel of the California Newspaper Publishers Association, which opposes the legislation, said in an interview with Rewire. In addition to potential criminal penalties, the measure would create new civil liabilities that Moore says could make journalists hesitant to publish sensitive information.  

“A news organization is going to look at it and say, ‘Are we going to get sued for this? Well, there’s a potential, so we probably shouldn’t distribute it,’” Moore said.

As an example of the kind of journalism that could be affected by the bill, Moore cited a Los Angeles Times investigation that analyzed and helped debunk Daleiden’s footage.

“Planned Parenthood’s bill would criminalize that behavior, so it’s short-sighted of them if nothing else,” Moore said.

Assemblymember Gomez disagrees about the scope of the bill. “We have tailored it narrowly to basically say it applies to the person who illegally recorded the video and also is distributing that video, so it doesn’t apply to, say, a news agency that actually ends up getting the video,” he said.

Late last week, the California Senate Appropriations Committee released AB 1671 to the state senate floor on a vote of 5 to 2, with Republicans opposing it. The latest version has been amended to remove language that implicated “a person who aids and abets” the distribution of secret recordings, wording civil liberties groups said could be used to sweep in journalists and lawyers. The latest draft also makes an exception for recordings provided solely to law enforcement for investigations.

But the ACLU of California and the California Newspaper Publishers Association said they still oppose the bill. (The Electronic Frontier Foundation said it is still reviewing the changes.)

“The likelihood of a news organization being charged for aiding and abetting is certainly reduced” under the new language, Moore said. But provisions already exist in the California penal code to implicate those accused of aiding and abetting criminal behavior.

“You can imagine scenarios where perhaps the newspaper published it and it’s an anonymous source, and so now they’re aiding and abetting the distribution, and they’re the only person that the prosecutor knows might have been involved,” Moore says.

In letter of opposition sent in June to Assemblymember Gomez, Kevin Baker, legislative director of the ACLU of California, raised concerns about how the measure singles out the communications of health-care providers.

“The same rationale for punishing communications of some preferred professions/industries could as easily be applied to other communications —e.g., by law enforcement, animal testing labs, gun makers, lethal injection drug producers, the petroleum industry, religious sects,” Baker wrote.

Gomez said there could be further changes to the bill as talks aimed at resolving such opposition continue. An earlier version passed the assembly easily by a vote of 52 to 26. The latest draft faces an August 31 deadline to pass the senate and a concurrence vote in the assembly before the end of the session. After that, Gomez said he hopes California Gov. Jerry Brown (D) will sign it.

“If we can strike the right balance [between the rights of privacy and free speech], my hope is that it’s hard for him not to support it,” Gomez said. 

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