chabbot carrot soup

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Electronically published October 25, 2006

Comparative Education Review, vol. 51, no. 1. 2007 by the Comparative and International Education Society. All rights reserved.0010-4086/2007/5101-0002$05.00

Comparative Education Review 71

Carrot Soup, Magic Bullets, and Scientific Research for

Education and Development

COLETTE CHABBOTT

Following the UN Millennium Summit in 2000, the Millennium DevelopmentGoals (MDGs) set global sector-specific development targets to be achievedby the year 2015. The MDGs for education are strikingly incongruent withthose for health. As shown in table 1, the main target for education is ex-pressed in terms of service delivery, whereas the main targets for health areexpressed in terms of outcomes. To make the health targets congruent withthe actual education target reduces them to access to a health clinic, asshown in italics. Conversely, to make the education target congruent with

the health targets entails elevating it to actual levels of learning for specificgroups, as shown in italics.

M. A. Clemenss recent analysis of the expansion of primary educationin the last 40 years concludes that, based on past trends, even the low standardof the actual education MDGs for education are patently unattainable (Clem-ens 2004), and he questions claims that several countries have made dramaticrecent progress inconsistent with past trends.1 Clemenss results derive inpart from his assumption that past rates of change and adoption in thetechnology of education are good proxies for future rates of change andadoption. This is consistent with arguments made at the 1990 Education forAll conference, to the effect that EFA could not be achieved with businessas usual, either in terms of funding or of delivery systems (World Conferenceon Education for All 1990, Article 7; Verspoor 1993). In the years immediatelyfollowing the EFA conference, UNICEF in particular set high hopes on in-creased funding for new low-cost, alternative approaches to expanding masseducation, showcasing five such approaches in a 1992 monograph titledWhat Are We Waiting For?2 These alternative approaches and the tech-

For cogent and constructive contributions, thanks go to three anonymous reviewers and manyothers, including Helen Abadzi, Robert Berg, Luis Crouch, Keiko Inoue, Nancy Kendall, John W. Meyer,Theodore H. Thomas, and James H. Williams. All errors are mine alone.

1 For example, Bangladesh met the mid-decade MDGs for education, but in a 2001 assessment ofClass V students in rural government schools, less than 2 percent achieved minimum levels of theterminal competencies for primary school (Chowdhury et al. 2002).

2 The five approaches are BRAC Non-formal Primary Education in Bangladesh, Escuelas Nuevasin

Latin America, Interactive Radio Instruction in Kenya and the Dominican Republic, the ZimbabweIntegrated Teacher Education course, and SAWA: A Magazine for Children in War-Torn Lebanon(Anderson1992).


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TABLE 1Targets for Millennium Development Goals

Service Delivery OutcomeEducation Achieve universal primary

educationReduce by two-thirds the number of children who can-

not read fluently at age 12Achieve a 50% improvement in levels of adult literacy

by 2015*

Health Ensure all children have access to ahealth clinic

Reduce by two-thirds the mortality rate amongchildren under age 5

Reduce by three-quarters the maternal mortalityrate

Note.Actual targets are in regular type; congruent goals are in italic type.*Of the six goals declared at the 2000 end of the decade conference for Education for All, this is the only goal

stated in quantitative terms.

nological innovations associated with them, however, have not been widelyadopted, and the pace of quality educational expansionthat is, learningin the last 20 years has been largely disappointing in much of sub-SaharanAfrica, South Asia, and in numerous countries in other regions (EFA GlobalMonitoring Report Team 2005).

In this article, I explore the role of health and education research inproducing technological innovations and global policy options and goals,such as the MDGs. I have chosen health research as a point of comparisonfor three reasons. First, unflattering comparisons of progress in the educationsector relative to progress in the health sector are a constant source of ir-ritation. Second, since the end of the 1990s, a series of debates on the relative value and feasibility of experimental methods more commonly found in

health than in education research has occupied many education researchersin the United States and United Kingdom. Third, the opportunity arose tostudy the history of the development of one magic-bullet technology inhealthoral rehydration therapyboth through recently published memoirsand through interviews with the principals involved.

This work is grounded in the world polity program of research. Scholarsin this program explore the rise and effects of a common world culturelargely derived from the Western Enlightenment (Thomas et al. 1987). Com-mitment to Western positivist science as the ultimate authority and justifi-cation for public policy is one key element of this culture (Drori et al. 2004).In the context of the world polity research program, neither world culturenor Western science is the only possible, much less the best conceivable,

culture or authority; they are simply, de facto, the present ones, dominatingpublic discourse at the international and, to a lesser extent, the national level(Lechner and Boli 2005). Resistance to and adaptation of this world cultureoccurs at all levels of society and scholarly disciplines (Anderson-Levitt 2003).However, in general, efforts to project conformity to this culture and to appealto science in contexts far removed from the conditions in which Western


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EDUCATIONAL VERSUS MEDICAL RESEARCH FOR DEVELOPMENT

culture and science originally obtained are of particular interest to worldpolity scholars, as are the roles of international organizations (Boli and

Thomas 1999; Chabbott 2003) and of modern educational systems (Chab-bott and Ramirez 2000) as carriers of world culture.The emphasis, then, on Western science throughout much of this article

indicates recognition of, rather than an uncritical endorsement of, its peculiarauthority in international development discourse. Along the same lines, thefocus in this article on global goals does not constitute an endorsement ofthose goals. Rather, global goals represent one of many efforts on the partof international organizations to rationalize global action and coordinatenational action in the absence of formal governance structures at the globallevel.

The article falls into two, roughly equal parts. The first 2 sections belowexplore patterns in research and innovation in two exemplary disciplines

core to the study of the individual outcomes in health and education: mi-crobiology and cognitive science. The following section, Development, De-liverables, and Delivery Systems, highlights the way two types of technologicalinnovation available to international development organizationsdelivera-bles and delivery systemsshaped two precursors to the MDGs: the Healthfor All (HFA) and Education for All (EFA) initiatives.

The second part, beginning with the section titled ORT: Developing aDeliverable, shifts the terms of the debate on scientific education researchto a different level. A case study of the development of oral rehydrationtherapy (ORT) explores the research program that generated one core HFAcomponent. The following section highlights several aspects of the ORTresearch environmentfocus, location, time, funding, international orga-

nizations, research methods, international status, and scientific statuswhichare not unique to health but are not evident in any ongoing program ofeducation research. The final section provides a summary and suggestions fora future research agenda that might generate better policy options and supportmore ambitious, yet possibly more attainable, global goals for education.

The Science of Health and Education Research

Two disciplines central to the development of individual outcome-ori-ented goals in public health and education here serve as exemplars of re-search in these sectors: microbiology and cognitive science. Although severalancient and modern disciplines underlie the current state of health sciences,

research in microbiology has played a particularly important role in thedevelopment of several HFA goals. Microbiology began its transformationinto a systematic, modern science in the late seventeenth century, with thefirst observation of microorganisms using a crude microscope. The subdis-cipline began a series of rapid advances in the second half of the nineteenthcentury, as improved microscopes and related instrumentation made it pos-


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sible to isolate and study ever smaller units of analysis: viruses, bacteria, cells,mitochondria. At the same time, public awareness of the germ theory of

disease led to a greater appreciation of the life-saving potential of microbi-ological research. Aided by ever more sophisticated instruments, complexprocedures emerged to preserve and accelerate biological processes in vitro,in test tubes or petri dishes, and independent of human subjects, creating awhole new arena for research in laboratories.

All of this increased the legitimacy of microbiology as an exact science,in which hypotheses and counterhypotheses could be generated, tested, andretested more quickly. Eventually, the long training necessary to learn to usesophisticated instruments in laboratories far removed from public scrutinyalso contributed to the public mystification of microbiology. At the sametime, the regular public successes of its workin the form of vaccines andantibiotics administered to millions of individualsand the close ties between

health research and teaching hospitals increased the authority of publichealth experts who attempt to bridge the divide between microbiology andpublic policy.

In contrast, although the history of education research sometimes tracesits philosophical origins to Plato or to Jean Jacques Rousseaus Emile, modernattempts to apply Western science to the study of an individual educationaloutcomecognitiondate only from the late nineteenth century, with theProgressive or New Educationists. One of the leading child psychologistsand cognitive scientists of the twentieth century, Jean Piaget, began hiscareer concerned with winning recognition, especially by his colleagues inphysics and the natural sciences, for the equally scientific nature of thehuman sciences (Munari 1994, 312). Although cognitive science is arguably

the most exact science to focus on education to date, precision instrumentson a par with the microscope, such as functional magnetic resonance im-aging (fMRIs), have only recently emerged, and their potential is still beingexplored.3

The outcome measure for cognitive sciencelearningis more subtlethan mortality or morbidity in microbiology. Relative to what a single bloodtest can reveal about the state of the body, a host of paper and pencil testsand performance assessments produce crude approximations of the state ofthe mind of the learner. Moreover, education has multiple desired learningoutcomeslearning content, learning citizenship, learning culture, learningto get along, learning to continue learning (Faure and the InternationalCommission on the Development of Education 1972; Delors and the Inter-

national Commission on Education for the Twenty-first Century 1996)andconsensus on objective measures of all these outcomes is not expected soon.

3 See the OECDs Center for Education Research and Innovations Brain and Learning Group athttp://www.oecd.org/about/0,2337,en_2649_14935397_1_1_1_1_1,00.html. In addition, some video-tape analyses are approaching high levels of precision within classroom studies (see Stigler 1999).


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Without more sophisticated instruments and discrete outcome indicators,with most of its work done in public rather than in laboratories, and with a

declining number of laboratory schools, cognitive scientists face more diffi-culty than their counterparts in microbiology in asserting their scientificjurisdiction and authority in matters pertaining to public policy. This is com-pounded, at least in industrialized countries, by a public with lengthy personalexperience in formal education systems who tend, as a result, to assumelearning is not rocket science (Moats 1999). In addition, the organization ofschooling may also isolate practitioners/teachers from scientists/researchersto a greater degree in cognitive science than in microbiology.

Finally, until relatively recently, the ultimate scope of findings in micro-biology was more universal than those in cognitive science. The appropriatecontent and target groups for education are expected to vary from place toplace, as different societies define their needs and employment opportunities

in light of different social structures, physical environments, economic op-portunities, history, and culture. Due to the idiosyncrasies of script, pronun-ciation, and spelling of various languages, children can become fluent readersin Italian in 1 year, whereas in English or French they may need four or five(Abadzi 2003).

Making Education Research More like Health Research

Health researchers, relative to education researchers, tend to operatecloser to Western scientific ideals and therefore are better positioned toplay the science trump card in public policy. For some in the education

policy community, making education more scientific has involved demand-ing more rigorous research methods and in focusing on applied ratherthan basic research.

Rigorous Education Research

In 2000 a group of mainly U.S. and British researchers launched theCampbell Collaboration to prepare and maintain systematic reviews of re-search on the effects of public service interventions, including education. 4

This effort is modeled on the Cochrane Collaboration, which since 1993 hasbeen preparing and maintaining similar reviews of research on the effectsof health interventions.5 Systematic reviews carried out under the auspicesof the Campbell and Cochrane collaborations encourage researchers to de-

fine their methods for selecting studies to be included in the review and forevaluating the evidence provided in those studies in advance of commencinga review. De facto such reviews tend to privilege studies with experimental

4http://www.campbellcollaboration.org, accessed May 2, 2005.

5http://www.cochrane.org, accessed May 2, 2005.


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research designs.6 To date, however, few education researchers use thismethod, as evidenced by the lack of any reviews of education research on

the Campbell Collaborative database (Mosteller and Boruch 2002; Cook2003;Torgerson and Torgerson 2003; National Research Council 2004) and thescarcity of randomized studies on education and health that adequately con-trol for the effect of external variables on education and health improve-ments in the Rockefeller University librarys Evidence-Based Medicine da-tabase (Bloom 2005, 439).

In the United States the Bush administration has challenged the scientificvalidity of much of the nonexperimental research that had previously guidedfederal funding for education. At the behest of the administration, Congresspassed the Education Sciences Reform Act of 2002, which created a newInstitute of Education Science,7 designed to refocus U.S. government fundingon educational practices supported by rigorous evidence, that is, experi-

mental methods (Coalition for Evidence-Based Policy 2003, 5). The U.S.Department of Educations What Works Clearinghouse recently conductedits first systematic review of the effects of curriculum-based interventions forincreasing math achievement at the middle school level; out of 46 interven-tions the clearinghouse found only two interventions that demonstrated asignificant, positive effect on achievement and were also supported by studiesusing rigorous methods (What Works Clearinghouse 2004).

Beyond the United States and United Kingdom, in 2004 the Organizationfor Economic Cooperation and Development held the first of four workshopsto explore evidence-based policy research in education, the first focusingon the use of randomized controlled trials (RCTs).8 Economists at the Poverty Action Lab associated with the Massachusetts Institute of Technology (Ba-

nerjee et al. 2003) and at the Indian Institute of Management in Ahmedabadhave used small-scale randomized controlled trials to evaluate low-cost edu-cation interventions in India, Kenya, and Colombia.9

Why do education researchers so rarely employ experimental methods? First, as described above, in many cases, education researchers do not

have the precision instruments necessary to isolate and control thephenomena of interest.

Second, education interventions are typically bundled in packages that

6Experimental research designs require that all cases are randomly allocated to either the ex-

perimental group that receives the treatment being tested, or to a control group that receives notreatment or an ineffective placebo treatment and hence provides baseline information on spontaneousdevelopments against which the effects of the experimental treatment can be measured (Marshall 1994,91).

7http://www.ed.gov/about/offices/list/ies/index.html, accessed January 22, 2005.

8http://www.excelgov.org/usermedia/images/uploads/PDFs/OECD-Baron.pdf, accessed June 8,

2004.9 For more information on other research using RCTs to analyze education interventions in Co-

lombia, India, Kenya, and Egypt, see http://www.povertyactionlab.com/projects/. For more on ran-domized field trials in general, see National Research Council (2004).


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preclude studying the discreet impact of individual interventions (Weiss2002).

Third, research since the 1960s has demonstrated that although teach-ers, classrooms, and schools can play an important role in classroomachievement, families and communities tend to play a more importantone (Weiss 2002), and, therefore, the logical unit of analysis for edu-cation policy research tends to be communities that are, by definition,too complex to be strictly comparable.

Fourth, the typical research cycle, that is, time elapsed between whenan intervention (e.g., a new curriculum) is introduced and the desiredoutcome can be measured (e.g., end of year exam) permits many factors(e.g., a flood that closes school for a month, an influx of migrant chil-dren in the middle of the school year) to interfere with the study ofthe learning process.

Fifth, current interest in experimental methods in education researchprivileges applied rather than basic education research; thus, it is arguedthat before there can be more randomized trials, there must be morebasic education research and more discreet interventions.

Sixth, randomized field trials are expensive; since many interventionsin public schools are funded on a shoestring, few can afford to dolarge-scale baseline data collection and return years later to do follow-up studies.

Use-Oriented Fundamental Research

Of course, the relationship between basic and applied researchor be-tween experimental and other research methodsneed not be so linear or

compartmentalized. Stokes suggests that funders of policy research considersupporting what he called use-oriented fundamental research (Stokes1997). As an exemplary practitioner of this approach, Stokes proposes LouisPasteur, one of historys greatest microbiologists, because he was equallymotivated to contribute to fundamental understanding of microbiology(e.g., his germ theory of disease) and to find practical applications of thatunderstanding in his own time and place (e.g., sterilizing milk or keepingbeets from turning to alcohol).

In the almost 130 years since Pasteur established the germ theory ofdisease, many microbiologists and epidemiologists have followed his leadinto use-oriented fundamental research, employing experimental meth-

ods with careful observation and expanding fundamental science as theyfocused on identifying practical, situation-specific applications. Amongthese were manySchweitzer, Koch, Walter Reedwho moved their researchto the tropics in order to study diseases more prevalent in less industrializedcountries, including malaria, cholera, and yellow fever. Although some cog-nitive scientists, such as Piaget, also belong in the use-oriented fundamental


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research category, it seems few have specifically focused on education issuesmost prevalent in less industrialized countries.

Finally, there is the funding issue. These stellar microbiologists wereamong the founders of what came to be known as tropical medicine, whichwas supported by the expansion of empire, whether explicitly, as in the caseof Britain in Africa, or less directly, as in the case of the United States inPanama. During the 4 decades of the cold war, governments in the indus-trialized first world continued strategic funding of tropical disease researchat least in part to stay engaged in the affairs of the former colonies in theless industrialized world. In comparison with health, less cold war fundingwent into education research, and education never developed a subsectorequivalent to tropical medicine. In addition, health research in the lessindustrialized world benefited from progress in areas that were profitable tothe private sector in the industrialized world. Few, if any, issues in public

education in industrialized countries appear to have similar profit-makingpotential, and private support has not been forthcoming.

Development, Deliverables, and Delivery Systems

How do these patterns of research play out in the international devel-opment organizations that formulate global goals? I suggest that the legiti-macy that health researchers, in comparison with education researchers, gainfrom their closer proximity to Western scientific ideals enables health pro-fessionals to forge more stable communities of international experts, or ep-istemic communities, who are able to rationalize compromises between com-prehensive and more selective approachesand push for more outcome-oriented,

coherent health policy options, such as those articulated in the MillenniumDevelopment Goals (see table 1, above).The Millennium Development Goals are the latest in a series of decla-

rations since the end of World War II that attempt to establish specific targetsfor national socioeconomic development; the HFA (1978) and EFA (1990)declarations represent earlier attempts. These declarations portray health andeducation as equally universal, comprehensive, and lifelong entitlements tobe guaranteed by national governments. The comprehensive, long-term ap-proaches needed to implement these declarations, however, have thus farproved beyond the capacities of international development organizations orbeyond the resources of national governments in less industrialized countries.In part this is because the public infrastructure and social capital needed to

sustain comprehensive approaches are more likely to be the long-term out-comes of sustained development efforts rather than prerequisites for them.The international organizations involved in both HFA and EFA, therefore,soon retrenched around more limited, selective approaches: Child Survivaland Universal Primary Education (UPE), respectively. In these campaigns,health had several revolutionary low-cost deliverables to offer but had to


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TABLE 2Global Approaches to Expand Health and Education Provision

Global Approach Health Sector Education Sector

Comprehensive approach Health for All (1978) Education for All (1990)

Selective approach Child Survival campaign Universal Primary Education (UPE)

Deliverables for selectiveapproach

Growth monitoring,ORT, breast-feeding,immunizations

None

Delivery systems for selec-tive approach

Hospitals, schools, bare-foot doctors

Conventional primary schools,complementary and alternativeprimary schools, interactive radioinstruction

develop a delivery system, while education started with at least small nationalschool (delivery) systems but no new revolutionary low-cost magic bullets (see

table 2).In the health sector, the move toward a more selective approach was ledby the Executive Director of UNICEF, James P. Grant. At a 1981 public healthconference, staff reported that he was moved by the testimony of an inter-national public health expert, Jon Rohde, who argued that half of all thedeath and disease among the children of the developing world was simplyunnecessary. . . . The bridge had not been built between what science knowsand what people needed (Adamson 2001, 23). In December 1982, just 4years after the HFA conference, UNICEF launched the Child Survival andDevelopment Revolution as a targeted campaign to halve global child deathsby 2000. This Child Survival campaign focused on four stand-alone, magic-bullet interventions, abbreviated as GOBI: growth monitoring (to detect mal-

nutrition), oral rehydration therapy (to treat diarrheal diseases), breast-feed-ing (to strengthen infant immune systems and reduce the use of infantformula), and immunizations (for the most common childhood diseases).Each of these inexpensive, low-technology, high-impact interventions ad-dressed the cure, prevention, and/or relief of one or more widespread, life-threatening conditions for which dependable diagnostic procedures andoutcome measures had been established. Each can be thought of as a dis-creet deliverable.

Many international organizations and public health experts were nothappy with the shift from HFA to Child Survival (Cueto 2004). A formerUNICEF staff member recalls the reaction in the international health com-munity:

[Grant] wanted to do [child survival] by means of massive, focused effort to makethree or four low-cost techniques like immunization and ORT available to almostevery child in every developing country. . . . [Critics thought n]obody could doit. The money wasnt there. The roads and the transport systems werent there.


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The clinics, the vaccinators, the electricity supply, the fridges, the cold chains, thecommunications capacityeven the demand wasnt there. . . . It seemed to bethrowing away years of commitment to integrated development strategies, basic

services, and peoples participation. It was reducing the prized complexities ofdevelopment to the contents of a sachet and a syringe. It was top-down. It was atechnological fix. It was tunnel-vision. It was, as the World Health Organizationsaid, monofocal. (Adamson 2001)

Despite lacking many of the necessary components of a delivery system, how-ever, for a time in the early 1990s, universal childhood immunization wasachieved (Bryce et al. 2003). In addition, annual global deaths caused bycholera and watery diarrhea in children less than 4 years old dropped fromabout 5.5 million in 1972 to about 2 million in 2002 (Greenough 2004). Mosthealth workers agree that while it did not achieve HFA single-handed, oralrehydration solutions (ORS) unquestionably knocked off huge reservoirs ofneed.10 Nonetheless, tension remains in the health community between magicbullets and a more comprehensive, long-term, institution-building approach.

In education, the selective approach eased in more quietly and muchless dramatically. Just 2 years after the 1990 EFA conference, UNICEF andUNESCO adopted a selective approach to EFA, agreeing to focus on UniversalPrimary Education. The focus was further narrowed in the Millennium De-velopment Goals, to UPE completion by 2015. In contrast with Child Survival,UPE was interpreted not in terms of individual outcomes or deliverables butrather in terms of a highly legitimated delivery system: primary schooling(Ramirez and Boli 1987).

The selective approach to EFA has had less apparent success than theselective approach to HFA for a variety of reasons. A conventional primary

school operates most days of the year and takes 5 or 6 years to produce agraduate, whereas a typical child immunization campaign can be imple-mented in a few weeks every year. Immunization campaign workers sufferhardships to reach and find temporary lodging in remote villages for a fewdays; teachers must be persuaded to put down roots and stay for several years.Furthermore, with poor quality instruction, basic literacy and numeracy maynot be achieved even after 6 years; just prior to the EFA conference in 1990,Fuller and Heyneman (1989) had warned that massive expansion of enroll-ments in already weak primary schools would result in lower quality as facilitiesand teacher education could not keep up.11

The pressure created by UPE brought several preexisting alternative pri-mary education delivery systems to the fore, such as Escuelas Nuevas and

BRACs primary schools (Anderson 1992). The pressure, however, did notstimulate the development of many new deliverables thatwere clearly cheaper,better, and faster components of a conventional primary education. Partici-

10Thanks to Nancy Kendall for this phrase.

11Thanks to an anonymous reviewer for a reminder of this important piece in EFA history.


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pants at the 2000 end-of-decade EFA conference in Dakar, Senegal, couldreport little progress in many high-priority countries in sub-Saharan Africa

and South Asia (UNESCO 2000a, 2000b).A comparison of the current state of research and interventions under-lying HFA and EFA might reasonably conclude here. However, in 2004 aresearch organization that played a pivotal role in the development of onemagic bulletoral rehydration therapycelebrated its fortieth anniversaryand received the first Gates Award for Global Health in 2001. These twoevents brought together many of the early principals, prompted the com-piling of oral and written histories, and brought to light some aspects ofhealth research often missing from more conventional accounts of sci-entific advance.

ORT: Developing a Deliverable

The development of an effective, inexpensive, and easily delivered treat-ment for diarrheal diseases, which are the second leading cause of deathamong children under 5 years of age in less industrialized countries (Blacket al. 2003), is often cited as one of the factors that gave the Child Survivalcampaign planners a basis for the goal of halving their mortality rate by2000.12 The story below describes a fitful pattern of research over more than150 years, during which the discovery of a broad spectrum treatment fordiarrheal diseases was a by-product of the search for a different deliverable:a cholera vaccine. A particular institutionthe Cholera Research Laboratory(CRL) in Dhakaestablished in the 1960s in an area with regular choleraepidemics played a key role in this discovery.

Pre-1960

Cholera is a watery diarrheal disease that can cause severe dehydrationand death in less than 24 hours.13 Historically, cholera is endemic to Asia,occurring seasonally in Thailand, the Philippines,Bangladesh, andseveral othercountries. When cholera epidemics in the nineteenth century expanded intoEastern Europe, Britain, andtheUnitedStates, thesearchformodernpreventive,curative, and palliative treatments was launched (van Heyningen and Seal 1983).

In 1854 John Snow first associated cholera with contaminated drinkingwater and cut short a London epidemic with a house-to-house survey thatled to a single contaminated public pump. Less than 25 years later, the cholerabacteria was identified by Pacini and reconfirmed by Koch in Calcutta (now

Kolkata). In the last half of the nineteenth century, however, the germ theory

12Thanks to Richard A. Cash, William B. Greenough III and Quaneta Greenough, W. Henry Mosley

and Bunny Mosley, David R. Nalin, David Sachar, David Sack and Jean Sack, and Josephine Sack andR. Bradley Sack for special help with this section. As of 2003, the leading cause of death for childrenunder age 5 is neonatal complications.

13Medicine distinguishes between watery diarrhea and more solid dysentery.


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of disease brought improvements in hygiene, waste disposal, and water san-itation that reduced cholera in Europe and North America, thereby reducing

demand for cholera research based on the new theory (van Heyningen andSeal 1983).Scientific misunderstandings delayed by more than 100 years the devel-

opment of a cholera treatment capable of success in over 95 percent of cases.14

First, until the mid-twentieth century, most doctors assumed that diarrhealdiseases injured the small intestine and that oral intake of food or liquidsduring diarrhea could cause further injury. Therefore, starvation was part ofthe standard treatment for such diseases, including cholera, rendering sur-vivors both dehydrated and malnourished and therefore more susceptible toother potentially fatal diseases (Ruxin 1994). Second, the medical communitywas reluctant to believe anecdotal evidence that vomiting patients could drinkenough fluid (up to 20 liters per day) to mitigate choleras dehydrating effects

(Greenough 2003). A handful of studies published in the 1950s by pediatri-cians claimed oral solutions containing carob flour, bananas, and even carrotsoup had benefited cholera patients, but these did not explain their resultsin terms of known physiological mechanisms.15 As a result, until the 1960s,standard treatment for cholera consisted of starvation coupled with expensiveIV solutions administered in hospital settings under the close supervision ofhealth professionalstreatment that was essentially unavailable to the vastmajority of cholera-affected people, who lived far from modern hospitals andcould not afford the IV treatment.

The 1960s

After World War II, with ground and naval forces deployed throughout

the Pacific and conflict rising in Korea and Vietnam, the U.S. governmentfunded research on cholera vaccines and on treatments at several sites inAsia. Capt. Robert A. Phillips, then directing the U.S. Navy Medical ResearchUnit II (NAMRU II), first observed the hitherto unsuspected phenomenathat cholera patients could absorb oral saline solutions by tube if glucose wasadded to the solutions. In 1962, Phillipss group attempted an oral therapyfield trial in the Philippines based on his observation, but the solution wastoo concentrated, and the methodology was inadequate, resulting in thedeaths of six patients (Ruxin 1994).

In 1960 the South East Asian Treaty Organization (SEATO) founded theCholera Research Laboratory in Dacca, East Pakistan (now Dhaka, Bangla-desh). After establishing laboratories and a hospital in Dacca, CRL staff iden-tified a field site with large, seasonal cholera epidemics in the Matlab sub-district, several hours away from the city, and set up the largest continuously

14Some earlier, partly effective treatments could cure up to 70 percent of the cases (David Nalin,

personal communication, June 28, 2005).15

(Chatterjee 1953; Ruxin 1994; Sack 2003).


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operating population surveillance system in the world (Aziz and Mosley 1994,35). The cholera vaccine trials were expected to begin as basic laboratory

research and to proceed to animal trials, clinical trials in the Cholera Hospital,and field trials in Matlab. The deaths during the 1962 NAMRU II clinicaltrial translated into a very cautious approach to trials in Dacca (Ruxin 1994). A Technical Advisory Committee, consisting of senior scientists from theUnited States, United Kingdom, Australia, and the Pakistan Medical ResearchCouncil, regularly reviewed the CRLs scientific agenda. Research protocolswere evaluated in terms of international standards for scientific merit andethical consideration (Henry Mosley, personal communication, June 19,2005). Early and ongoing commitment to provide care to cholera patientswhen epidemics occurred, whether or not those patients were involved infield trials, engendered cooperation from the local communities in Matlab(Greenough 2004).

Cross-cultural communication, professional competition, short-term ver-sus life-long commitment to the research at hand: these and other nonscien-tific issues complicated and enriched the work at the CRL. Resident staff andscientists, both Bengali and expatriates (mainly from the United States butsome Australian) served as the core of the CRL. Many expatriates came viathe U.S. National Institutes of Health (NIH) and the U.S. Centers for DiseaseControl (CDC) and often continued to work on related research after theyreturned to the United States. Despite lack of reliable long-distance telephoneservice, facsimile machines, and e-mail, personal connections between staffat the CRL and these centers were close and helped to ensure better coor-dination than might otherwise be expected. Scientists at the Johns HopkinsInternational Center for Medical Research and Training (ICMRT), who wereworking at the Infectious Disease Hospital of the School of Tropical Medicinein Calcutta, were working on a parallel track with the CRL, and some par-ticipants suggest rivalry (or, in gentler terms, exchange) stimulated scientistsin both organizations to work quickly (McGrane 2003). This was the VietnamWar era, and fresh faces arrived on a regular basis in the form of youngAmerican doctors who chose the U.S. Public Health Service over the militarydraft (Ruxin 1994).

In order to better understand the context of cholera, newly arrived sci-entists were required to spend an extended internship in Matlab, and staffroutinely briefed the local health community (Ruxin 1994; Quotah 1999;Greenough 2003). Thus, personal engagement with the problem was raised,

to the extent that one expatriate scientist, having inadvertently contractedcholera while in Matlab, wrote it up as a case study. When one laboratoryscientist who played a major role in working out the details of the chemicalcomposition of ORS blandly concluded his formal report with one line con-cerning potential implications for cholera treatment, oral glucose therapycould be of value in the treatment of cholera and that the requirement for


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expensive and scarce intravenous fluids may be reduced thereby, local doc-tors came to different conclusions: One of the [tea] plantation doctors, Dr.

Mackay, responded ecstatically. . . . This is one of the most profound de-velopments in the treatment of . . . cholera diarrhea in this century. AndI remember being a little startled by that and saying to myself . . . gosh,maybe, hes right (Norbert Hirschorn, quoted in Ruxin 1994).

Although technical supervision of the CRL from NIH and CDC was close,ample funding for the CRL came from nonmedical sources with few stringsattached. In the early 1960s, at the height of the cold war, the U.S. govern-ments primary interest in funding the CRL was to keep Pakistan tied to the West. The proceeds from the sale of U.S. food aid paid most local costs;Pakistan provided a campus and a building. The U.S. government then pro-vided core foreign currency funding, and Australia (also a SEATO member)contributed scientists and equipment. One scientist recalls:

It was literally like an open checkbook. There was no limit to the projects thatcould be done locally. . . . The State Department . . . didnt care if we did researchor not. . . . If we had just done nothing but just take care of sick people that wouldhave been enough as far as the State Department was concerned. . . . [USAID]

wanted all kinds of reviewing and reporting . . . with the possibility that they mightclose [CRL] if it didnt fit their agenda. [I heard secondhand] the U.S. Ambassadortelling [the USAID director] outright that this laboratory is basically to serve apolitical function and it is not subject to any kind of review for merit! . . . I hardlyrecall really working out budgets. (Mosley 2003)

Microbiology provided cholera researchers with a ready arsenal of in-struments and measurement standards, and the cholera research itself pro-duced more. Inexpensive cholera cots originally developed by Ray Wattenof NAMRU II, working in Thailand during an epidemic in the 1950s, provideda simple way to measure each patients fluid loss. The CRL and ICMRT alsocontributed new instruments and technology, such as Monsurs medium,named after the Bengali scientist, K. A. Monsur, who designed a way toincrease the speed with which cholera colonies could be identified. Workingwith scientists in Copenhagen, David Sachar and colleagues developed aninstrument to measure the electrical charge of the small intestine and therebyhelped to establish that it did not shut down during cholera, confirmingPhillipss earlier observation. In addition, as equipment in the U.S. rapidlyimproved and was replaced, the CDC and NIH forwarded a steady stream ofstill quite up-to-date equipment to the CRL (Mosley 2003).

Researchers learned that the chemical composition of the IV solutionneeded to match the composition of the fluid patients were losing. They alsolearned that the amount of IV solution going into a patient needed to equalthe fluid lost; too much IV solution could cause congestive heart failure, toolittle and the body would not rehydrate. Within a short period in the 1960s,the fatality rate for patients who arrived at the hospital severely dehydrated


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dropped from 3040 percent to less than 1 percent (Ruxin 1994). The finalpiece in the ORT puzzle fell into place in 1968 at the Memorial Christian

Hospital in Malumghat, Chittagong, on the Burma border with Bangladesh(then East Pakistan). The evening after a failed field trial, a young publichealth service doctor, David Nalin, realized that one of the key protocolsregarding IV solutionthe volume of ORS going into the patient needed toexactly equal the volume of fluid being lostneeded to be extended to theoral solution (Nalin 2003).

Given his own experiences and the generally conservative field trial en-vironment in which the CRL operated, it was not surprising that when Nalinreturned to Dacca with his insight, Phillips, now the CRL director, was initiallyreluctant to let staff work on clinical and field trials to test this new practicaltreatment because such applied research would divert CRL scientists frombasic research that was the principal mandate of the CRL (Ruxin 1994).

However, with support from senior scientists at partner institutions in theUnited States and the deputy director of the Cholera Hospital, Nalin andcolleagues secured the necessary backing in late 1967 and spring 1968 forthe first successful clinical trial, based on a corrected study design. Despiteresistance, later in 1968, the young doctors were allowed to implement alarge-scale, closely monitored, and ultimately successful clinical field trial withan all-oral rehydration solution (ORS).

And in 1971, with an outbreak of cholera in the refugee camps in WestBengal during the Bangladesh War of Independence, ORT prepared byICMRT staff and administered by family members, with little medical supervision and with limited stores of IV fluids, brought the mortality rate forcholera down from more than 40 percent to less than 5 percent (Mahalanabiset al. 1973). Over time, through both clinical and field trials, ORT was es-tablished as effective for a wide range of watery diarrheal diseases and, mostimportant, in children as young as 1 month of age. Equally significant, re-searchers learned that children and adults treated early enough would in-stinctively drink the solution to the point of hydration, eliminating the needfor medical personnel to carefully measure stool output.

Since 1968

Despite publication of the ORS studies by CRL and ICMRT scientists ininternationally respected medical journals, such as the Lancet, ORT did notimmediately become the global treatment of choice for diarrheal diseases.

ORT was an inexpensive, over-the-counter treatment that could be admin-istered by family members, thereby eliminating the need for consultationswith medical professionals and for the purchase of relatively expensive drugs,such as antibiotics. Pharmaceutical companies saw no profit in producingORS, doctors were reluctant to demedicalize diarrhea, and patients couldnot believe something so simple would work. ORS, without support from the


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medical profession and the pharmaceutical companies, had no delivery sys-tem and was at risk of remaining on the shelf with other new health tech-

nologies that were relevant but unavailable to less industrialized countries.There was even some resistance within the CRL, as night nurses sometimestried to substitute IV for oral solution to avoid the tedious work of wakingup each exhausted patient every few minutes to encourage them to drinkmore ORS (Rahman 1994).

Oral rehydration therapy was indeed a magic-bullet treatment, but it wasin need of a gun. The stories of the organizations that helped promote ORTat the national and global levelBRAC, UNICEF, and WHOare told else-where (Chowdhury and Cash 1995). Global acceptance of ORT occurred, 10years after its discovery, at the 1978 Alma Ata conference, where UNICEFand WHO publicly endorsed ORT, and the science supporting the interven-tion was introduced to health experts from all parts of the world (Chowdhury

and Cash 1995). ORT is now recommended by international health orga-nizations, the American Academy of Pediatrics, and the CDC, and representsa significant technology transfer from the less industrialized world. Ironically,ORS is now widely available in inexpensive packets almost everywhere in theworld except in the country that largely funded its development, the UnitedStates (Santosham et al. 1997).

Health Research, Education Research, and Development

In many ways, research at the CRL and ICMRT was both basic and appliedand therefore has many of the hallmarks of Stokess (1997) use-oriented

fundamental research. Some reflections on the relevance of this case to ed-ucation research and, in some cases, to EFA are organized below under sevenheadings: focus, location, time, funding, research methods, scientific status,and technology transfer.

Focus

From the start, the CRL was focused on one small but important com-ponent of what would become HFA/GOBI: prevention or treatment of asingle infectious disease. Education researchers have not to date establisheda research program focused on one similarly discrete component in thecomplex package of interventions that constitute a basic education. Many

promising education innovations therefore remain on a par with carrotsoup, that is, packages that have not been parsed into discreet interventionsand outcome measures, and studied as such. As important as in the globalhealth community of the 1970s and 1980s, the education research communityhas reservations about the selective approach to education, particularly thoseinvolving magic bullets.


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Location

Many CRL scientists appear to share common ground with education

researchers in their emphasis on research conducted in situ and on the lackof a straight line from basic to applied research. Many of their accountsincluded a reference to an article by a CRL scientist, Taking Science Wherethe Diarrhea Is (Rohde and Northrup 1976). Their statements seem tosuggest that a research center for cholera set up in the practically cholera-free industrialized world would not have produced ORT.

Time

The transformation of rehydration therapy from an expensive treatmentdelivered in a sterile medical setting, where trained professionals carefullycalibrated fluid input and output every 4 hours, into ORS that could bedispensed by family members in refugee camps using whatever water was at

hand, was not accomplished in a year or two by visiting consultants. It drewon more than 100 years of instrumentation and involved 6 years of full-timework for dozens of researchers in several research centers, more than a decadeof surveys and field trials to move the preparation of ORS from laboratoriesto rural homes (Chowdhury and Cash 1995), and a further decade to bereproduced in other high-priority countries. No discreet component of EFAbenefits from such a sustained program of use-oriented fundamental re-search, product development, and/or marketing research in an internationalinstitution in any less industrialized country today.

Funding

Interest in funding research on cholera ebbed at the end of the nine-

teenth and the beginning of the twentieth centuries as the disease becameless of a threat to the industrialized world. Later in the twentieth century,the cold war gave cholera research a boost. Members of SEATOmainlyAustralia and the United Stateswere interested in a cholera vaccine to keeptheir troops healthy in whatever international conflicts might occur in thatregion. In addition, the United States wanted to spend money in Pakistan tohelp tie it to the West and East Pakistan just happened to be a good researchsite for cholera. This important windfall of funds for cholera research camewith few strings attached and was not the result of more rational planningand allocation of research funds by international organizations working inthe health sector, such as the chronically underfunded WHO.

Similarly, as the specter of mass illiteracy ebbed in the postindustrial worldat the end of the twentieth century, interest in and funding for research onthis and other education issues more relevant to the less industrialized worldstagnated. In the first decade of the twenty-first century, however, the Waron Terror began pumping more development assistance into education pro-jects in less industrialized Muslim countries than ever before. So far none of


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these funds is earmarked for research, and they come with far more accountingstrings attached than those associated with the cold war.

International Organizations

Like WHO, UNESCO has been underfunded such that its internationalinstitutes are mainly clearinghouses for innovations, not centers for de-signing and implementing long-term research programs. Most research oneducation in less industrialized countries is funded by other internationaldevelopment organizations and focuses on stand-alone design and evaluationrelated to projects. By definition, these studies address packages of inno-vations and usually lack baseline performance, cost, or control group data.The sort of funding these organizations offer and the limited time framein which they must produce results is not conducive to funding use-orientedfundamental research.

Research Methods

For ORT, randomized field trials came after 100 years of research, onlyafter promising interventions had been developed and tested in limited set-tings. Controlled trials were the primary research method used to prove theefficacy of various formulations of ORT in the 1960s and 1970s. However, atthe early and late stages of research, qualitative and nonexperimental studieswere critical in identifying possible directions for research and how treatmentsmight be adapted to increase acceptance and use (David Sack, personal com-munication, June 23, 2005).16

International Status

The CRL was created with close ties to the respected international healthresearch and teaching centers in the United States and later established working relationships with similar centers in other countries. These tiesbrought expertise, equipment, informal second opinions, rigorous institu-tional review, training and exchange opportunities for long-term Bengali staff,publication opportunities, and a broader audience for CRLs findings. At apublic health conference in 1981, it was a CRL alumnus, Jon Rohde, whoimpressed UNICEFs director with the potential of ORT and other simplepublic health interventions to increase child survival on a global scale.Though several outstanding institutes for educational research have beenoperating in less industrialized countries for decades, education researcherslack an international research institution with the sort of multinational sup-

port enjoyed by the CRL.

16 One CRL veteran suggests that the lack of nonexperimental research in the 1960s was perhapsbecause most of the critical exploratory research was completed before the CRL was established (DavidSachar, personal communication, June 20, 2005). Another stressed the importance of insights scientistsobtained in the field: Most of research is asking questions and you ask better questions in the field(Richard Cash, personal communication, June 25, 2005).


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Scientific Status

Articles on ORT began appearing in respected international journals,

such as the Lancet, within a year of its first successful clinical trial. However,this only occurred after international development professionals and publichealth experts struggled for 810 years to raise the profile of ORT in thescientific and international development communities. Eventually, the dis-covery of ORT led to the formation of diarrheal diseases as a new subdisciplinewithin tropical medicine and to many international scientific awards andrecognition for CRL scientists but, thus far, no Nobel Prize. It appears thatuse-oriented fundamental research, therefore, does not guarantee the ulti-mate recognition of scientific legitimacy, even in health.

Can Education Research Deliver?

Research played an important role in developing innovative deliverablesthat subsequently enabled international organizations to formulate ambitiousyet achievable goals for HFA and for the health MDGs. In the ORT case, use-oriented fundamental research focused on a discrete, highly valued outcomeled to a better, cheaper, and faster deliverable addressing that outcome, the formulation of more compelling, scientifically rationalized policy

options, and the promulgation of more meaningful and achievable global goals.

Of course, a case study of one health innovation does not prove that aprogram of use-oriented fundamental education research focused on a highly valued outcome will necessarily produce an important new deliverable for

education. Given the complexity of education, carrot soup interventions maybe the only viable approach to EFA. However, the details of the case highlighta long-term research strategy not yet explored with respect to educationfocused on discreet interventions that, though unable to address EFAs wholecloth, might yet be able to drain huge reservoirs of need.

What might a use-oriented, fundamental research program in support ofEFA look like in education? First, it would apply advances in education re-search to issues mainly of concern to countries with low levels of literacy.Identifying and parsing the relevant issues into smaller, discrete outcomesand developing reliable outcome measures would probably be the first stagein the research. For example, compulsory, age-segregated, and graded pri-mary schools are institutionalized globally as the preferred means of im-

parting basic education to children, not only in the MDGs but in the con-stitutions of most less industrialized countries (Ramirez and Ventresca 1991).For the foreseeable future, however, many communities in Africa and partsof South Asia will not be able to find sufficient professionally trained, child-centered primary school teachers to effectively operate this preferred schoolmodel. Most of these communities, however, already have adults and ado-


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lescents with 69 years of education who would be willing to help childrenachieve fluent reading and basic numeracy skills. But there are few carefully

tested, broadly applicable programs capable of training and supporting thoseadults, either in or outside a school setting. Moreover, designing and pilotingsuch programs is hampered by the lack of simple, reliable measures by whichprogress on early literacy in young children might be measured. Such mea-sures, in turn, would need to be informed by reliable, context-specific, earlychildhood development standards that, again, remain to be developed formany less industrialized countries. Thus reading is rocket science, and sciencemay be needed to render it childs play.

Second, such research would be most effectively carried out in one ormore countries with low levels of literacy by international and national re-searchers with long-term funding and strong ties to well-established researchcenters of international repute. This research would be multidisciplinary and

would include randomized, controlled trials as credible deliverables emergeand need to be tested and where such trials are part of a process to refinethe deliverables into their most basic form. However, as Bloom suggested inthis journal recently: Effective policy requires a strong evidence base, anda robust mix of studies has the potential to push our understanding forward(Bloom 2005, 451).

Can funding be found for this sort of use-oriented fundamental edu-cation research in less oriented countries? There are some encouragingsigns. Challenging the focus of the MDGs on primary school completionalone, a recent World Banksponsored literature review concluded thatstrong rates of return in primary education are attributable to the acqui-sition of basic knowledge, not to different amounts of completed schooling.Similarly, growth of national income seems more strongly linked to nationalliteracy levels than [to] educational attainment/average years of schooling(Boissiere 2004). An increase in emphasis on learning outcomes, ratherthan on a delivery system, such as primary education, could create demandon the part of organizations like the World Bank for more research onoutcomes and deliverables, both of which demand more research.

Given the narrow mandates of conventional international developmentorganizations with respect to research, however, education researchers shouldnot expect funding from those organizations sufficient to launch long-terminternational research programs. In terms of public funds, the cold war isover but the war on terror may yet produce some flexible funding, broadly

targeted funds for good-will building in Muslim countries, including cross-national research partnerships. In terms of private funds, the Rockefeller andFord foundations have largely withdrawn from large-scale research institutionbuilding efforts, but a new generation of foundations might conceivably de-velop a vision for education research focused on and in high-priority EFAcountries. For example, in April 2006, the Bill and Melinda GatesFoundation,


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presently focused on health, released a one-time request for proposals forimproving the quality of learning outcomes in the developing world.

At the same time, more compelling arguments for funding educationbased on learning outcomes are also emerging from cognitive science. Re-search on child development and adult learning is expanding our under-standing of childrens innate readiness for learning and, by extension, whatis lost when learning is delayed. A case is beginning to be built, tightly tiedto child development, for cognitive health, which might, conceivably, mirrorone of the most effective arguments for the Child Survival campaign.

Morality must march with capacity was UNICEFs Jim Grants rallyingcry for Child Survival. Usually attributed to Arnold Toynbee, a twentieth-century historian of Western civilization, the cry combines several cherishedcomponents of the present Western Enlightenmentdriven world culture.The notion that modern science dictates morality (and not the reverse), that

science has expanded the capacity of the world to address previously un-assailable problems, and that the mere existence of that science compelsactionmust marchall resonate deeply in a culture in which science isthe highest authority and positivism the conditioned response. Althoughindividual human rights remain an important rationale in world culture,science-based arguments appear to be more broadly compelling than rights-based approaches, as more potential funding entities accept the former thanthe latter.

To date several factors have contributed to a lack of investment in thesort of research necessary to fuel compelling, science-based arguments foreducation. These include an appropriate respect for the contextual nature of most education

innovations, well-justified fears that focused research would deteriorate into an ex-

pensive but ultimately fruitless search for magic bullets, concern with the irrelevance of most scientific research to pressing

grassroots education issues, and a proper skepticism with respect to the overwrought claims of science

in the context of the present world culture.However, without innovations, access to education, let alone quality educa-tion, is likely to proceed at its historically slow pace. And innovations notrefined to their essential elements and rigorously tested beyond one site,however excellent, remain, in effect, carrot soup. Finally, even tested inno-vations must attract the understanding and commitment of practitioners and

policy crafters, and gain the consensus of education experts in internationalorganizations before they can yield more compelling policy options andbettergoals.17

17 The consensus-building phase of the ORT story contains many useful insights for educationpolicy analysts and makers. Space does not permit that analysis here.


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