How poverty and racism 'weather' the body, accelerating aging and disease

Transcript

DAVE DAVIES, HOST:

This is FRESH AIR. I'm Dave Davies, in for Terry Gross. In this world of information overload, where you can find endless opinions every day, truly original ideas are rare. But my guest, public health professor Arline Geronimus, came up with one decades ago that has stood the test of time and a lot of research. She posited an explanation for why Black, brown, working class and poor people had poorer health and shorter life expectancies, one that differed from popular explanations about genetics and life choices regarding diet, exercise and substance use.

Geronimus suggested that the stress of struggling with poverty and discrimination did damage to people's bodies at the cellular level, stress which built up over time and led to chronic health problems. It would explain, to cite one example, why Black women who give birth in their 20s have more complications than those who become mothers in their teens. The older women had endured the stress of their difficult living conditions longer and thus had suffered more damage to their health. Geronimus called this corrosive process weathering, and the idea drew eye rolls and criticism when she first advanced it. But research by Geronimus and others have generated a wealth of supporting data over the years.

Geronimus explains the process and its impact and explores what can be done about it in a new book titled "Weathering: The Extraordinary Stress Of Ordinary Life In An Unjust Society." Arline Geronimus is a professor at the School of Public Health and research professor at the Institute for Social Research at the University of Michigan. She's also an elected member of the Institute of Medicine of the National Academies of Science. Arline Geronimus, welcome to FRESH AIR.

ARLINE GERONIMUS: Thank you. I'm glad to be here.

DAVIES: You know, in the book, you cite some examples of people whose early death dramatically illustrates the effects of weathering. Do you want to take one of these folks and just explain kind of in clear, you know, terms how the life they led undermined their health?

GERONIMUS: So Jason Hargrove was a bus driver in Detroit, about 50 years old, and he was an essential worker. So during the COVID pandemic, starting early, he had to drive the other essential workers around Detroit to their place of employment on buses that were loaded like sardines. And he came to the public's attention when one of his passengers who wasn't wearing a mask coughed on him. And he had to kind of - because he doesn't want to be - he wants to be professional and not seen as an angry Black man, he kept a lid on his fear and anger that she had done that until after she got off the bus. But then he made a recording onto his Facebook page where he vented about all this, and you could see that he was feeling very stressed about it all and that also he was going to great pains to also make clear on the video that he was not an angry Black man or a lazy Black man, that he went to work every day to keep the city running, even in a pandemic, that he had a wife and kids.

And you think about it, and you realize, if someone coughed on me, if you're a white person, say, you probably wouldn't have to explain why you're upset about that in the heat of a COVID pandemic. But he first had to kind of present a social identity that wouldn't be threatening. And so maybe you say, well, that's kind of a pain, but what's the big deal? Well, what's the big deal is that that along with all the other stressors that we recognize in the life of people who are poor or working class or of color itself activates a human physiological stress process that when it's activated chronically, as it more often is in people in oppressed or exploited populations, literally wears down your heart, your arteries, your neuroendocrine - all your systems, all your body systems so that in effect, you become chronologically old at a young age. And in his case, he actually did come down with COVID a few days later, and he died about a week later.

DAVIES: You know, the research that you decide in here, some of it's stuff about life expectancy by race and age, and we'll get to that. But let's talk just a little bit about what happens when these dangerous situations arise. How does it affect the body, and how does that translate into the modern experience?

GERONIMUS: So human bodies have evolved. And the reason we haven't gone extinct yet is because when we're faced with an acute, threatening, especially life-threatening challenge, our body automatically activates this release of hormones. And what those hormones do as they flood your body is they increase your heart rate, they increase your breathing rate, they propel oxygenated blood to your large muscles quickly. So that sort of increases your capacity to fight or flight. They send - they galvanize fats and sugars from your storage areas of your body into the bloodstream to provide energy towards that ability to fight or flee. And meanwhile, they also - many people don't take this part into account - they also don't send a lot of nutrients or oxygenated blood to parts of your body organs or if you're pregnant, your fetus, that aren't going to help you fight or flee.

So that process, when you're fighting or running from, you know, the cheetah is a wonderful adaptive process that is designed to last about three minutes and that after that three minutes, you either have escaped or you have been - you're dead.

DAVIES: (Laughter).

GERONIMUS: It's over, right. It's over. So either way, these systems, which are life-saving, are meant to be short. And then after the three minutes, if you're still alive, your breathing rate goes back to normal. Your sugar and fat is brought back into storage sites. Your heart comes to a normal rhythm.

And so it's a wondrous fact that our body does this and it's really, you know, very protective in these life-threatening situations. The problem in modern world is certainly these happen if you're in a life-threatening situation, and people recognize that when they talk about trauma. But a lot of it is simply to everyday life - coming home after night shift work and having to stay wide awake and vigilant so you don't forget to get off your bus for the next bus to go home, trying to get your kids up for school at 5 in the morning so you can also get to work, and being those children and having to sit in your school for an hour or two with just one or two other kids while - you know, even before the security guards have come in, the schools that have security guards, before you can even start your day. These - this means that the stress hormones are chronically flooding your body. The fats and sugars that catapulted into your bloodstream for energy are constantly flooding your body. It means your heart rate is up.

You know, like any other overexercised muscle, you'll start to get an enlarged heart. You'll start to get hypertension from pushing so much blood through certain arteries and veins to get your heart rate going and your breathing going. If you were pregnant, you might lose your baby because that's not - it's actually probably more adaptive if you're in fight or flight to not be carrying a baby. But even if you don't lose the baby, you'll shunt nutrients away from it because they can't be spent on the growing baby. And so your baby may be born low birth weight or growth retarded because it hasn't been well nourished in the womb.

DAVIES: So these effects of constant stress on people who encounter these conditions, it - there are impacts that you describe. And there's research that shows this actually damages bodies at the cellular level. And I think this is a little too technical for us to get into in detail. People can find it in the book, but things like over time cells have trouble dividing because there are changes that can be physically seen, damage that that occurs from the constant release of these stress hormones. Is there research that shows this damage is more prevalent among these marginalized populations than others?

GERONIMUS: Yes, there is some such research, including some work I've done, but it doesn't always go the way conventional wisdom would think. It's not that every Black person has more damage than every white person. In fact, if you look at those in poverty, poor whites suffer the most damage of any group, as we've shown in some of our work. And so how much damage you have is really about - it's not just a linear or - if you're Black, you're worse off and you're white, you're better off. It's how it's really about how much stress versus social support you get in your everyday life, and how many stressors and whether they're, you know, they're objective ones like pollution. Diesel pollution, for example, is very physiologically stressful as well as leading to asthma.

So it's sort of a contextually fluctuating situation, and it happens in degrees. But because African Americans and low-income Americans are more likely to suffer more of these stressors, they are more likely to be weathered, weathered severely and weathered at younger ages.

DAVIES: But the physiological damage has been observed in this. There are studies that show that. Now, the other thing I wanted to just ask here is that white, affluent Americans - many of them would say, gosh, we lead stressful lives too. Our kids are, like, you know, going crazy taking advanced courses to try and get in good schools. And then they get out, and then they get these high-powered jobs where they're working around the clock and trying to impress the bosses and manage a family. Is their stress different? Do you not see this kind of cellular damage?

GERONIMUS: In extreme cases, you can see that cellular damage. For instance, one study showed that among white, affluent women, those who had to raise an autistic child, and previously healthy women, their cells were more damaged than women like them or mothers like them who weren't raising autistic children. So this is a human process that will happen to any of us under the right conditions, or I really should say the wrong conditions.

But for the most part, the people you're talking about who are sort of crazy busy and under the kinds of stressors you're mentioning will not suffer a lot of damage because they also can have paid time off. They can take vacations. They can hire people to do their housework or even order their food be delivered. It's not a relentless day in, day out. They still have many choices. They still have time to relax. They're not dealing with the stereotypical racism aspect that also can activate this process.

So the problem is stress is this very diffuse term. And we think of it as something you can just meditate your way out of or take a vacation or a break. Many people in our country can't even take a break during working hours.

DAVIES: OK. We need to take a break here. Let me reintroduce you. We are speaking with Arline Geronimus. She's a professor of public health at the University of Michigan. Her new book is "Weathering: The Extraordinary Stress Of Ordinary Life In An Unjust Society." We'll continue our conversation in just a moment. This is FRESH AIR.

(SOUNDBITE OF SOLANGE SONG, "WEARY")

DAVIES: This is FRESH AIR. And our guest is Arline Geronimus, a professor of public health at the University of Michigan. She's known for offering a theory to explain the poorer health and life expectancy of Black, brown, working-class and poor people, the idea being that they suffer repeated and enduring stress from poverty and discrimination which undermines their health. Her book is called "Weathering: The Extraordinary Stress Of Ordinary Life In An Unjust Society."

You know, one of the explanations that has been given often for the poor health of people in African American communities is the presence of so many teenage births. And this was a huge priority, to try and - you know, the thought was that it's bad for the kids. It's bad for moms. And so there was a huge public information campaign to encourage, you know, not having kids until later and to provide, you know, birth control and all of that to make that happen. And in fact, what you note is that over the past three decades, teen - rates of teen pregnancy have fallen a lot and particularly sharply among African Americans.

And so we should have expected that maternal mortality rates, for example, that is the rates - moms dying from childbirth, which were alarmingly high, should have dropped also. But what happened?

GERONIMUS: They went up. And that is completely consistent with weathering. The older you have your children, if you're subjected to weathering, especially this most severe weathering, the more likely both you may die or your child may die or your child will be born very low birth weight, preterm or low birth weight or growth retarded and may even have lifelong - if they survive may even have lifelong disabilities because of that. And so we had a very naive idea, which I think was based on well-meaning people who were themselves, maybe, professionals and knew all the opportunities their well-off children might miss if they had children young, and also had reason to believe the health part really didn't matter, that you're in your prime of life, you know, through your reproductive ages. And, you know, you might run into some problems with fertility if you wait too long. But it's not that your actual health will be affected in ways that can harm you or your baby. But that's a kind of erasure of the true experiences of African Americans, especially those in poverty, who are already weathering by their early 20s. They're probably weathering much younger but are actually showing the manifestations, the health manifestations, by their early 20s.

And so what has actually happened - and we've done research where we've tried to simulate, what did the actual move to older ages at childbearing, how did it affect maternal mortality? And how did it affect infant outcomes? And we found that actually, both for white and Black people, but much more severely for Black, that shift that we worked so hard to achieve has actually been a big part of why we're seeing not just maternal mortality rates go up, but poor - you know, babies born too early or too small has also increased among white women as well as Black, though, much more for Black. So we have, in effect, one of the problems preventing teen childbearing was intended to solve - was these high rates of infant death and low birth weight and maternal mortality. And we are the only country that has seen these increases. Other Western countries have seen decreases over the same time period in maternal mortality.

DAVIES: Right. So there are a lot of factors that anyone should consider about when to start a family. And you're not advocating that people incentivize teenage motherhood, right? But tell us a little bit about this and how - kind of reactions you got.

GERONIMUS: I do want to be clear that I'm not saying we should have policies to encourage teen motherhood. And in fact, the entire argument is far more nuanced than that. And it's really an argument for reproductive freedom or reproductive justice, where people know better about their lived circumstances and their life expectancies and who they can rely on to help them care for kids. I just want to be clear. The problem here is what society does that leads to weathering. And if we're thinking about policy here, we want to think about how to make it less risky to have your kid at 25 than it is now if you're in one of these very weathered populations. It's not that we want to just tell people in these populations, you should all have kids as teens.

DAVIES: Right. It wasn't the way it was always perceived at times. But the point is, we need to change the conditions under which people live so that this isn't happening, right?

GERONIMUS: Right. Exactly.

DAVIES: All right. Your policy prescriptions - you focus a lot on maternal care. Are there things changing? Are there examples of how improvements have been made or planned?

GERONIMUS: Well, maternal mortality still keeps going up, so nobody's made the biggest improvements (laughter), or the really fundamental improvements. But I think more and more people are understanding that systematic racism in the medical care system is part of the problem, that there are ways around it. Whether those ways are having birth attendants who are doulas or midwives rather than physicians, having your birth at home, ways where you will be less stressed during and feel safer during the birth can make a difference. But at this point, we don't have enough midwives or doulas or maternity care providers at all. We have about one maternity care provider per 15,000 births. And that's not spread evenly over the country.

In rural areas, there are ones where there's not a single maternity care provider. So we also have to do things that get more people trained, and trained not just as OB-GYNs but as midwives and doulas. So there's a lot more to do. And we know it's urgent. The World Health Organization calls our levels of maternal mortality a human rights violation. We should not have these levels. It's totally preventable. We're not going to see those maternal death rates go down very fast. And as I said, they've been going up every year. And certainly, COVID played into that, too. But even before COVID, the rates were just going up.

DAVIES: Let's take another break here. Let me reintroduce you. We are speaking with Arline Geronimus. She's a professor of public health at the University of Michigan. Her new book is "Weathering: The Extraordinary Stress Of Ordinary Life In An Unjust Society." She'll be back to talk more after a short break. I'm Dave Davies, and this is FRESH AIR.

(SOUNDBITE OF DARRELL GRANT'S "FILS DU SOLEIL (FOR TONY WILLIAMS)")

DAVIES: This is FRESH AIR. I'm Dave Davies, in for Terry Gross. We're speaking with Arline Geronimus, a professor of public health at the University of Michigan. She's known for offering a theory to explain the poorer health and life expectancy of Black, brown, working-class and poor people. The idea, borne out in many research studies, is that people in marginalized communities suffer ongoing stress from poverty and discrimination, which damages their body at the cellular level, leading over time to serious health problems. Her new book is "Weathering: The Extraordinary Stress Of Ordinary Life In An Unjust Society."

You write about a raid in 2008 on a meat processing plant in Postville, Iowa. This is a really dramatic immigration raid that involved a Black Hawk helicopter and the arrest of 400, nearly 400, mostly Hispanic people. You and some colleagues did an interesting study on the possible impact on childbirth in the months following this raid. Tell us what you found.

GERONIMUS: Yes, this was a horrible raid. As you said, it was militarized. It was completely unanticipated. And these almost 400 workers were all arrested. They didn't have time if they had papers to show they were documented. They were shackled together. They were sent to a cattle congress. The women were given ankle bracelets so they could go home if they had kids to take care of. But you could see how this would have affected all the people literally in the raid or maybe their family members. And certainly among those groups of people, the women who were pregnant during the raid - their chance of having low birth weight and preterm babies went up compared to where - this was in Iowa - the Iowa Latinx population rate of birth outcomes had been before and during the time where white Iowans' rates continued to go down.

But what was almost more surprising or is more surprising to most people is to learn this happened - this increased rate over the nine months or year right after the raid occurred to Latina women throughout Iowa, whether or not they were anywhere near the raid, whether or not they were documented or undocumented, whether they were American citizens or green card holders. It made them very vigilant and therefore experiencing chronic stress arousal. It made them afraid to go out into public space. It made them very anxious about relatives they had or even close family members who might get caught in the next raid. It made them not want to go in public places or spend much money because they wanted to keep their resources in case they had to flee. So they were kind of under a long-term, you know, fight-or-flight physiological situation.

And it's well understood that that kind of stress can lead to low birth weight or preterm births. People likened it to being in an earthquake. People likened it to famine. People - you know, they wouldn't let their children go to school. They were frightened for them. And then on the other side, there may have been employers who were less likely to employ you if you were Latinx because of their own prejudices or fears of being raided themselves.

DAVIES: Right. You also note that there have been other studies which shows that if a particular group have been affected by a widely publicized event which increased suspicion of that group - and you've seen similar impacts. I wanted to ask you about a study - studies that have been done of Mexican immigrants to the United States and how their health changed the longer they were in the United States. This was really interesting. What does the data tell us?

GERONIMUS: It's been known for a while that among Mexican immigrants, they're - actually tend to be healthier when they first come to America. This is not a surprise. There's even a term for this in demography where you realize that the people who have sort of the get up and go and the physical ability to move and go through the things they go through to be able to immigrate to our country are on average younger and more healthy than their peers in Mexico. So people have noticed for decades that new immigrants are generally healthier. But then as time has gone on, people have looked at, well, are they still healthier later?

And it's been observed now for probably 20 years that the longer you're here as an immigrant, you become less healthy. But people just chalked that up to, well, you become assimilated to bad American habits. You're eating at McDonald's. You're not exercising - you know, all our go-to things whenever we're thinking about, well, what causes a population to have ill health? What our study did was question that from a weathering perspective. We thought that possibly there were other factors at play, either instead or in addition to those kind of factors.

And so we set up a study where we looked at immigrants to the US from Mexico who had been here in the U.S. different amounts of time. But we looked at people of the same age, so it wasn't that one group was way older and one group was younger. But we concentrated on middle age because that's where some of the worst weathering happens. And - or manifest. And what we found was a few things - that the longer the immigrants had been in the United States, the worst health they had, the most stress-related diseases they had. And we actually controlled for these kind of behaviors. How much fat was in their diet? How much did they exercise? Their socioeconomic status - as a group, the people who are here longer are more educated and may have higher incomes than groups who are here shorter.

And without going through all the tales, we found that it pretty much ruled out what everyone had taken as just common sense that it was bad behavior that caused this and that, in fact, despite good behavior and despite higher socioeconomic status, the longer - for instance, 40-year-olds who had been in the U.S. for 20 years were much more likely to have stress-related diseases and weathered bodies than those who had been here 10 years or five years.

DAVIES: Right. Well, and it's interesting that your study found that health effects seem worse on upwardly mobile Mexican Americans. People who got better-paying jobs probably brought them into neighborhoods and workplaces where they had a lot more contact with Anglos, who - you know, as opposed to their own community. It seemed that they suffered, in some cases, more weathering health effects. What would be the practical experience here? What's the experience that might explain that?

GERONIMUS: The experience that might explain that is you're kind of - you're a fish out of water. If you've been raised in an immigrant family from Mexico and then you're moving into predominantly white American, affluent and well-educated communities in institutions, whether they be colleges or even high school sometimes or your professional place of work, where you don't share the same assumptions or background, where the people you're working with don't appreciate all you've been through, where you're having to always be on your guard and manage how you portray yourself or present yourself to try and not fulfill stereotypes that you think people you're working with or going to school with might have about you, just like Jason Hargrove (ph) did on his video - and that means you're at a certain level of vigilance and looking for cues everywhere of whether you belong, whether you're welcome, whether you're going to be subject to what many people call microaggressions, although I'm not so sure they're so micro.

And so that - those experiences themselves can cause weathering. Meanwhile, the immigrants who stayed in their ethnic enclave with other people in communities who are also immigrants, who speak Spanish most of the time or who can go to grocery stores where they can get the ingredients they need to replicate all the foods, you know, they think of when they think of home, that are comforting - you know, you've gone toward something becoming socially mobile, but you're also going away from something that was very meaningful and a source of support and a source of validation.

DAVIES: You know, just to be clear, I mean, you're not arguing against economic or social mobility. I mean, this is really about the way we treat each other in this society, right?

GERONIMUS: Yes. But from a purely health perspective, which is also an indicator of a lot of things about well-being and opportunity in the context that we live in of a society that is racist, is oppressive, is class-conscious, that it's not all good. And we won't solve health inequalities between Blacks and whites or Latinx and whites or other groups simply by getting people more education or higher incomes, that they come with this chronic stress arousal can happen in - more likely in those kind of unsupportive environments than they will in the more supportive environments if you stick with your own group. But it is not - weathering is not against social mobility. It's not for segregation. It's for nonerasure. It's for us seeing and recognizing what is really happening and what it does to you biologically and realizing if we want to eliminate health disparities or promote health equity, we have to attend to what's happening in these different settings.

DAVIES: We need to take another break here. Let me reintroduce you. We are speaking with Arline Geronimus. She is a professor of public health at the University of Michigan. Her new book is "Weathering: The Extraordinary Stress Of Ordinary Life In An Unjust Society." We'll be back in just a moment. This is FRESH AIR.

(SOUNDBITE OF CHARLIE HADEN'S "EL CIEGO (THE BLIND)")

DAVIES: This is FRESH AIR. And we're speaking with Arline Geronimus. She's a professor of public health at the University of Michigan. She's known for offering a theory to explain the poorer health and life expectancy of Black, brown, working-class and poor people, the idea being that they suffer ongoing stress from dealing with poverty and discrimination, which undermines their health over the long run. The book is called "Weathering: The Extraordinary Stress Of Ordinary Life In An Unjust Society."

How did you come up with the term weathering?

GERONIMUS: I came up with the term weathering because I was first inspired to think about this idea when I was in college, actually, and as an 18- and 19-year-old myself among very elite college classmates and one of the first women to go to the school I went to, which was Princeton, one of a minority of Jews. Princeton had had, you know, Jewish quotas up until just about a few years before I went to Princeton. I actually experienced a little of - again, on a much lighter level. I don't want to say it's like living in a high-poverty urban area that's been totally disinvested in. But I got, again, a sense of what it's like to be somewhere where you're not completely wanted. I was there at a time when actual alumni were angry that women were there. And there were active attempts and even organizations put together to try to get the women out.

So at that same time, I also worked in a clinic which also had a school for pregnant teenagers. So they were my very age. And I started seeing all kinds of evidence of how much worse their health was than mine or than all my privileged Princeton classmates of the same age. And I saw this act of effortful coping that I now realize itself is a sign of weathering. And so I wanted to say that while weathering means your body gets eroded by these corrosive forces, I wanted to also say, but you don't kind of lie down and become fatalistic about it. They work to figure out how to survive and maybe overcome in a system that's rigged against them. And they do what it takes, whether it's three jobs or whether it's overcrowded housing or saving all your money to feed your kids and to get them more advantages. They do what it takes every day. And they go into workplaces that are not only toxic, but where they have to worry about how they're viewed or seen, which, as we know now, is weathering itself.

So I liked that weathering encapsulated both names. Weathering is also withstanding a storm, as well as being beaten down by it. But in the end, when you do the weathering that's withstanding the storm, it's not cost-free. The work you've done to survive is obviously shelter in many ways for you. And it kept you surviving. But it's also storm itself.

DAVIES: You know, when I read this book, I find the case very convincing that this stress from poverty and discrimination undermines health over the long term. But, you know, I'm not immersed in, you know, public health research. Is this a concept now that is fairly widely accepted in your field?

GERONIMUS: Yes, I think it is now. And in fact, my election to the National Academy of Medicine was based on my weathering research and my weathering concept. So I think it's very widely accepted in the public health field.

DAVIES: Do you feel weathered for having spent decades of criticism and abuse?

GERONIMUS: Yes. But I try to make that into something positive and think about that I did what's called a participant observation study in weathering. And I think it made me understand better, and not just purely on an intellectual level, but down to my own cells what the experience of weathering is like.

DAVIES: Explain what you mean. A participant observation study?

GERONIMUS: That's a kind of study that is largely done by ethnographers or anthropologists, and where they sort of - in order to study a community, they live there. They become embedded in it. They may get a job there. They sort of start to participate in the everyday life of that community. So they're both observing the actual members of that community, but they're also participating. And that both gives them a greater sense of what's really going on, it also leads to greater trust on the part of the actual community members towards them so that they open up more. So it's a very important way to get a qualitative understanding of what makes a community tick and what are the trade-offs they're facing.

DAVIES: Right. And so have you seen some of the health effects that weathering would produce? I mean, there are some of these cellular things, these things called telomeres, which I'm - if I'm describing this right, it's these caps on the ends of chromosomes which tend to be eroded with this. Have you suffered some of these effects? Do you know?

GERONIMUS: I don't know if I've suffered the effects of telomere shortening because I've never measured my own telomeres. But I've certainly suffered some of the chronic disease effects. I've suffered, and at earlier ages than I might have otherwise. I've seen - you know, now we have all these devices that, like, monitor your sleep while you're sleeping and what your heart rate is. And I knew this intellectually that when you're chronically aroused, your heart stays elevated even when you're sleeping. But I learned that mine does that on days that I'm really stressed.

And even though I knew it cognitively, actually seeing it - so I could have gotten my eight hours of sleep, you know, the things we think are what matter. And then I'll see that, you know, what my ring tells me is my recovery index is alarming because I didn't recover because my heart stayed elevated all day. So that gave me an extra layer of understanding, and also why it's not as simple as just take a deep breath. You know, when you're fast asleep, you don't know to take a deep breath or, you know, think good thoughts or just get those eight hours. It's the quality of that sleep in terms of your body having the chance to recover from your day's stressors that is as or more important than just the number of hours you get.

DAVIES: Well, Arline Geronimus, thank you so much for speaking with us.

GERONIMUS: Oh, you're very welcome.

DAVIES: Arline Geronimus is a professor of public health at the University of Michigan. Her new book is "Weathering: The Extraordinary Stress Of Ordinary Life In An Unjust Society." Coming up, Maureen Corrigan reviews "Biography Of X," the latest novel from Catherine Lacey. This is FRESH AIR.

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