Joseph Mocanu is Co-founder and Managing Director of Verge HealthTech Fund, which invests globally in seed-stage healthcare technology startups relevant to emerging Asia that focus on disease prevention and management, digital therapies, and health system efficiency.
Chad talks with Joseph about the healthcare landscape in different places of the world, funding criteria for companies, and how the pandemic has changed prospects for the fund and the market in general.
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CHAD: This is the Giant Robots Smashing Into Other Giant Robots Podcast, where we explore the design, development, and business of great products. I'm your host, Chad Pytel, and with me today is Joseph Mocanu, Co-founder and Managing Director of Verge HealthTech Fund, which invests globally in seed-stage healthcare technology startups relevant to emerging Asia that focus on disease prevention and management, digital therapies, and health system efficiency. Joseph, thank you for joining me.
JOSEPH: Thanks so much, Chad, for having me.
CHAD: So you have been focused on emerging Asia healthtech for a little while both at Verge HealthTech Fund, and prior to that, how did you get involved in this space?
JOSEPH: I wish I had a really cool, deliberate story that made it sound like it was a smooth transition from point A to point B. But I simply have to owe it to an opportunity to transfer to the region through my old employer which is Oliver Wyman, a global management consultancy. So I joined this consultancy in 2011 after doing my Ph.D. and MBA really to understand how to be a better investor, which, again, sounds a little bit backwards.
But I had worked at a hedge fund in China just after my MBA, and I learned that they use management consulting techniques to add value to their portfolio companies. And I thought that's a great skill to learn. And it'd be great to even learn it in English and doing it in healthcare 100% of the time.
So I had joined Oliver Wyman in 2011 in Toronto office back home, where I spent a lot of my life. And they asked me one day if I wanted to transfer to the Singapore office to help start healthcare over there. And when I went to Singapore, of course, it's this futuristic city, really well planned. It's got a lot of fine names and a reputation globally of being a modern cosmopolitan place to do business. Some people refer to it as Asia-lite. But the surrounding areas have a lot of issues when it comes to their health systems. I knew this from an academic perspective, having studied about the region before moving to Singapore but seeing it firsthand was a completely different experience.
At the time, I was working for primarily pharmaceutical clients, helping them with market access and other commercially relevant activities. And they were faced with a fundamental challenge of trying to sell their product, which was usually placed in the premium category to markets that had difficulty affording this. And not only did it have difficulty affording this, it had difficulty in delivering it as well as in using the product appropriately, making sure it gets to the patients when it's needed at the right time, at the right dose. And so they were looking for partners. They were looking for partners on the ground that could assist with this delivery education, the technology, and the financing around it as well.
Now, there was a real shortage of said partners on the ground. At the same time, there were also insurance companies that wanted to expand their business. They also realized that the policies tended to be a bit simple, and they tended to resemble one another across competitors. And also, to manage increasing claims, they had a tendency to increase the premium that they charged. This was not possible to do indefinitely. And at some point, they needed to actually manage the medical conditions, which you're probably seeing more and more of in the U.S. and in Western markets, less so of in this part of the world.
And then lastly, you had conglomerates and investors who said, "Hey, we hear healthcare is going to be a pretty hot field. How do we get started? How do we invest?" And all of this basically set me on a mission of target hunting. And during the course of this, well, I met a lot of interesting companies, a lot of them really, really early in their journey and really too small for any of my clients to find a meaningful way to engage with them. And unfortunately, they couldn't get to the point where they are relevant and large enough to engage with without a lot of capital.
This is where, you know, you'd have a nice investment ecosystem coming in to fill in the gaps. This, unfortunately, did not really exist at the time. And I had the hubris of thinking that I could do something about it by being an angel investor and starting to support these founders directly, which, thankfully, seemed to work to a certain degree. It worked to the point where one day, I woke up, and I realized I had 13 angel investments, 9 of which were in healthcare technology, and not a lot of money left in my bank account to do other things with.
CHAD: Uh-oh. [laughs]
JOSEPH: Yeah. And at the same time, I also realized that the work that those founders are doing is a whole lot more impactful than me sitting up until 3:00 o'clock in the morning every night writing PowerPoint slides or begging analysts to write the PowerPoint slides that would more or less sit and collect dust on my clients' shelves for various reasons. So I came to the realization that I need to do this full time.
I didn't have, you know, $10 million in my pocket as reference to spending all my money on angel investments. So I realized that I have to use other people's money, and the way to do that is to join a fund. Now, the problem with that idea is that there weren't any funds that were doing this, like really, really early investing in healthtech companies in the region that was really geared to helping solve some of these really big access challenges. So then I realized I had to start a VC fund that did this and only this. So that's really kind of a long-winded introduction as to how I got started with this.
CHAD: Yeah, I want to come back to the process of actually starting a VC fund in a bit. But I'm curious, were the companies that you were doing angel investment in and now doing seed-stage investment in do they tend to be local companies, or do they tend to be international companies that are planning to solve a problem locally?
JOSEPH: It's funny you ask that. At the beginning, they were local. Well, actually, if I really were to take a step back, the very first angel investment I made was for a mentee, and she was based in Toronto. But I'd say that the first true angel investment I made, you know, it was in Singapore, first and foremost, because I was there. And then I started branching out. I started making investments in the Philippines. I started looking at companies in Taiwan and other parts.
And actually, that opened my eyes to the fact that there may be other companies around the world that are trying to solve a problem that may not necessarily be in my own backyard. So I started to, you know, cheekily, I sent my wife to tech conferences around the world. And she herself is an entrepreneur from the tech industry; hardware was her specialty. And we started identifying companies from all over the world. And the second angel investment where I was the very first investor was actually from a company in South Africa with similar challenges.
So the things that we saw as major health system deficiencies or maybe shortages in infrastructure and human capital were very much true not just in Southeast Asia but in a lot of parts of the world. And we noticed that while there were different reasons for why they ended up in that position, the outcome was similar.
CHAD: I'm not sure that everyone listening has a good sense of what the healthcare landscape actually looks like in these different places of the world. So let's take insurance, for example; what is the insurance landscape, generally speaking, in Southeast Asian countries?
JOSEPH: So, in Southeast Asia, we do have insurers. I mean, private insurance is certainly there. But it's just not --
CHAD: Do most companies have public insurance, too, like universal healthcare?
JOSEPH: That depends on which country you're in. Now, the one interesting thing about our entire region is that they've all committed to universal healthcare coverage. I would say that the implementation thereof has been heterogeneous; let's put it that way. Out of Southeast Asian countries that are not Singapore, I'd say that Thailand probably has the strongest public healthcare system. And in fact, they even do health technology assessments, which is really looking at the true cost-effectiveness of a new intervention versus what's currently done in practice to make decisions as to whether they're going to pay for it. And they cover a pretty high percentage of their population with this.
And then there are other places where the financing mechanisms are in place, but you don't necessarily have the doctors or the hospitals where they need to be to address the needs of the population. Still, we are dealing with places that are not fully urbanized. And in fact, a good deal of the population is still working on the pharm, basically.
One of the other complexities of our region is that just between the Philippines and Indonesia, which together has a combined population of 380 million at least, maybe it's 390 now, you've got 25,000 islands, and not all of those islands tend to hold major tier-one cities, even though they can hold a lot of people. And if there is one thing about healthcare that seems to be a universal truth is that highly skilled workers like to live in the rich cities.
CHAD: And so what I'm hearing is that on an individual island, if there's not a major city there, the access to the actual healthcare might be really limited.
JOSEPH: That is exactly it.
CHAD: In these economies in these countries, it's typical to have private insurance layered on top. But the pharmas probably aren't doing that, right?
JOSEPH: Oh, no, no, unfortunately not. There are some pilots of trying to do co-ops or collective insurance or micro-insurance policies. But again, when you look at the amount of premium that they could pay in, the kind of coverage they get is pretty basic.
CHAD: So, how does that landscape influence the solutions that startups are creating?
JOSEPH: Well, first and foremost, you've got to try to get some sort of mechanism by which you can seek care without having to travel too much. And I think that concept is extremely familiar to all of us thanks to the global pandemic that I hope we're coming out of right now, although there's always a new strain surprising us.
The idea of basic telemedicine is one that can have a great deal of impact in these populations. But even before that, just understanding the importance of healthcare, like, what the concept of healthcare is, what the concept of the modern medical system is, is something that a fair number of people never really had awareness of.
And I'll call out an example country, and I try not to call out too many examples. But Indonesia did a really good job of educating people about the concept of healthcare when they promoted their universal healthcare coverage. Even if they didn't have the ability to deliver it as well as they wanted to or as widespread as they wanted to, at least they got people paying attention to this concept called health. So awareness is really the first step.
The second challenge is all right, so you know health exists. When do you know when you need it? Where are you going to find a doctor? How do you know if a doctor is even good? And how do you know that the products that you're going to get are appropriate? So there are so many challenges that you have to face when you are in a lack of access situation.
CHAD: I assume you're getting pitched on a lot of ideas coming to your fund, a lot of startups. Correct me if that's wrong. [laughs]
JOSEPH: No, no, that's absolutely true. So one of the blessings and curses of being one of the very few super early-stage healthtech venture funds out there is that there aren't many of us out there. And when we started...let's just put it this way, if I could find a fund that was doing what I wanted to do, I would have sent my CV in, and I couldn't.
And starting a fund was basically the last thing I wanted to do, having never worked at a VC before or ever raised money in my life before. So I still think that we are the only truly global impact-oriented seed - I hate the term pre-seed, but I'll use it because of the audience's familiarity with it- investment fund out there right now for healthtech. So by virtue of that, we do see a lot of companies.
CHAD: So what are some of the criteria?
JOSEPH: So I'd say some of the criteria that we look for is number one, are you solving a real problem? And we define a real problem by the breadth of the problem, like, how many people are suffering from it or how systemic is this problem if it's an infrastructural one? And depth being how severe is this problem: is it life or death, or is it a minor inconvenience? So first and foremost, it's got to be solving a real problem.
Second, it's really around the team. You need a lot of clinical, technical, and commercial experience in order to pull off a healthtech startup successfully. And even before that, we want to understand why are you doing this? Because this is not easy. I'd say on a scale of 1 to 10, doing a startup is like an eight, and then doing a healthtech startup is like an 11. It's slow; it's technical, it's regulated, it's super risky.
And health systems are very pathway-dependent in the intent to not have many things in common with one another. So it is really, really hard. So we want to know the motivation. Are you going to stick through the thick and thin, or are you doing this healthtech startup because you think healthtech is cool or hot this particular period in the market cycle? So that's another criterion.
Another criterion is, well, what's your edge? I mean, okay, you can have a great team, and I think that is definitely a prerequisite. You can solve a problem. But do you have something that could make sure that you are going to be competitive and remain competitive?
CHAD: Given the barriers to market entry that you just outlined, do most of the companies that you're investing in have any sort of traction already in the market, or where are they in the product development or business development cycle?
JOSEPH: I'm going to give the ultimate cop-out answer of it depends.
CHAD: [laughs] Yeah.
JOSEPH: But I will qualify that by saying it depends on whether it's hardware or software, and it depends whether it's regulated or non-regulated. So if you are a software company that's unregulated so, what does this mean? It could be like a marketplace. It could be health education. It could be some telemedicine in a loosely regulated market. We'd really like to see user traction. We'd really like to see revenue even.
However, if you're a device company and you need to get FDA before you can earn a single dollar, we're okay with it being a science experiment or a prototype on the table as long as the science part of it has been de-risked. So if we know that the fundamental scientific principles are sound, then we're willing to take the productization and regulatory risk because we've been through this journey ourselves.
CHAD: And also, you said a team is really important, so if it's a team that has never gone through that before, that's less attractive than a team that has done it before, I assume.
JOSEPH: Yeah, absolutely. However, one of the challenges is that outside of the U.S., certain European markets in Israel, it's really difficult to find a team that's gone through the entire medical device development process before. So you are going to rely heavily on your professional service providers, consultants, advisors, other investors who've done this before. And as long as you have at least a path to getting to a point where you can unlock and utilize that expertise, that's okay. But if you don't, then that's a really, really big risk.
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CHAD: Earlier, you said FDA. FDA is a United States thing. Do most countries in Southeast Asia have a local regulatory agency like the FDA that things need to be approved through?
JOSEPH: Yep, every single one. The question is, what's the process to go through that? Generally speaking, the FDA, as well as the European equivalent, which is the CE Mark, are used as predicates in order to kind of shortcut the process, make it go a little bit faster. Because then you don't have to create a bunch of new work or get the local regulator to really try to do things that they're unfamiliar with.
CHAD: You said it's fairly rare for teams to have concrete experience doing that in the local market. Does that mean that most of these markets have been served by, I don't know, large companies previously?
JOSEPH: Yeah, and still are. A fair number of emerging markets don't even have the manufacturing capability to even do local production, so they require a lot of importation. I'd say that this is a different case when it comes to generic pharmaceuticals and maybe vaccines and some consumables. But complex devices and biologics are generally manufactured in more developed markets or larger economies.
CHAD: Yeah. Well, you mentioned the pandemic, and I'm curious how the pandemic has changed either your prospects for the fund but also the market in general.
JOSEPH: I would say, again, it's both a blessing and a curse. So during the start of the pandemic, there was a great deal of societal and economic uncertainty around where are we going to be as a species in six months? And I remember early 2020; it was kind of these Hollywood movies that would paint this kind of semi-apocalyptic picture of where we're going to end up. And as a consequence, people really puckered up and stopped investing in things.
I would say that the other side of it is now much of the world understands what it's like to not have access to quality healthcare or even access to healthcare. You see people not going to the hospital for things that they ought to and then suffering the consequences at home, like, let's say, not going for that heart checkup, and then you having a heart attack at home and passing when you otherwise wouldn't have. Or even cancer patients having to delay their therapy because the hospital is just too full.
So this concept of telemedicine which has always been resisted by both the payers and providers for being infeasible, or inaccurate, or impossible to fund properly, suddenly had to be done. And the concept of telemedicine is fairly old. I mean, how else would you treat your astronauts in space in the '60s if they got sick? So this is something that NASA thought of and invented and implemented, you know, decades and decades ago. And finally, this came forward.
And I was pleasantly surprised to see...and again, I'll quote the U.S. here where The Center for Medicare & Medicaid Services or CMS actually reimbursed a bunch of remote procedure codes, which is pretty amazing. And I think that was opening Pandora's Box. There's no going back from that.
So I think telemedicine is absolutely here to stay. And the real challenge now is really how to make it more user-friendly, how to improve it, how to improve the decisions that come from it. I really don't think it's going back. And as a consequence of this, it's really benefited a lot of our startups that were trying to build this remote-connected future anyway.
CHAD: Has there also been an influx of those kinds of startups?
JOSEPH: Absolutely. I would say that there has been a veritable Cambrian explosion of startups where everyone and their uncle is starting a healthtech startup as well as a healthtech fund. I see a lot of new funds coming up promising to invest in this space. So I think it's good in that there's going to be a lot of really new ideas, and hopefully, it's going to improve the standard of care for everyone around the world. But at the same time, it is creating a lot of noise, and it's becoming increasingly difficult to filter through that.
CHAD: Do the solutions tend to be local? I guess the nature of my question was, you know, like messaging apps. [laughs] Different countries have different popular messaging apps. What do you see as the penetration of different telemedicine solutions in the different countries? Do you think it's going to be, oh, you know, this is popular in this country? Or do you think it's possible for one company to come in and really have a significant impact in the market across multiple markets?
JOSEPH: Yeah, I think it's eventually going to be the latter. So at the start, you do see that you have your national champions. And like instant messaging apps, it's kind of like a 90-10 rule where the number 1 player takes 90% of the market, number 2 takes most of what's left, and then number 3 player caters to some niche or another. And I see two competing forces here; one is, yes, there may be a big player like Babylon or Crew who comes in and rolls up everything backed by heaps of capital.
But the other thing could also be that all the health systems start saying, "You know what? Why are we working with an external company? Why don't we just develop all these capabilities ourselves and then keep the patient captive?" And you are starting to see middleware providers who are basically providing that telemedicine layer, white-labeling it, or giving API access to the providers themselves, the legacy providers themselves, and then allowing them to do that.
And I actually saw this statistic...I don't know how accurate it was, but I saw a chart in the U.S. that white-labeled or internal telemedicine consults exceeded the number of Teladoc consultations, which is the largest platform in the U.S., at some point last year.
CHAD: I'm wondering, do you know if Teladoc uses Twilio?
JOSEPH: I really should know the answer to that question, but unfortunately, I do not.
CHAD: Because my sense is the real winner in this game might be companies like Twilio because I think everyone is using them. [laughs]
JOSEPH: That makes a ton of sense. So when we do look at some investments, we actually want to invest in middleware because why duke it out to be the platform when you're the utility provider?
CHAD: So let's turn our attention to the actual creation of the fund. And I know you just opened your second fund last month, right?
JOSEPH: Actually, this month. I mean, last month was the paperwork, but it takes time for stuff to get approved.
CHAD: Yeah, fair enough. So you already said actually starting a fund was, I think you said, the last thing on earth that you wanted to do. Why was that the last thing you wanted to do?
JOSEPH: Frankly, it was a whole lot more uncertainty than I was prepared to handle at the time. And I was either blessed or cursed with this momentary clarity of purpose where I knew with all my being that this is what I wanted to do with myself for, if not the rest of my life, a very long time. And the only alternative, or rather the only choice to pursue this at the time, was really starting a fund. So that's what I had to do, right?
CHAD: And how large was the first fund?
JOSEPH: It was pretty small; it was $7.6 million, which in local currency equates to a nice number of just above 10 million sings.
CHAD: And where did you...I'm going to ask where that ended up coming from. But in terms of the mechanics of actually starting a fund, what did that look like?
JOSEPH: Well, it depends on each market. But typically, what happens is you need to first have permission from the regulator in order to actually start and run a fund. So in Singapore, you need to apply for a venture capital fund management license from the Monetary Authority of Singapore. That's what had to be done first, and we got that approved in a pretty good time, actually. I think we might have captured a lull period because now, with all the funds coming out, I've heard the queue is months long in some cases.
And then came the business of incorporating the fund itself and then starting to draft all the legal paperwork, the conditions, the private memorandum or prospectus, depending on which geography and how regulated you are, that you show around to investors once they've expressed interest in learning substantially more details about your fund beyond what a simple PowerPoint deck or a casual coffee conversation can yield.
And then you start collecting commitments, and then you start collecting the money. And at some point, you have enough money to say, all right, we'll do a close or first close, and that then gives you permission to start deploying that money into investments. And some funds they'll only do one close, some funds will do a first close, and then a final close when they get the rest of the money in or some money committed and then calling the rest of it to come in. Or some will do multiple closes just so that they have the ability to keep deploying continuously while they're doing this fundraising process.
And in our case, we were doing rolling closes. So we would close every few months, and we'd continue to deploy. And by the time we finished fundraising, we actually already had nine companies out of the 15 that we have in our portfolio done. So it really depends on all sorts of different factors, which we probably don't have that much time to get into. And I risk perhaps putting my foot in my mouth and misspeaking if I give too many examples.
CHAD: [laughs] When it comes to starting a fund, how cookie-cutter is it? Or do you find yourself having to create everything from scratch, all the legal documents, whatever platform you might be...or access you might be giving to the people who are contributing to the fund?
JOSEPH: I'd say, again, it depends where you are. I think in the U.S. and especially with the advent of great service providers platforms like AngelList and Assure, it is super cookie-cutter. In our part of the world, I still think it's somewhat cookie-cutter, but we got a little too cute.
JOSEPH: We thought, okay, it's our first time doing a fund. I've been an LP in other funds. What did I wish I had as an LP? And as a consequence, we introduced some hurdle rates of tiered carry, and even zero carry if we don't hit a certain return. And all that really did was just create more questions from the investors. So we should have probably done it as cookie-cutter as possible in hindsight.
CHAD: So I often hear from founders who talk about how it's important to have a VC fund behind you that you agree with, and want to work with, and are excited about, and that can be value additive. Do you need, as someone raising a fund, do you need to consider things like that or other things when it comes to the people you're taking money from the fund?
JOSEPH: Absolutely. Maybe knock on wood here, but our relative inexperience when starting a fund probably selected out all the folks who might not have gotten along with us anyway. And the fact that we're pretty straightforward and direct with what we want to do in our objectives probably helped with that selection process as well on the positive side. But I absolutely, absolutely can recommend having that alignment of values and mission with those who are on the journey with you for a good decade. It's like getting married, right?
CHAD: Yeah. Well, so when you're planning a fund and thinking about time horizons, is a decade what you're thinking about?
JOSEPH: Yeah, all things considered. So our fund lifetime was eight years from final close. But still, it takes time to raise the fund and plan the fund, and you have people that are on board even before the fund begins. So it is a decade-long relationship, at least. And then some of the larger funds because they want to have a longer investment period, will push that out even further where they're going to be a 10-year fund from final close.
And if you have enough of your portfolio that hasn't exited yet but still has some value to be uncovered, you may ask your investors to extend the fund life even further. So this is a supremely long relationship that you have. And aside from evergreen funds that don't have a fund lifetime, I think this is about as long as it gets, although I have seen some people float the idea of a 20-year fund or a 50-year fund, but that's really not widely practiced. I think five years is the fastest I've seen, and ten seems to be the average.
CHAD: Where did that first fund come from? How did you drum up the interest and decide who would be a part of it?
JOSEPH: It's really the folks who have known me the longest or worked with me. So you know how they say when you're raising money for a startup, you get it from the three F's, Friends, Family, and Fools? For funds and for first-time fund managers, I think it's a pretty analogous group of people, although I don't think we have any fools.
JOSEPH: And, unfortunately, don't have family either. So it's really all friends, old co-workers, old clients, and then the people that they introduced us to. There were some serendipitous moments where people liked what I said at a conference, or we asked a tough question. And people asked, "Well, how can you ask such a tough question?" Then they got to know us and then decide to invest from there. But majority of it was just introductions, warm introductions. We never did any cold emails.
CHAD: Have there been any exits in the first fund?
JOSEPH: Not just yet. We do come in as either the first or second investor in these companies. So there is quite a long journey that we expect before we, you know, see some exits. There may be some this year. But if I look back at my angel investments, there was only real serious talk of an exit at the six-year mark for one of the companies that's doing really well. And even that exit turned out to be just another, you know, the investor changed their mind, and instead of buying the company, they decided to just invest more money into it. So this is a long journey.
CHAD: Yeah, definitely. Did that make putting together the second fund any harder, or is that what everyone expects?
JOSEPH: I am cautiously optimistic because we're still so early in our journey that the only folks we've really spoken with are the ones who invested in our first fund or passed on our first fund because they don't back first-time fund managers. They come to expect that your second fund is built on the momentum of the first fund. And it's really your third fund that's built on the exit and actual realized track record of your first fund.
CHAD: That makes sense. What do you think is next for Verge HealthTech?
JOSEPH: Well, first things first, we got to get started with the second fund and see if we can build something to scale. I mean, the first fund was an experiment. It was a small fund, you know. Could we build the world's seed-stage global impact healthtech fund on basically a shoestring? And the second fund is now let's take everything that we wish we had for the first fund and scale it up so bigger initial ticket sizes because we want to own more, the ability to follow on properly, the ability to do more deals, which requires a much bigger team which we now have.
As well as to go back and support the winners of our first fund as well as some of the companies that maybe we made a mistake on and passed but still have a strong enough relationship to revisit and get them on the next round or the round after that, or just new companies that the market has moved. You know, the area that we might have been really interested in at the seed stage is now a pre-A stage or an A stage.
So that's really what we want to do with the second one. And it would be amazing to see where this goes. I'm thrilled that we actually have, well, I think, one of the best healthtech investment teams in the world; maybe I'm slightly biased with this.
JOSEPH: And I'm excited to see what we can do together.
CHAD: That's great. Well, I wish you the best. And I really appreciate you for stopping by and sharing with us. If folks want to follow along with you or get in touch with you, where are the best places for them to do that?
JOSEPH: Probably LinkedIn is the best way to do it. Also, I have a blog on Medium, which I'm sure can be linked in the show notes. I've been really bad...I've been traveling intensely in the past half-year. But I promise my next blog post will be interesting.
JOSEPH: Because I just got back from Rwanda and Saudi Arabia, which are two very, very different countries, however, with a great emphasis on improving healthcare, especially on the digital side.
CHAD: Well, that's exciting. So folks definitely can find the links for that in the notes, which you can find the notes; you can subscribe to the show and a full transcript of the episode at giantrobots.fm. If you have questions or comments, email us at firstname.lastname@example.org. And you can find me on Twitter at @cpytel.
This podcast is brought to you by thoughtbot and produced and edited by Mandy Moore. Thanks for listening, and see you next time.
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