Cablegate: Joint Research On Health/Environmental Effects Of

Published: Sun 16 Feb 2003 01:22 AM
This record is a partial extract of the original cable. The full text of the original cable is not available.
E.O. 12958: N/A
1. (U) This is an action cable. Please see Paragraph 13
2. (SBU) SUMMARY: To date, the Government of Vietnam (GVN)
has made little, if any, progress towards achieving the
goals set forth in the Memorandum of Understanding (MOU)
signed in Hanoi on March 10, 2002, following bilateral
meetings held in Hanoi after the International Agent
Orange/Dioxin Conference funded by the U.S. National
Institute of Environmental Health Sciences (NIEHS).
Embassy believes that this lack of progress reflects the
unwillingness of the GVN to allow its scientists to engage
in genuinely transparent, open rigorous scientific
investigation to determine the true extent of the impact of
AO/dioxin on health in Vietnam. We believe that the GVN
will attempt to control, disrupt, or block any research
project that could potentially produce scientific evidence
that refutes the GVN's allegations of broad, catastrophic
damage to the health of Vietnamese citizens, especially
birth defects. Joint research on the environmental issues
will probably be limited to projects that focus on soil
sampling and searches for low-cost emerging remediation
technologies. Another factor that has hampered overall
Vietnamese responsiveness has been the disruption of the
leadership and functioning of National Steering Committee 33
(responsible for oversight of all issues related to Agent
Orange) that resulted from the creation of the Ministry of
National Resources and Environment in August 2002. Despite
this assessment, the Embassy advocates continuing the USG
effort to promote cooperative scientific research programs,
while at the same time taking a straightforward approach to
counter the Vietnamese propaganda campaign that hinges on
non-scientific, but visually effective and emotionally
charged, methodology aimed at laying blame on the USG. Two
new proposed projects funded by NIEHS, one in environmental
remediation technologies and one in health research related
to pregnancy, will provide a gauge by which to further
assess Vietnamese attitudes and intentions. END SUMMARY
3. (U) Dr. Anne Sassaman, Director, Extramural Grant
Program, National Institute of Environmental Health
Sciences, visited Hanoi during October 27-31, 2002, to
continue the dialogue with Vietnamese counterparts on joint
scientific research on health and environmental effects of
Agent Orange (AO)/dioxin in Vietnam, and to determine status
of Vietnamese efforts and attitudes towards pursuit of goals
defined in the Memorandum of Understanding signed on March
10, 2002, following bilateral discussions in Hanoi.
Embassy/Hanoi EST Officer accompanied Dr. Sassaman to most
of her relevant meetings. In November, Dr. Sassaman briefed
members of the Interagency Working Group on AO/Dioxin (IWG-
AO/D) in Washington on the results of her visit. On January
16, 2003, Embassy EST Officer met with Dr. Nguyen Tien Dung,
Director, Office 33, to follow-up on the unresolved issues
that had been discussed during Dr. Sassaman's visit. In
early February, EST Officer also met with NIEHS officer in
charge of organizing an environmental assessment and
remediation workshop and the U.S. lead investigator in a
joint health research project that has received approval and
funding by NIEHS. Embassy wishes to provide the IWG with
our observations and assessment of Vietnamese attitudes
toward implementation on joint scientific research.
4. (SBU) Although the history of U.S. Government (USG)
efforts to engage the Vietnamese in joint scientific
research go back as far as 1994, we will look at events over
the past two years, beginning in December 2000 at the
bilateral meetings held in Singapore. Based on our
observations of Vietnamese behavior over the past two years,
interaction with key players and observers on the Vietnamese
side following the March 2002 International Conference in
Hanoi funded by NIEHS, the results of Dr. Sassaman's recent
visit, and EST Officer's recent meetings with Office 33, the
Embassy's assessment is that the Government of Vietnam (GVN)
has no intentions of allowing its scientists to engage in
genuinely transparent, open, rigorous scientific
investigation to determine the true extent of the impact of
AO/dioxin on health in Vietnam. Why? Because, we believe,
the GVN will never permit research that in any way might
discredit the main theme of its two-decade long propaganda
campaign, i.e., AO/dioxin is to blame for a huge range of
serious health problems - especially birth defects and
mental retardation - of residents of central and southern
areas and/or northern soldiers who served there. We feel
certain that many responsible GVN and Communist Party
officials know that allegations of the extreme degree of
adverse impact of AO/dioxin on health are grossly
exaggerated and unsupported by any objective measure. Thus,
to engage in a truly comprehensive scientific research
program would expose the official folly, and place the
government in an untenable position. It would also open a
Pandora's Box of questions about why the GVN - and more
importantly, the Communist Party - has misled its people and
focused on demonizing AO/dioxin and failed to carry out
appropriate public health programs that could have mitigated
other sources of threats to human health. It is our
assessment that the GVN will permit only research that they
are confident will support and/or lend credence to their
claims. Thus, any proposal that includes verifiable
measures of exposure, and independent validation of
diagnosis, the sine-qua-non of scientific study for health
impact assessment, will not be acceptable to the GVN. If
there is any uncertainty about the outcome of the research,
they will either not approve it or cancel it if subsequent
indications imply that the results could contradict their
propaganda message. We believe there are Vietnamese
scientists who, if given the opportunity, would seek to
conduct high quality scientific research. No matter what
their motives and intentions, virtually all Vietnamese
scientists view joint research with U.S. experts as an
excellent mechanism by which to acquire training, equipment,
and technology. Why did the GVN finally agree to
scientific research? In our view, they realized that
agreement to engage in joint research would give the
appearance of cooperation with the USG, while at the same
enhance their leverage in pursuit of their main objective -
financial compensation and support for research
infrastructure from audiences sympathetic to their
propaganda message. Thus, we believe the GVN's highest
priority continues to be waging its ongoing propaganda
campaign to morally indict the USG in collaborations with
sympathetic members of the broader international community
as its highest priority. Engagement in a scientific
research endeavor is a secondary, supporting effort of the
primary strategy to force the USG to bow to international
pressure and in the words of several of the international
interlocutors of the GVN's position, "address the chemical
holocaust that has been visited on Vietnam - to fully
remunerate and premeditate the devastation caused and denied
since the 1960's."
5. (SBU) On the environmental side, the Vietnamese probably
will not attempt to exert such heavy-handed control because
the focus of initial research is to test/evaluate relatively
inexpensive emerging soil sampling and remediation
technologies in locations where both sides agree there is a
high probability of dioxin residue in the soil (i.e., the
suspected "hot spots"). The ongoing pilot project between
U.S. EPA and the Vietnamese scientists at a suspected hot
spot in Danang Airbase is the only ongoing project upon
which to judge Vietnamese behavior. We note that permission
for the soil samples obtained from that site to be sent back
to the U.S. for state-of-the-art testing was not granted
until after/after the soil sampling tests in Hanoi
demonstrated the high probability of a heavy dioxin residue.
We are waiting on the results of the testing in the U.S. and
follow-up visits by EPA. The next phase of the "Danang
Project" is to seek methods of defining the parameters of a
"hot spot" and evaluating/assessing emerging low-cost
technologies for a pilot remediation project. The
counterpart Vietnamese scientists are enthusiastic about
this project.
6. (SBU) The Vietnamese are more willing to study the
environmental effects, but we anticipate that there are
caveats. We predict they will not participate in or allow
studies that would cause problems for their agricultural
export industries. Thus, any study that looks at dioxin
contamination of food products will only be permitted if it
cannot be generalized to types and classes of foods that are
only of commercial importance to Vietnam, or in areas that
do not have any commercial food production. Thus, it will
never be possible to do broad and scientifically useful
ecologic studies of dioxin. Second, they will not permit
studies that undermine their propaganda campaign. For
example, the Hatfield Consultants research report showed
that in the areas of heaviest spraying, the AO/dioxin
applied by aerial spraying was no longer at levels
considered hazardous to health. This finding has never been
publicly admitted or commented on by the Vietnamese - and
subsequent soil sampling for areas of aerial spraying has
not been permitted.
7. (SBU) National Steering Committee 33, the entity
responsible for oversight and management of all programs to
deal with all issues related to AO, is composed of
representatives from at least ten different ministries or
equivalent level organizations. The government decree that
established Committee 33 is classified "secret"; most or all
documents related to AO or the committee's actions are also
classified as they are considered to have national security
implications. The senior representative from each ministry
or agency is a Vice-Minister or equivalent rank. Committee
33 guides/controls the health and environmental research,
the internal propaganda campaign, the campaign to acquire
foreign donations, etc. Although we do not know the precise
mechanisms by which this committee operates, we assume that
ministries such as S, Natural Resources and Environment,
Foreign Affairs, Health, Culture and Information, National
Defense, and Public Security as well as the Communist Party
Central Committee and the National Assembly play important,
key roles in the decision making process. Former Minister
of Science, Technology and Environment Dr. Chu Tuan Nha
served as the Chairman until he was replaced as Minister in
August 2002. Minister Nha, a scientist, was viewed by the
Embassy as someone with a generally pragmatic, objective
attitude who supported scientific research (but still
spouted the party line about "victims" when necessary). In
October 2002, Committee 33 Standing Vice-Chairman Dr. Pham
Khoi Nguyen, who has now moved from his position of Vice-
Minister of S to become a Vice-Minister in the newly
created Ministry of Natural Resources and Environment
(MONRE), told Dr. Sassaman that a recommendation had gone
forward to the Office of Government to appoint a Deputy
Prime Minister (DPM) to chair the committee. Dr. Nguyen
commented that elevating the chair to a higher level would
make the Committee more efficient (presumably because a DPM
would have more clout to resolve disputes between
ministries). However, in January 2003, the GVN issued a
decree appointing Mr. Mai Ai Truc, Minister of Natural
Resources and Environment, as the new Chairman. Although
the chairmanship was not elevated to the DPM level,
oversight of Committee 33 was shifted from DPM Pham Gia
Khiem, whose portfolio includes S and education, to First
DPM Nguyen Tan Dung. This shift in oversight of Committee
33 coincided with placement of MONRE under the oversight of
DPM Dung. Minister Truc is not a scientist. His academic
background is literature; his entire career has been spent
working in the Party and/or People's Committee of Binh Dinh
Province. Despite Minister Truc's lack of scientific
credentials, he has told the Ambassador that he has first-
hand experience with the spraying of AO and AO's impact on
the environment and health. He said that, in his home
province, AO had caused bananas to grow to an enormous size.
The poor, starving residents had no choice but to eat this
AO-contaminated fruit. As a result, the women had borne
many children with birth defects. Minister Truc's comments
dovetailed nicely with the Vietnamese propaganda line. The
Ambassador responded politely that there could be many other
possible causes of birth defects, including deficiencies in
prenatal care and the diet of pregnant women, and this
potential myriad of factors was the basis for the USG's
desire to conduct good scientific research to find the
8. (SBU) In discussions with the Dr. Nguyen Tien Dung,
Director of Office 33 (permanent staff for Committee 33),
Dr. Sassaman described the process for
reviewing/approving/funding research grants submitted to
NIEHS. A key feature was the independent peer review to
evaluate the quality of the science. Dr. Dung explained
that, in the Vietnamese process for research on topics
related to AO/dioxin, a proposal would undergo scientific
review (not an independent peer review, but one conducted by
a government ministry, such as Ministry of Health for health-
related research), and then go to Committee 33 for final
approval. Committee 33's decision would be based not on the
merits of the science and/or potential benefits to
understanding the issue, but rather on non-scientific
factors and points of view (e.g., internal political,
national defense). Both Dr. Dung and MONRE Vice-Minister
Dr. Pham Khoi Nguyen frequently used the term "control" when
describing Committee 33's role. Dr. Dung explained that
data/information related to GVN policy on AO was still
considered a "state secret" and water, soil, human
tissue/blood samples were also considered to be state
secrets. Committee 33's approval would be required each
time a scientist wished to send such items out of Vietnam
for testing and analysis. In response to a question about
the process for obtaining approvals, Dr. Dung explained that
even if Committee 33 approved a research proposal that
clearly defined parameters of health research (defined
geographic area, target population, intended use of samples,
etc), approval would not be a blanket approval for the
lifetime of the project. Committee 33 would have to approve
the shipment of each batch of samples. The authority cannot
be delegated to a single senior official or to a sub-
committee. This control factor would allow the Vietnamese
to stifle a research project at any point. In this context,
Dr. Sassaman and Dr. Dung discussed the unresolved issues in
the MOU related to: a) the degree to which research
findings will be made available to the international
scientific community; b) the avenues through which research
findings will be published; and c) the process that must be
followed for publication approval. Dr. Dung's description
of the Vietnamese perception of these issues was that
"control" (of information and research findings) was of
paramount concern to Committee 33. Dr. Sassaman explained
that no credible U.S. researcher would be willing to invest
time and effort into a project which could be undermined or
whose findings could not be published. Dr. Sassaman
stressed that this was not a point to be taken lightly, and
Dr. Dung promised to relay her remarks to Committee 33.
9. (SBU) On January 16, 2003, EST Officer met with Dr. Dung
to discuss the status of Vietnam's efforts to move forward
on the issues discussed with Dr. Sassaman. Dr. Dung offered
the following.
-- Office 33 has submitted a proposal to Committee
33 and Chairman Truc for establishing a mechanism for
general approval for human tissue and blood samples to be
sent abroad for testing and analysis. Dr. Dung would not
offer an anticipated timeframe for approval.
-- Committee 33 has not yet appointed Vietnamese
members of a Vietnam-US Joint Advisory Committee, which per
the March 10 (2002) Memorandum of Understanding, would be
established to define the scope of the joint research
program; coordinate the collaborative research program on
human health and environmental effects of Agent
Orange/Dioxin; and review and approve research content areas
under the program. (BEGIN COMMENT: The U.S. members were
appointed in the summer of 2002. END COMMENT)
-- Dr. Dung advised that Committee 33 had not yet
received the Vietnamese text of a joint grant proposal for
joint health research project submitted to NIEHS by a U.S.
investigator with a Vietnamese Ministry of Health
counterpart investigator. (BEGIN COMMENT: During Dr.
Sassaman's October 2002 visit, she discussed this proposal
with both Dr. Dung and the Vietnamese investigator. At that
time, the Vietnamese investigator stated that the proposal
was being translated into Vietnamese. Subsequently, in
January 2003, the proposal was evaluated via NIEHS's
independent peer review board and scored well enough to
receive funding. EST Officer informed Dr. Dung that NIEHS
would be willing to fund the project only/only after
receiving formal confirmation that Committee 33 had approved
the project, and the issues of publication and human
tissue/blood testing had been resolved. END COMMENT)
10. (SBU) The following is a brief review of GVN actions
that tend to support our assessment.
--During the December 2000 bilateral talks in
Singapore, the Vietnamese delegation spent three days in a
failed attempt to get the U.S. side to sign a Memorandum of
Understanding which included a U.S. commitment to provide
humanitarian assistance to all the "victims" of AO/dioxin as
a pre-condition for engaging in joint scientific research.
A central theme was "the research has already been done and
we already know the results show direct cause-effect
relationship between AO/dioxin and the health of Vietnamese
--The Vietnamese print and visual media
consistently conveys the message that there are many
"victims" of AO for which the USG should accept
responsibility providing humanitarian assistance. The
frequency and tone sharpen just before and just after
significant events.
--The Vietnamese organizers (under direction from
Committee 33) refused to allow the international press to
attend the March 2002 conference. Following the conference,
the main theme of Vietnamese media articles was not related
to the science. Rather, the theme was "the USG finally
admitted that U.S. military forces had sprayed millions of
gallons of AO during the war."
--The GVN's consistent, persistent message has
been, "we do not need the science to prove a link between
AO/dioxin and the health of our people. We already have
the proof." This message runs counter to any expression of
intent to engage in serious joint scientific research, but
it is being parroted by the press (as mouthpieces of the
Party and the bureaucracy of government), by government
officials at all levels, by educated citizens in all walks
of life, and by many international NGOs and other
institutions. The success of the propaganda campaign has
strengthened the GVN's resolve to continue on that front
while at the same time maintaining a faade of willingness
to engage the U.S. in scientific research on health effects.
--Except for the Danang soil sampling project, the
GVN has made no progress towards achieving goals set forth
in the March 10 MOU, not even to appoint members to the
joint advisory committee that is to provide oversight to
define the scope of the overall joint research program;
coordinate the collaborative research program on human
health and environmental effects of Agent Orange/Dioxin; and
review and approve research content areas under the program.
The creation of MONRE and the subsequent turmoil caused in
establishing a new management team within Committee 33 can
explain some of the inertia. However, at the same time, the
propaganda campaign was not disrupted.
11. (SBU) As an indicator of the pervasiveness of the
Vietnamese position on AO/dioxin, we would like to share the
failure of our recent efforts to engage the Vietnamese in a
broader effort to look at public health issues that that
might be easily resolved. At several points, HHS has
suggested to Vietnamese counterparts an affordable and
effective national campaign to eliminate cretinism.
Multiple sets of national data strongly indicate that
cretinism is the leading cause of preventable mental
retardation. Hypothyroidism in pregnant women due to lack
of iodine has been a national epidemic for as long as the
data has been recorded. Multiple surveys have shown
prevalence rates of between 15 and 40% of goiter in pregnant
women. Various biochemical surveys have documented many
pregnant women with no detectable iodine in their urine.
This provides conclusive evidence that their baby will be
born with a significant mental defect, and in many cases,
with severe and profound mental retardation. Off the
record, many international public health experts estimate
numbers of cretins born each year in Vietnam at a minimum in
the tens of thousands. However, we have been unable to get
the GVN to engage in a substantive, high priority national
program for elimination of this deficiency. There could be
various reasons for the GVN's reluctance to start such a
program. We understand that it took the World Health
Organization many years to convince some African countries
to participate in a similar program. However, we must
assume that some knowledgeable Vietnamese officials
recognize that conducting such a public campaign would lead
even the average citizen to wonder if the condition of a
vast majority of profoundly retarded children, whose
affliction has been blamed on AO/dioxin, could have been
avoided easily by pre-emptive remediation of a nutritional
deficiency. Here are other examples of easily remediable
problems that are given insufficient attention, perhaps
because doing so would undermine the AO/dioxin blame game:
the high rates of cerebral palsy in the general population
due to birth injury, the epidemic of liver cancer due to
chronic active hepatitis because of poor medical practices
and inadequate blood screening. Both of these conditions
are routinely blamed on AO/dioxin. Parenthetically, we also
note a similar approach taken to another significant issue
of disability in Vietnam - the issue of UXO. The government
makes every attempt to use this to generate sympathy and
funding, especially with the international community, and
often links the two issues of AO/dioxin and UXO together to
maximize the effect of demonizing the US for the "holocaust"
of the Vietnam War (a term that is constantly used by the
GVN and their international sympathizers). The GVN never
mentions that much of the UXO resulted from their own
military and guerilla operations in the affected provinces
and any attempt to quantify this is always stopped
12. (SBU) Pending Projects By Which to Gauge Vietnamese
Attitudes and Intentions:
a. (SBU) On 7 February, EST Officer and NIEHS
officer Dr. William Suk met with the two lead Vietnamese
scientific investigators in the Danang Soil Sampling Project
being conducted jointly with U.S. EPA. Dr. Suk is taking
the lead in an NIEHS plan to organize a workshop in Vietnam
to explore new, emerging technologies related to
environmental assessment and remediation. This workshop
would be the first step in the next phase of the Danang
Project already discussed between EPA and the counterpart
Vietnamese organization for this project, the National
Center for Natural Science and Technology (NCST). The
Vietnamese investigators were very excited about the
potential for this workshop, and offered the use of NCST
facilities. However, they emphasized that GVN and Committee
33 approvals would not be automatic. They expressed
optimism that Dr. Dang Vu Minh, Director General, NCST (and
a member of the Communist Party Central Committee and a
member of the National Assembly), who was tasked by the GVN
to manage the Danang Project, would support the workshop.
b. (SBU) On 8 February, EST Officer met with Dr.
David Carpenter, School of Public Health, University of New
York at Albany, who is the lead U.S. investigator on a joint
research project with the Hanoi Medical University related
to effects of AO/Dioxin on pregnancy. In January 2003, this
project was approved by NIEHS for a 3-year grant. NIEHS is
withholding release of funds pending receipt of formal
notification that Committee 33 has approved the proposal
without substantive changes. Dr. Carpenter was in Hanoi to
meet with the lead Vietnamese investigator. (COMMENT:
Embassy suggests that the IWG seek more details on the
project from NIEHS. END COMMENT) Dr. Carpenter, having
expected some obstacles related to funding issues, was
upbeat after his conversations with the Vietnamese
investigators. However, as noted in Paragraph 9 above, this
proposal has not been yet been submitted to Committee 33 for
approval. The lead Vietnamese investigator did not mention
any problems related to obtaining approval for shipment of
blood samples to the U.S. and predicted approval would be
granted for the overall project by April 2003. EST Officer
and Dr. Carpenter discussed the potential for Committee 33,
even after granting general approval, to interfere with the
efficiency of the research. (BEGIN COMMENT: On 7 February,
one of the NCST investigators in the Danang Project, who was
familiar with the Carpenter project, voiced the opinion that
Committee 33 would never approve a project which allowed all
blood samples to be shipped to the U.S. for analysis. The
investigator cited ongoing problems (mainly lengthy delays)
in obtaining Committee 33's approval to ship soil samples to
the U.S. and third countries. END COMMENT) Embassy views
this project to be a litmus test to evaluate the GVN's
willingness to pursue good science and demonstrate its
intentions towards health research on the AO/dioxin issue.
This is a pioneer endeavor.
13. (SBU) The USG must decide how to address the issue of
scientific cooperation, since it is now clear that the GVN
is unwilling to engage in any real scientific cooperation
and will undercut the effort to serve its propaganda
objectives. We feel that ignoring this situation will have
the probable outcome of continued success on the part of the
Vietnamese in engaging the broader international community
to exert pressure on the USG to remediate and remunerate all
the "victims." The issue is how to address this. We
encourage the IWG and others in the USG to focus on this
-- The Vietnamese are succeeding at their
longstanding propaganda campaign. We need to counter the
disinformation with valid, scientifically documented
information. We should challenge bogus, slanted journalism
- both vernacular and international - with factual,
objective responses that expose the fallacies of the GVN
propaganda and describe other potential factors that
contribute to the health problems that the Vietnamese
attribute solely to AO/dioxin. Silence or bland, non-
specific responses will only tend to "confirm" the
disinformation in the eyes of the audience. We should
publicize our efforts to engage and support the Vietnamese
in joint scientific research, and expose foot dragging
and/or efforts by the GVN (Committee 33) to stymie the
progress of a worthwhile project. We should not hesitate
to respond to efforts to attribute all maladies to AO/Dioxin
by noting the large number of Vietnamese who are victims of
their own government's inability to provide them with
adequate nutrition, quality medical services and protection
from environmental. The Embassy cannot accomplish this
alone. Our Public Affairs Officer, with support from the
new HHS officer (not yet selected) who will serve as Embassy
Health Attach, needs support to deal with Vietnamese
propaganda campaign and the constant barrage of queries from
the international media. Embassy requests that the IWG,
with support from NIH/NIEHS, prepare a concise summary on
dioxin, which Embassy and other agencies involved in the
AO/Dioxin issue can use as a basis for talking points that
address key questions related to dioxin and what the
international scientific community knows about it. Our
intent is that this would provide sufficient factual,
objective information that would demonstrate why the USG has
taken the position that there are many unanswered questions
about the health effects, and justify our call for further
scientific research to determine how much, if any, adverse
impact AO/dioxin has had on health in Vietnam. In other
words, we need to be able to counter the Vietnamese position
that exposure to dioxin, no matter under what circumstances
and at what levels, eliminates all other possible causes of
a health problem. This document would also serve as a
primer for the uninformed, particularly the press who tend
to focus solely on the fact that dioxin is a persistent
organic pollutant linked to health problems.
-- The Embassy is not advocating that we turn our
backs on sincere, genuine efforts to pressure the Vietnamese
to engage in serious scientific research. We advocate
continuing a proactive approach to demonstrate to all
stakeholders that we want the March 10 MOU to be a framework
for advancing science, not just a piece of signed paper that
serves as "evidence" for the Vietnamese propaganda machine
to prove that the U.S. accepted blame for spraying
herbicides during the war and by default accepted the
allegations of causing catastrophic damage to the health of
hundreds thousands of Vietnamese citizens. Embassy will
support the U.S. agencies (NIEHS, EPA, CDC) in all phases of
the Danang Project, including the new initiative on
exploring remediation technologies, and the health research
project currently awaiting Committee 33 approval. We will
try to "push the right buttons" from the Office to
Government down to the functional agencies in the Vietnamese
bureaucracy to keep up pressure for implementation of these
--Embassy expects the soon-to-be assigned Health
Attach to take the lead in promoting cooperation in health
research by supporting NIEHS programs and by interacting
closely with the appropriate counterparts in the Ministry of
Health and the medical universities.
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