<div dir="ltr"><div class="gmail_default" style="font-size:large"><br></div><br><div class="gmail_quote"><div dir="ltr" class="gmail_attr">From: <b class="gmail_sendername" dir="auto">People's Health Movement</b> <span dir="auto"><<a href="mailto:dlegge@phmovement.org">dlegge@phmovement.org</a>></span><br></div><br><br><div class="msg5709282195146691145"><u></u>
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<span class="m_5709282195146691145mcnPreviewText" style="display:none;font-size:0px;line-height:0px;max-height:0px;max-width:0px;opacity:0;overflow:hidden">But needs much more work</span>
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<h1 style="text-align:center;display:block;margin:0;padding:0;color:#202020;font-family:Helvetica;font-size:26px;font-style:normal;font-weight:bold;line-height:125%;letter-spacing:normal">New framework promises to give practical effect to WHO definition of 'health'</h1>
<p style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:150%;text-align:left;margin:10px 0;padding:0;color:#202020">Item 14, at this week's meeting of WHO's Executive Board, addresses Well-being and Health Promotion. The item emerged as a follow up to the 10th Global Conference on Health Promotion, held in Geneva in December 2021, which produced the <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=ad268e19da&e=125964ddcc" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">Geneva Charter for Well-being (2022)</a>. </p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:150%;text-align:left;margin:10px 0;padding:0;color:#202020">A draft resolution on Well-being and Health Promotion was submitted for EB150 (<a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=d532404d98&e=125964ddcc" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">EB150/CONF./5</a>) by UAE but was not considered, apparently on the grounds of time. The draft was also full of brackets. A more polished draft resolution was presented to WHA75 (<a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=3a70c73850&e=125964ddcc" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">here</a>). This was adopted, with virtually no debate, as <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=3c0afab361&e=125964ddcc" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">WHA75.19</a>. This resolution requested the DG to develop a framework on achieving well-being including innovative approaches using health promotion tools. </p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:150%;text-align:left;margin:10px 0;padding:0;color:#202020">The draft <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=773347f34b&e=125964ddcc" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">Global Framework</a>, published in late 2022, was designed to incorporate health promotion approaches and tools in responding to major global challenges related to environment, public health, social, economic and political instability affecting the health and well-being of populations. </p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:150%;text-align:left;margin:10px 0;padding:0;color:#202020"><a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=24999f3670&e=125964ddcc" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">EB152/20</a> describes the background and development process of the draft WHO framework and invites the Board to note the report and to provide further guidance. </p>
<h2 style="display:block;margin:0;padding:0;color:#202020;font-family:Helvetica;font-size:22px;font-style:normal;font-weight:bold;line-height:125%;letter-spacing:normal;text-align:left">Appreciation </h2>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:150%;text-align:left;margin:10px 0;padding:0;color:#202020">This draft framework promises to give practical effect to the definition of health enshrined in the <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=cd5ccc26d8&e=125964ddcc" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">WHO Constitution</a>: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”</p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:150%;text-align:left;margin:10px 0;padding:0;color:#202020">This is appreciated. However, the draft framework needs more work and perhaps closer supervision of its development. </p>
<h2 style="display:block;margin:0;padding:0;color:#202020;font-family:Helvetica;font-size:22px;font-style:normal;font-weight:bold;line-height:125%;letter-spacing:normal;text-align:left">Style: rhetoric or technical </h2>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:150%;text-align:left;margin:10px 0;padding:0;color:#202020">The present draft includes slabs of text taken from the <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=fea1d667bb&e=125964ddcc" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">Geneva Charter for Well-being</a>, generally expressed in the same rhetorical style. This use of inspirational rhetoric is customary in the outcome document of a conference of experts but it is not appropriate in what should be a sober, evidence based, technical document, as was called for in WHA75.19. </p>
<h2 style="display:block;margin:0;padding:0;color:#202020;font-family:Helvetica;font-size:22px;font-style:normal;font-weight:bold;line-height:125%;letter-spacing:normal;text-align:left">Conceptualisation of health promotion</h2>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:150%;text-align:left;margin:10px 0;padding:0;color:#202020">Operative Para 2(1) of <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=a5a91f3a85&e=125964ddcc" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">WHA75.19</a> asks the DG to identify the role that health promotion could play in achieving well-being. It is clear from context that the purpose of this request was to clarify the role that health promotion could play in promoting well-being if the proposed framework were to be adopted and implemented by WHO. </p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:150%;text-align:left;margin:10px 0;padding:0;color:#202020">However, the conceptualisation of ‘health promotion’ which is offered is ambiguous, variously treating health promotion as an institutional sector, comprising experts and organisations, versus treating health promotion as a body of principles and practices that health practitioners, agencies and administrations might apply in their work. To say that ‘Health promotion seeks to influence policies and programs’ (page 6 of the draft <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=64b0c4829b&e=125964ddcc" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">Global Framework</a>) treats ‘health promotion’ as a singular entity with its own agency. Further on, health promotion is described as “a lever for strengthening empowerment at individual and community levels beyond consultation, participation or other forms of engagement”.</p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:150%;text-align:left;margin:10px 0;padding:0;color:#202020">It would be useful to recognise a bit more clearly that the project of creating a well-being society (or civilisation) is informed in different sectors and communities by a very wide range of principles and paradigms of practice. Indeed the professional and civic practice of health practitioners is informed by a wide range of principles and paradigms, including but extending well beyond ‘health promotion’ (whether understood as an institutional sector or a body of principles and practices). </p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:150%;text-align:left;margin:10px 0;padding:0;color:#202020">On page 6 of the draft framework we are advised that “Health promotion is the process of enabling people to increase control over, and improve, their health”. But health promotion is clearly not the only “process of enabling people to increase control over, and improve, their health”. For many people the use of traditional or complementary medicines is a process of increasing control over and improving their health. Health promotion is not the only body of principles and practices which support governments, communities and individuals “to cope with and address health and well-being challenges in order to advance healthier populations and environments” (page 6). </p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:150%;text-align:left;margin:10px 0;padding:0;color:#202020">The framework does acknowledge that “that promotion of health and well-being is often achieved by professionals who are not trained as health professionals” but even here health promotion (however conceptualised) claims a role, in this case mediating between different interests. </p>
<h2 style="display:block;margin:0;padding:0;color:#202020;font-family:Helvetica;font-size:22px;font-style:normal;font-weight:bold;line-height:125%;letter-spacing:normal;text-align:left">No theory of change</h2>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:150%;text-align:left;margin:10px 0;padding:0;color:#202020">There is no theory of change articulated in this draft and it is hard to discern a robust theory of change from the text.</p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:150%;text-align:left;margin:10px 0;padding:0;color:#202020">The first requirement of a theory of change is to identify whose practice will be directly impacted by the action in question - in this case the adoption by WHO of the proposed framework. </p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:150%;text-align:left;margin:10px 0;padding:0;color:#202020">On page 10 we are advised that the main target audience “includes key stakeholders from communities and governments, local and national, working within and beyond the health sector”. Presumably this is intended to mean that these are the agents whose practice might be influenced, however indirectly, by this framework. However OP2(2) of WHA75.19 is clear that the framework will support the “translation into practice of innovative approaches for well-being using health promotion tools, new technologies and approaches to contribute to the WHO general programme of work”. The closest the actual draft gets to this is the statement on page 12 that “The Framework is also expected to accelerate actions outlined by existing WHO global action plans” but it is far from clear how. </p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:150%;text-align:left;margin:10px 0;padding:0;color:#202020">The reference to a vision could form part of a theory of change. However, the vision statement (“Societal well-being that enables all people to flourish and achieve their full physical and mental health potential throughout their lives and across generations”) seems tautologous; societal well-being enables personal well-being; presumably personal well-being aggregates into societal well-being.</p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:150%;text-align:left;margin:10px 0;padding:0;color:#202020">A vision for well-being should also speak about relationships including our relationships with each other (solidarity, listening, collaborating), our relationships with our communities (giving and receiving, collaborating), our relationship with our work (contributing, being creative, being appreciated, being useful), and our relationships with Mother Earth. </p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:150%;text-align:left;margin:10px 0;padding:0;color:#202020">The body of the draft framework comprises a series of six strategic directions, four of which are taken directly from the Geneva Charter. Each strategic direction comprises a series of ‘policy orientations’ with ‘examples of interventions at national level’. These directions, policy orientations and interventions are good and if implemented widely would probably contribute to well-being societies.</p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:150%;text-align:left;margin:10px 0;padding:0;color:#202020">But there are no drivers. Taking a random example (from page 14): “Re-orient investments and dis-incentivize production and consumption of health-harming products and services, towards health-promoting alternatives”. Many governments, organisations and people are working in various ways towards this end but there is nothing in this draft framework which suggests how the adoption of this framework by WHO will add value to their work. </p>
<h2 style="display:block;margin:0;padding:0;color:#202020;font-family:Helvetica;font-size:22px;font-style:normal;font-weight:bold;line-height:125%;letter-spacing:normal;text-align:left">Lack of senior involvement</h2>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:150%;text-align:left;margin:10px 0;padding:0;color:#202020">This text suggests limited involvement of experienced technical writers. </p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:150%;text-align:left;margin:10px 0;padding:0;color:#202020">The draft <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=21077af6c1&e=125964ddcc" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">Global Framework</a> is entitled “Achieving well-being: A global framework for integrating well-being into public health utilizing a health promotion approach” on page 1 but on page 8 there is reference to “The WHO Promoting healthier populations framework” which apparently refers to this document. </p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:150%;text-align:left;margin:10px 0;padding:0;color:#202020">The structure of the document is confused. On page 9 the framework is described as comprising “a key vision, an overarching goal, key objectives, guiding principles and an initial implementation and monitoring plan”. However, as the document proceeds, the section of ‘Guiding principles’ is replaced by ‘Fundamentals of Well-being’; 'Implementation and monitoring plan' is replaced by 'Strategic directions and actionable policy orientations' and the promise of a monitoring plan is not fulfilled. </p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:150%;text-align:left;margin:10px 0;padding:0;color:#202020">The ebullient rhetoric, the failed proof reading, the confused structure of the document, and the lack of a theory of change all suggest a lack of senior involvement in its development. </p>
<h2 style="display:block;margin:0;padding:0;color:#202020;font-family:Helvetica;font-size:22px;font-style:normal;font-weight:bold;line-height:125%;letter-spacing:normal;text-align:left">Underlying causes</h2>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:150%;text-align:left;margin:10px 0;padding:0;color:#202020">The oddly titled section, ‘Underlying causes of well-being erosion and societal impacts’ is somewhat limited in scope. </p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:150%;text-align:left;margin:10px 0;padding:0;color:#202020">The reference to ‘economic development models’ is appreciated. However, the dominant contemporary model of economic development is neoliberalism and this has been deliberately put in place by very powerful agents and forces over many decades, including the devastations of structural adjustment and selective liberalisation (liberalising trade and investment but not the movement of people or access to knowledge). How the proposed framework might strengthen WHO's approach to the 'well-being erosion' due to the neoliberal ascendancy is not spelled out. </p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:150%;text-align:left;margin:10px 0;padding:0;color:#202020">The reference to rapid urbanisation is appreciated and the implied reference to the huge informal settlements in the Global South where poverty, unemployment and lack of basic urban infrastructure are major barriers to health and well-being. However, many of these people were small farmers who have been driven off their land as part of the transformation of global food systems, driven by transnational food corporations and protected by WTO agreements. How the proposed framework might strengthen WHO's engagement with the political economy of food systems is not spelled out.</p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:150%;text-align:left;margin:10px 0;padding:0;color:#202020">Patriarchy and misogyny are threats to the well-being of half of the people on the planet. It is surprising that these are not noted.</p>
<h2 style="display:block;margin:0;padding:0;color:#202020;font-family:Helvetica;font-size:22px;font-style:normal;font-weight:bold;line-height:125%;letter-spacing:normal;text-align:left">What happened to the call for a NIEO articulated in the Alma-Ata Declaration?</h2>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:150%;text-align:left;margin:10px 0;padding:0;color:#202020">It is disappointing that there is no reference in this draft to the call for a new international economic order (NIEO, adopted by the UN General Assembly in 1974) which is referenced in para 3 of the Alma-Ata Declaration. </p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:150%;text-align:left;margin:10px 0;padding:0;color:#202020">A core principle informing the Alma-Ata Declaration is that primary health care practitioners and organisations should work with their communities to identify, analyse and respond to the factors in their lives and environments which shape their health and well-being. This is particularly clear if the Alma-Ata Declaration is reviewed in the light of WHO’s <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=773b94819f&e=125964ddcc" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">‘Health by the People’</a> by Kenneth Newell (1975) which informed the development of the Declaration and included a range of case studies where primary health care practitioners and organisations were working with their communities to engage directly with the forces shaping their health. </p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:150%;text-align:left;margin:10px 0;padding:0;color:#202020">The significance of the reference to the NIEO in the Alma-Ata Declaration is that it goes beyond high level goals to articulate quite specific reforms to global economic governance. The implication is clear that if PHC practitioners and their communities want to engage with the processes which reproduce their poverty, food insecurity, etc here are some specific policy reforms to advocate for. </p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:150%;text-align:left;margin:10px 0;padding:0;color:#202020">The author/s of the framework would do well to consult the 2014 <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=e97bfd6e85&e=125964ddcc" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">Declaration of Santa Cruz</a>: <i>For a new world order for living well</i> and the address by Evo Morales at the same conference, <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=ee00c81275&e=125964ddcc" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">‘For a global brotherhood among the peoples’</a>. </p>
<h2 style="display:block;margin:0;padding:0;color:#202020;font-family:Helvetica;font-size:22px;font-style:normal;font-weight:bold;line-height:125%;letter-spacing:normal;text-align:left">Listening to the Latin American school of social medicine and collective health</h2>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:150%;text-align:left;margin:10px 0;padding:0;color:#202020">WHO has been slow to recognise the power of ‘living well’ or <i>buen vivir</i> which has been very influential in Latin American public health. The author/s of the draft framework are to be appreciated for hinting that the new interest in well-being might owe something to the indigenous traditions from which the idea of buen vivir emerged. </p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:150%;text-align:left;margin:10px 0;padding:0;color:#202020">The framework would benefit from two other innovations from the Latin American school of social medicine/collective health. </p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:150%;text-align:left;margin:10px 0;padding:0;color:#202020">One of these is the insistence on distinguishing between <i>social determinants</i> (as factors which are shown to influence population health) and <i>social determination</i> (which focuses on the forces and dynamics which reproduce those factors). There is very little in the draft framework which addresses the social and political <i>determination</i> of health except at a very general level. </p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:150%;text-align:left;margin:10px 0;padding:0;color:#202020">The second innovation is the turn from public health to <i>collective health</i> in order to avoid over-stating the role of the government in shaping population health and to highlight the ways in which the health of populations is shaped by the forces, engagements and dynamics of communities and civil society more broadly. </p>
<h2 style="display:block;margin:0;padding:0;color:#202020;font-family:Helvetica;font-size:22px;font-style:normal;font-weight:bold;line-height:125%;letter-spacing:normal;text-align:left">Donor transparency</h2>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:150%;text-align:left;margin:10px 0;padding:0;color:#202020">One of the issues not being discussed in the current debate about Sustainable Financing for WHO is about donor transparency. Who has agreed to fund this initiative? What has been their role in the development of the initiative and in its progression through the governing bodies? Have all proprieties in relation to conflict of interest been complied with? </p>
<p dir="ltr" style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:150%;text-align:left;margin:10px 0;padding:0;color:#202020"><b>PHM urges the Board and the DG</b> to review the oversight arrangements and consultative processes in place for the drafting of this framework. It is too important to allow it to fail through technical weakness, donor indulgence, and great power cynicism.</p>
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<p style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:150%;text-align:left;margin:10px 0;padding:0;color:#202020">See our more detailed commentary on this item <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=e1455138d2&e=125964ddcc" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">here</a>. The Tracker page for EB152 is <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=67ca385819&e=125964ddcc" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">here</a>.</p>
<p style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:150%;text-align:left;margin:10px 0;padding:0;color:#202020">The <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=6cf8305d53&e=125964ddcc" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">WHO Tracker</a> and PHM item commentaries are produced as part of WHO Watch which is a project of the <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=0142e3a183&e=125964ddcc" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">People's Health Movement</a> in association with <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=72e94689a7&e=125964ddcc" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">Medicus Mundi International</a>, <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=497dcc7f06&e=125964ddcc" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">Third World Network</a> and a number of other civil society networks. WHO Watch aims to contribute to democratising global health governance, through new alliances, new information flows and by broadening the policy discourse.</p>
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<p style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:150%;text-align:left;margin:10px 0;padding:0;color:#202020">To provide feedback on this newsletter please write to <a href="mailto:editor@phmovement.org/" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">editor@phmovement.org</a>.</p>
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