@農자료창고

날이 갈수록 커지는 도시와 농촌의 격차. 이것도 양극화라 정의할 수 있다.

프랑스의 농촌 지역도 그러하여, 점점 빵집이 사라지고 있단다. 농촌에서 사라지는 게 어디 빵집 뿐이겠는가? 아이가 줄면서 학교도 폐교되고, 사람이 떠난 빈 집은 무너져 버리고, 버스와 택시도 줄어들거나 사라진다. "신선한 빵"으로 대표되는 각종 상품과 서비스를 누리는 권리도 도시만의 것이 되고 있다.

https://www.nytimes.com/2019/11/10/world/europe/france-bakery-closures.html#click=https://t.co/f8cXJXxFzm

출처: UNC Cecil G. Sheps Center for Health Services Research, Henry J. Kaiser Family Foundation

오바마 케어를 거절한 주에서 농촌의 병원이 무너지고 있다

미시시피, 사우스캐롤라이나, 조지아, 오클라호마 주의 농촌 병원들 가운데 절반 이상이 2011년부터 2017년까지 손실을 보고 있다. 

캔자스 주에서는 출혈이 더 광범위하다. 3개의 농촌 병원 가운데 2곳이 7년 동안 적자로 운영되었다. 5곳은 강제로 폐쇄되었다. 

큰 손실을 내고 있는 병원들

오바마 케어에 따라 의료 보장제도를 확대하는 걸 거절한 5개의 주에서 손실을 보고 있는 병원의 비율

참고: 코네티컷 주는 농촌의 병원이 3곳 뿐이어서 이 비교에서 제외되었다.

출처:Center for Medicare & Medicaid Services - Cost Reports

이들 주의 공통점은 의원들이 수십만 명의 의료보험이 없는 주민들에게 보험을 제공하고 농촌 병원의 수익을 증대시키는 일명 오바마 케어(Affordable Care Act)에 따라 의료 보장제도를 확대하는 걸 반대한 곳이란 점이다. 

극심하게 보수적이고 본질적으로 연방정부를 불신하는 주의 정치인들은 워싱턴의 관료들이 후한 오바마 케어의 기금에 손을 떼고 의료의 부담을 줄이기 위해 주에게 떠넘길 것이라며 의료 보장제도를 확대하기 위한 10%의 비용에 망설이고 반복하여 우려를 표했다. 

농촌 병원의 생명 징후

오바마 케어를 거부한 주들은 농촌의 병원을 폐쇄하고 손실을 볼 가능성이 더 높다.

참고: 수익성 한계 = 순수익 / 총수익 (2011-2017)

그건 아직 일어나지 않았다. 

한편, 진홍색 미국 농촌의 주민들 -농민, 농업노동자, 소규모 사업주 및 직원, 노약자- 은 병원의 좌초와 폐쇄를 목격하고 있다. 

텍사스 농촌 및 지역사회 병원 단체의 수장이자 의료 보장제도의 확대를 지지하는 존 헨더슨John Henderson 씨는 “나에겐 역설적인 상황이다. 우린 다른 주에서 적용 범위를 확대하기 위해 연방 소득세를 납부하고 있다. 우린 우리의 적용 범위를 내보내고 있으며, 수십억 달러를 상정하고 있다."고 말했다. 

전문가들은 오바마 케어를 수용하는 일이 농촌 병원을 구제하는 방법이 아니며 폐쇄되는 수많은 병원을 구하지 못한다는 데에 동의하지만, 돈을 거절하는 게 현명하다고 믿는 사람은 거의 없다.  

미국 농촌이 직면하고 있는 위기는 수십 년에 걸쳐 극심해지고 있으며, 아수라장은 곧 끝나지 않을 것처럼 보인다. 

일자리 감소와 결합된 농촌 지역의 높은 빈곤률, 인구 고령화, 건강보험 부족 및 다른 어려움에 처한 기관과의 경쟁 등은 어떠한 정부 정책이 시행되든지 농촌 병원의 생존을 어렵게 만들 것이다. 

어떤 이는 노력할 필요도 없다고 한다. 그들은 광범위한 폐쇄가 자유시장 경제가 작동한 결과이고, 계속 파산하는 편이 도움이 될 것이라 한다. 하지만 어떤 농촌 지역사회도 자신의 뒤뜰에서 그러한 도태가 일어나길 바라지 않는다.

오클라호마 병원협회의 패티 데이비스Patti Davis 대표는 “병원의 폐쇄는 작은 마을에게 두려운 일이다."라고 한다. “생활을 위험에 빠뜨리고, 지역사회에 도미노 효과를 일으킨다. 의료 전문가들이 떠나고, 약국은 문을 닫으며, 요양원은 폐쇄되고, 주민들은 가장 취약한 시간대에 가장 가까이 있는 시설까지 가는 데에 구급차에 의존해야만 하게 된다." 

병원이 없으면, 어느 지역에 새로운 사업을 유치하여 사람들이 떠나지 못하게 하기도 어려워진다고 그녀는 말한다. 

위기를 더 잘 이해하기 위하여, 피츠버그 모닝선Morning Sun과 그 모회사인 게이트하우스 미디어GateHouse Media의 기자들은 3개월 동안 미국 전역의 약 2200개 병원의 금융 자료를 분석하여 손실을 보는지, 폐쇄 가능성에 직면해 있는지를 조사했다. 또한 보도기자들은 학술 연구를 세세히 읽고, 20여 명의 병원 관계자, 협회 임원, 기타 보건 전문가와 이야기했다.  

조사 결과: 

-미국 농촌은 2010년 이후 106건의 병원 폐쇄가 발생하며 깊고 장기간의 위기에 처해 있다. 메사추세츠 컨설팅 회사 iVantage Health Analytics와 채플힐에 있는 노스캐롤라이나 대학의 보건 서비스 연구를 위한 Sheps 센터에 의하면, 약 700곳이 불안한 상태이며, 약 200곳은 붕괴 직전에 있다. 

-최악의 상황에 처한 병원은 주로 의료 보장제도 확대를 거부한 주에 있다. 이들 주에서는 지난 10년 동안 일어난 106건의 폐쇄 가운데 77건이 해당되었다. 또한 이들 주에 있는 시설의 손실율이 더 높고, 집단적 이윤 폭도 더 낮다.   

-가장 밑바닥은 보수적인 Sam Brownback 주지사가 8년 동안 통치한 캔자스 주이다. 109개의 농촌 병원 가운데 70개가 2011-2017년까지 손실을 보았고, 7개는 미국의 농촌 병원 가운데 가장 나쁜 실적을 보인 20곳에 순위를 올렸다. 인근 오클라호마 주에 있는 병원들은 더 나은 성과를 내지 못했고, 미국 최남단에 있는 여러 주에서도 마찬가지라고 할 수 있다. 

-하지만 최근 주민들이 의료 보장제도를 확대하기로 투표한 한 개의 주에서만 전국적 경향이 뒤집혔다. 도시 병원의 희생과 작은 마을들과 함께 일하려는 그들의 의지 덕에, 유타의 농촌 병원은 2011-2017년까지 전국에서 가장 수익이 높았다. 그 기간 동안 단 14%만 손실을 보았고, 아무곳도 강제로 폐쇄되지 않았다.

“20년 전 우리는 도시의 병원에서 돈을 조금 걷어서 농촌의 병원으로 보내는 정책을 수립했다."고 유타 병원협회의 부회장 데이브 게셀Dave Gessel 씨는 말한다. “그것이 우리의 모든 병원의 기초가 되었다." 

게셀 씨는 몰몬교가 통일된 영향력을 제공했다고 덧붙였다. “유타의 농촌은 몰몬교가 상당히 강하다. 그러한 연결, 그러한 유대 때문에지역 주민들은 만약 자신들이 뭉치지 않으면 상황이 정말로 나빠질 수 있다는 걸 깨달았다." 

‘우린 모두를 돌본다' 

국가의 현행 농촌 병원 체계는 모든 마을에는 현대적 시설이 있어야 한다고 믿는 1940년대로 거슬러 올라간다. 하지만 의료 기술의 급속한 발전으로, 의료 서비스에 대한 수요와 공급은 도시 지역으로 이동했다. 

텍사스 A&M 대학의 농촌과 지역사회 보건연구소의 대표 낸시 디키Nancy Dickey 박사는 “1970년대와 1980년대에 우리가 할 수 있는 대부분의 일들은 작은 마을에서도 합리적으로 잘 이루어질 수 있었다."고 한다. “하지만 신경외과학, 현미경 수술 등 과학적 발전과 진보는 다양한 기술 전문가들을 지원하기 위해 더 많은 기술과 인구를 필요로 하게 되었다."  

농촌 병원에서 제공할 수 있는 서비스의 숫자는 그 결과 줄어들었고, 많은 병상이 필요하지 않게 되었다고 디키 박사는 말한다. 그와 함께 일자리가 말라 버리면서 농촌 인구가 줄어들고 청년들이 떠나 버렸다. 이로 인해 농촌 지역사회는 나이가 들고 빈곤한 인구가 늘어나고 건강보험이 없는 사람들이 증가했다. —1990년대에만 180곳이 넘는 농촌 병원을 폐쇄시킨 재정적으로 어려움에 처하게 하는 인구 통계 

폐쇄에 의해 경각심을 느낀 정치인들은 Critical Access Hospital 지정의 제정을 포함하는 법안을 통과시킴으로써 대응했다. 이는 농촌 병원의 선택된 집단이 의료 보장제도 환자에게 적용되는 모든 비용을 보장하도록 하는 내용이다. 

CAH 지정은 만약 병원 운영에 1년 동안 100만 달러가 소요되고 그 병원에 며칠 동안 치료를 받는 1명의 의료 보장제도 환자가 있다면, 의료 보장제도가 병원에 실질적으로 100만 달러를 상환하게 된다는 의미라고 캔자스 키오와Kiowa의 키오와 지구 병원District Hospita의 최고 경영자 로버트 휘태커Robert Whitaker 씨는 설명한다. 만약 똑같은 병원에 의료 보장제도 환자 1명과 블루 크로스Blue Cross와 블루 쉴드Blue Shield의 보험가입자 1명이 있다면, 의료 보장제도는 50만 달러를 지불하는데 블루 크로스는 몇 천 달러에 달할 수 있는 환자가 병원에 머물 때의 비용만 지불하게 된다.

자신의 병원이 주로 의료 보장제도 환자만 치료하는 휘태커 씨는 병원의 생존이 CAH 지정 덕이라고 보며, 비용 관리와 수익성 높은 환자의 유지에 모두 주의를 기울인다. 

휘태커 씨는 “우린 모두를 돌본다지만,  혼합에 주의한다.”고 한다. 

그 결과, 키오와 지구 병원은 2011-2017년까지 농촌 병원의 64%가 손실을 보는 상황에서 같은 기간 560만 달러의 이익을 기록했다.

키오와Kiowa 지구의 병원

손실을 보고 있는 주에서 드문 수익성

출처: Center for Medicare & Medicaid Services - Cost Reports

Experts say the CAH designation helped other rural hospitals as well, contributing to a significant drop in closures during the first decade of the 21st century. But when the Great Recession hit, many rural hospitals found themselves in another deep financial hole. Closures began rising again — a trend that has not relented despite the economic rebound.

“If you don’t take the expansion,” said Dickey, the Texas A&M professor, “it’s a challenge to make sure you have enough paying patients coming through the door.”

농촌 병원의 폐쇄

Source: Center for Medicare & Medicaid Services - Cost Reports

‘A market that regularly fails‘

Looking at the data, it’s hard not to conclude that hospitals in non-expansion states are suffering far worse that those that embraced Obamacare. But for most of these states, refusing Medicaid was not their only problem.

Most have higher poverty rates and more hospitals concentrated in adjacent geographical areas. Many also lack coherent statewide policies to address the crisis.

Texas, for instance, experienced 17 closures since 2010 — the most in the country, according the Sheps Center for Health Services Research at UNC Chapel Hill. But practically all of them were located in the eastern and southeastern parts of the state.

폐쇄된 병원

오바마 케어를 거절한 주들은 농촌의 병원을 폐쇄하고 손실을 볼 가능성이 더 높다. 

Source: UNC Cecil G. Sheps Center for Health Services Research

These are small agricultural communities, explained Henderson, who heads The Texas Organization of Rural & Community Hospitals. The population is generally poorer than in other parts of the state and hospitals are closer to each other.

By comparison, hospitals in West Texas are further apart. They have less competition, and they are often supported by property taxes connected to the oil and gas industry, Henderson said. When oil prices are up, hospitals in these communities have access to more resources.

The same is true for some hospitals in Oklahoma.

“The biggest part of our profitability stems from the fact that we’re supported by a local county sales tax,” said Cindy Duncan, chief executive of Roger Mills Memorial Hospital in Cheyenne.

From 2011 through 2015, her hospital recorded profits because oil and gas companies were spending lots of money to buy pipes and pumps and fracking fluids. But when oil prices dropped and drilling stalled, the hospital started reporting losses.

“We saw a big shift in 2015,” Duncan said. “The community sales tax declined by 90 percent.”

로저 밀스 기념 병원(Roger Mills Memorial Hospital)의 순수입

Source: Center for Medicare & Medicaid Services - Cost Reports

It’s not just Texas and Oklahoma. In Kansas, survival of rural hospitals also depends on what local resources they can draw on.

“Because many of our hospitals are affiliated with local governments, each locality might take a different approach,” said Kari Bruffett, the Kansas Health Institute’s vice president for policy.

It’s clear those disparate approaches aren’t working.

Not only did Kansas lose five hospitals since 2010, it also is home to some of the worst performing rural hospitals in the country. They include Kiowa County Memorial Hospital in Greensburg and Morton County Hospital in Elkhart, which both lost more than $17 million between 2011 and 2017.

출혈 중인 캔자스 주의 두 병원

Source: Center for Medicare & Medicaid Services - Cost Reports

“From where I’m sitting, it really does go back to resources and whether there has been Medicaid expansion,” said April Holman, executive director of the Alliance for a Healthy Kansas. “Expansion on its own won’t save any hospital, but it does play into the funding mix that helps sustain rural hospitals.”

Terry Hill, senior advisor to the National Rural Health Center in Duluth, Minnesota, agreed that Medicaid expansion would help troubled hospitals in Kansas and other states.  But he said the situation in the Deep South is more problematic because rural hospitals generally get paid much lower rates for both Medicaid and private insurance than states like New York or Minnesota.

At the same time, unaddressed health care needs in the South are often greater.

Alabama, for example, has a higher poverty rate, a higher incidence of diabetes and other chronic conditions and a larger percentage of patients who can’t pay their medical bills. Those dynamics have contributed to the closure of six rural hospitals and the second lowest margin of profitability in the country behind Kansas.

There are some academic researchers and politicians in conservative states who believe there are good reasons for the failure of rural hospitals and that the free market should be left to decide the winners and losers.

Navigant, a Chicago-based healthcare consulting firm, recently published a report stating that 153 of the 430 unstable rural hospitals in the United States are “not essential.” If they go down, their communities would find other ways of meeting residents’ needs.

That conclusion is supported by a 2015 Harvard University study that looked at 195 hospital closures between 2003 and 2011 and found that, while patients had to travel further after a shutdown, death rates and other key indicators of quality health care did not worsen.

But George Pink, deputy director of the North Carolina Rural Health Research Program at the Sheps Center,  isn’t convinced the free market is the best model for rural America.

“Healthcare has shown itself many times over to be a market that regularly fails,” Pink said. “If you think of a small, rural community, miles from anywhere else, you wouldn’t expect the market to jump in and provide solutions. Think about the high percentages of poor, chronically ill, elderly, and disabled in these towns. These are not people with a lot of political power.”.

‘We rallied around to help them‘

While hospitals in most states that declined to expand Medicaid are struggling, Utah provides a notable exception.

Gessel, the executive vice president of the Utah Hospital Association, says that’s because his state has certain advantages.

One is that hospital systems in Utah are more concentrated than in other parts of the country. There are only four, and the largest — Intermountain Healthcare — controls nearly half of the 21 rural hospitals in the state.

Utah also has a diversified and growing economy, a low poverty rate and a tradition of donating generously to charity, Gessel said, and rural hospitals have been successful in attracting experienced executives from bigger markets.

As a result, only three rural hospitals in Utah reported losses from 2011 through 2017, and collectively its 21 hospitals logged the highest profit margin in the country.

유타 주는 추세를 뒤집다

Source: Center for Medicare & Medicaid Services - Cost Reports

“Over a 24 year period there were three or four hospitals that might have closed,” Gessel said. “But everyone rallied around to help them."

Pink, the professor at UNC’s Sheps Center, said several other states have taken novel approaches to addressing the crisis. Louisiana recently passed the Rural Hospital Preservation Act that supports rural hospitals with wrap around funding, and North Carolina is about to follow its lead.

“These are useful initiatives,” Pink said.  “But I don’t know of any hospital that’s opposed to Medicaid expansion. It’s good from a financial standpoint. But more importantly, it provides access to health care for vulnerable people.”

원본 http://gatehousenews.com/ruralhospitals/financialtroubles/

http://www.ecologyandsociety.org/vol17/iss4/art40/

요약

We hypothesize that biological diversification across ecological, spatial, and temporal scales maintains and regenerates the ecosystem services that provide critical inputs—such as maintenance of soil quality, nitrogen fixation, pollination, and pest control—to agriculture. Agrobiodiversity is sustained by diversified farming practices and it also supplies multiple ecosystem services to agriculture, thus reducing environmental externalities and the need for off-farm inputs. We reviewed the literature that compares biologically diversified farming systems with conventional farming systems, and we examined 12 ecosystem services: biodiversity; soil quality; nutrient management; water-holding capacity; control of weeds, diseases, and pests; pollination services; carbon sequestration; energy efficiency and reduction of warming potential; resistance and resilience to climate change; and crop productivity. We found that compared with conventional farming systems, diversified farming systems support substantially greater biodiversity, soil quality, carbon sequestration, and water-holding capacity in surface soils, energy-use efficiency, and resistance and resilience to climate change. Relative to conventional monocultures, diversified farming systems also enhance control of weeds, diseases, and arthropod pests and they increase pollination services; however, available evidence suggests that these practices may often be insufficient to control pests and diseases or provide sufficient pollination. Significantly less public funding has been applied to agroecological research and the improvement of diversified farming systems than to conventional systems. Despite this lack of support, diversified farming systems have only somewhat reduced mean crop productivity relative to conventional farming systems, but they produce far fewer environmental and social harms. We recommend that more research and crop breeding be conducted to improve diversified farming systems and reduce yield gaps when they occur. Because single diversified farming system practices, such as crop rotation, influence multiple ecosystem services, such research should be holistic and integrated across many components of the farming system. Detailed agroecological research especially is needed to develop crop- and region-specific approaches to control of weeds, diseases, and pests.

INTRODUCTION

Diversified farming systems share much in common with organic, multifunctional, sustainable, and agroecological management approaches and outcomes. The key indicators of a diversified farming system is that diversification across ecological, spatial, and temporal scales serves as the mechanism for maintaining and regenerating the biotic interactions and, in turn, the ecosystem services—e.g., soil quality, nitrogen fixation, pollination, and pest control— that provide critical inputs to agriculture (see also Shennan 2008). Across ecological scales, a diversified farming system includes several or all of: (1) genetic diversity within crop or livestock varieties; (2) varietal diversity within a single crop or livestock species; (3) multiple intercropped species, and/or integration of fish or livestock species; and (4) noncrop plantings and seminatural communities of plants and animals, such as insectary strips, hedgerows, riparian buffers, pastures, and woodlots. Across spatial scales, diversified farming systems promote agrobiodiversity through practices located within field (e.g., composting, intercropping, insectary strips, agroforestry), across the whole field (e.g., crop rotations, cover cropping, fallowing), around field perimeters (e.g., hedgerows, border plantings, grass strips), across multiple fields (mosaics of crop types and land-use practices), and at the landscape-to-regional scale (e.g., riparian buffers, woodlots, pastures, and natural or seminatural areas). Across temporal scales, asynchronous tilling, planting, harvesting, cover cropping, crop rotations, fallowing, or flooding contribute to the maintenance of landscape-scale heterogeneity (Shennan 2008), while no-till, perennial grass, forb or tree cropping systems, hedgerow set-asides, and forest gardens allow the natural processes of ecological succession to enhance agrobiodiversity dynamically (Altieri 2004, Glover et al. 2007, Bhagwat et al. 2008). 

Agrobiodiversity is sustained by diversified farming system practices and it also supplies multiple ecosystem services to agriculture, thereby reducing the need for off-farm inputs. For example, through composting and manuring, soils are produced that harbor diverse microbial and invertebrate communities which in turn promote nutrient cycling (Mäder et al. 2002, Reganold et al. 2010). Through intercropping of nitrogen-fixing legumes with grains, farmers achieve the well-known phenomenon of “over-yielding”—i.e., the production of a larger amount of each crop per unit area relative to production in monoculture—thereby increasing yields while reducing or eliminating fertilizer inputs (Vandermeer 1992). Intercropping is thought to promote over-yielding because different crops grown together can utilize more of the available resources (e.g., crops with different rooting depths can access a larger fraction of spatially stratified nutrients and water) or because one crop facilitates the growth of the other (Hauggard-Neilsen and Jensen 2005). By enhancing floral diversity on farms through insectary strips, hedgerows, or retention of seminatural areas, farmers may enhance or attract natural enemies and/or wild pollinators to their crops and thereby increase pest control or reduce or eliminate the need for honey bee rentals (Kremen et al. 2002, Morandin and Winston 2005, Letourneau et al. 2011). The supply of these ecosystem services (e.g., soil fertility, pest control, pollination) is critically dependent on the maintenance of the underlying biodiversity—from soil microbes to flora and fauna—and on their interactions (Altieri and Nicolls 2004, Hooper et al. 2005, Zhang et al. 2007, Hajjar et al. 2008, Shennan 2008, Jackson et al. 2009). Maintaining diversity across scales through diversified farming system practices not only enhances these ecosystem services (Table 1) but promotes their resilience in the face of disturbances such as drought, deluge, or pest infestations (Tengo and Belfrage 2004, Lin 2011).

Increasingly in the Global South and largely in the north, diversified farming systems have been replaced with highly simplified industrial monocultures (Benton et al. 2003, Tscharntke et al. 2005, DeFries et al. 2010). Average field and farm sizes have increased, while noncrop areas in and around farms have decreased, leading to higher levels of homogeneity at both the field and landscape scales. The collective simplification of agroecosystems has led to a loss of biodiversity and to reductions in the supply of key ecosystem services to and from agriculture (Tscharntke et al. 2005, Zhang et al. 2007). Without these ecosystem services, monocultures become dependent on off-farm inputs. For example, without the integration of farming practices that fix nitrogen, make efficient use of nutrients, and build soil fertility (see Table 1), growers must purchase and apply synthetic fertilizers. Similarly, without practices that prevent the build-up of pests and pathogens and promote diverse communities of natural enemies, growers must purchase and apply pesticides. While effective in producing high yields, conventional chemical inputs that substitute for ecosystem services contribute to significant environmental and social harms, including soil degradation, eutrophication of surface and groundwater, loss of biodiversity, increased greenhouse gas emissions, marine dead zones, and occupational and dietary exposure to toxic agrochemicals (Tilman et al. 2002, Diaz and Rosenberg 2008, Hayes et al. 2010, Marks et al. 2010, Gomiero et al. 2011a). Industrialized agriculture is also partially responsible for creating a range of social and economic impacts, including loss of access to land, corporate control of agricultural inputs, and the inability of small-scale producers to compete on the global market, resulting in high rates of poverty and the loss of food security for small holders (Bacon et al. 2012, Iles and Marsh 2012). 

We assessed the ecological performance of biologically diversified farming systems as compared with conventional (industrialized) systems across 12 key ecosystem services that represent inputs to farming (e.g., soil fertility), mitigation of externalities associated with farming (e.g., energy-use efficiency), adaptation of farming to environmental change (e.g., resistance and resilience to extreme weather events), and outputs from farming (crop productivity) (Table 2). We begin by discussing biodiversity, because it underlies all other services (Millennium Ecosystem Assessment 2005), and then we discuss the related services of soil quality maintenance, nutrient management, and water-holding capacity. Next we cover control of weeds, plant pathogens, and arthropod pests. We continue with pollination services, and then with climate-related services, including carbon sequestration, energy-use efficiency/reduction of global-warming potential, and the resistance and resilience of farming systems to extreme weather events. Finally, we consider crop productivity, including discussion of the potential trade-off of lowered yields against biodiversity and habitat conservation.

METHODS

RESULTS AND DISCUSSION

Biodiversity

Soil quality

Nutrient management

Water-holding capacity

Weed control

Disease control

Arthropod pest control

Pollination services

Carbon sequestration

Energy-use efficiency and reduction of global-warming potential

Resiliency to environmental disturbances: severe weather conditions

Crop yield

Trade-offs between crop productivity and biodiversity conservation

CONCLUSIONS

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