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Sudden Unexpected Nocturnal Death Syndrome among Hmong Immigrants: Examining the Role

of the "Nightmare"
Author(s): Shelley R. Adler
Source: The Journal of American Folklore, Vol. 104, No. 411 (Winter, 1991), pp. 54-71
Published by: American Folklore Society
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SyndromeamongHmong Immigrants
Examiningthe Role of the "Nightmare"

SuddenUnexpected NocturnalDeath Syndromehasbeenregarded as havingan

exclusivelypathophysiological A on
etiology. focus factorsaffectingHmong
refugeesin the UnitedStates,suchas traditionalbelief,genderroles,and the
impactof war, migration,and rapidacculturation,revealsthe eventthat may
provokethefatal syndrome.A supranormal nocturnalexperience,traditionally
knownas the "nightmare" andfamiliarto theHmong,appearsto actas a trigger
for fatal disorder.

IN 1980, a frighteningpatternof unexplaineddeathswas brought to the atten-

tion of the Centers for Disease Control by a medical examiner in Portland,
Oregon, who noted that the recent death of a SoutheastAsian from an unde-
terminedcausewas similarto a deathhe hadinvestigatedearlier.Since the first
reporteddeath, which occurredin July 1977, more than 100 persons of various
SoutheastAsian ethnic groups have died from the mysterious disorderthat is
now known as SUNDS, the Sudden Unexpected Nocturnal Death Syn-
drome.' The sudden deathshave an unusuallyhigh incidenceamong Laotians,
particularlymale Hmong refugees. The rate of death from SUNDS among
Laotian-Hmong men has reached alarming proportions, being equivalent to
the sum of the rates of the leading five causes of naturaldeath among United
Statesmales (Baron et al. 1983).
Despite numerous studies of SUNDS-which have takeninto accountsuch
varied factors as nutrition, toxicology, heart disease, metabolism, and ge-
netics-investigators appearto be no nearerto discovering exactly what it is
that is killing these seemingly healthy people in their sleep. The April 1989
report from the Centers for Disease Control in Atlanta, Georgia, states that
"althoughstudies have suggested that a structuralabnormalityof the cardiac
conductionsystem . .. and stress . .. may be risk factorsfor SUDS, the cause
of the deathsremainsunknown" (RefugeeHealthIssuesQuarterly1989:1). This
problem is reiteratedin a pamphletissued in 1987 by the Asian Sudden Death
Information Center in Minnesota that describes the present situation suc-
in theFolkloreandMythologyProgram
Shelley R. Adler is a doctoralcandidate
at the Universityof California,LosAngeles

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Adler, SuddenDeathamongHmongImmigrants 55

cinctly:"In spite of past and ongoing studiesof SUNDS, healthspecialists

havenot foundwhatcausesit."
Medicalresearchto datethushasprovidedno completeexplanationfor the
for the medicalexaminerof St. Paul,recallsthe perplexitythatcharacterized
early investigations of Hmong sudden deaths: "We drew a complete
blank. In eachcasewe askedourselveswhat they haddiedfrom andthe
answerwas 'Nothing'" (Monagan1982:36).Infact,deathcertificates of most
SUNDS victimsstatethatthereis no knowncauseof death.
The Westernbiomedicalsystemprovidesno adequateanswerto the ques-
tion of what causesSUNDS; however,a studyof Hmong traditionalbelief,
recentfindingsin sleepresearch,anda considerationof the Hmong refugee
experiencerevealimportantfactorsthatI suggesthavea rolein triggeringthe
syndrome.As a directconsequenceof maintaininga folklorist'sperspective,I
am ableto presenta fundamental hypothesisthathasbeenoverlookedby re-
searchers in otherfieldsof inquiry.Therearecertainemphasesandvaluesthat
characterize folkloristicswhichhaveprovenindispensable to my investigation
of the problemof Hmong SUNDS: the comparativeandbroadlyinterdisci-
plinaryapproachaimedat understanding andrespectingtheindividual'spoint
of view;thesearchforuniversalsin humanthemes,andtheattemptto explain
continuitiesandconsistenciesin termsof individualexperience;anda premise
centralto folklorestudy'sintellectualhistoryanddevelopment,"thatordinary
peopletend to be underestimated and thattheirknowledgetendsto be dis-
creditedby authorities"(Hufford1990).
My hypothesisregardingthe etiology of SUNDS, basedon preliminary
fieldworkanda reviewof previousandcurrentresearch,is thata supranormal
nocturnalexperienceknown as the "nightmare"andfamiliarto the Hmong
actsas a triggerfor the suddennocturnaldeaths.I use the word "nightmare"
not in the modernsenseof a baddream,but ratherin traditionaltermsas the
nocturnalvisit of an evil beingthatthreatensto pressthe very life out of its
terrifiedvictim(Hufford1976,1982;Ward1977).3(To avoidconfusion,I use
Nightmare [uppercase]to referto the spiritor demonfigureof nocturnalas-
saultsandnightmare [lowercase]to referto the basicexperience;thatis, the
impression of wakefulness, immobility,realisticperceptionof the environ-
ment, and intense fear.)
Accordingto descriptionsof the Nightmarespirit,the sleepersuddenlybe-
comes aware of a presence close at hand. Upon attempting to investigate fur-
ther, the victim is met with the horrifying realization that he or she is com-
pletely paralyzed. The presence is usually felt to be an evil one, and often this
impression is confirmed by a visual perception of the being, which places itself
on the sleeper's chest and exerts a pressure great enough to interfere with res-
The characteristics of the nightmare, those that by their frequency of oc-
currence can be said to form the core (the minimal requirements) of the ex-

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56 Journalof AmericanFolklore104(1991)

perience,are (1) the subjectiveimpressionof wakefulness,(2) the feelingof

immobility,(3)therealisticperceptionof theenvironment,and(4)intensefear
andanxiety.Variousotherfeaturesthatoften,butnotof necessity,accompany
thecoresymptomsincludethe victim'slying on his or herback,the sensation
of a presence(usuallyevil andoften visualized),a feelingof pressureon the
chest,difficultrespiration,andaninabilityto speak.4(Theattemptto callout,
when heardby others,is in the form of panickygroans[DonaldWard,per-
The nightmaresyndromeappearsto be universal.Thereareinnumerable
instancesof the nightmarethroughouthistoryandin a multitudeof cultures.
Traditionsof the nocturnalpressingspiritappearin literatureas earlyas an-
cientGreece(ephialtes = leapupon;Roscher1979)andinstancesarepresentin
diverseareas,asevidenced,forexample,by termsin the followinglanguages:
Frenchcauchemar (fromLa.calcare= to trampleupon,squeeze),GermanAlp-
druck(= elf pressure),Polishzmora,Russiankikimora, Spanishpesadilla,Es-
kimo augumangia. A completelist would go on for pages.All of theseterms
refer,in theiroriginalsense,to a nocturnalpressingspirit.
Beforeconsideringthe Nightmarespiritas it appearsin Hmong tradition,
it maybe helpfulto thoseunfamiliarwith the experienceto includea typical,
albeitliterary,accountfrom a Britishmonographon the subject.The night-
mareinspiredat leasttwentytreatisesfromthe mid 17thto the mid 18thcen-
tury, but it was not until 1763thatthe firstdescriptionof the experienceap-
pearedin Englishin An EssayontheIncubus, orNightmare,writtenbyJ. Bond:
The nightmaregenerallyseizes people sleeping on their backs, and often begins with frightful
dreams,which are soon succeededby a difficult respiration,a violent oppression on the breast,
anda total privationof voluntarymotion. In this agony they sigh, groan, utterindistinctsounds,
and remainin the jaws of death, till, by the utmost efforts of their nature, or some externalas-
sistance,they escapeout of that dreadfultorpid state. As soon as they shakeoff that vast oppres-
sion, and are able to move the body, they are affectedby strong palpitation,great anxiety, lan-
guor, and uneasiness;which symptoms graduallyabate, and are succeededby the pleasing re-
flectionof having escapedsuch imminent danger. [E. Jones 1931:16]

The varioushistoricaldiscussionsareof interestin thatthey demonstratethe

stabilityof the nightmareexperienceacrossculturesandthroughtime. Ideas
regardingcausation(e.g., evil spirits,poor circulation,indigestion)andpre-
vention (e.g., sleepingwith a knife or Bible underone's pillow, avoiding
sleepingon one'sback),as well as methodsfor escapingthe terroronceit be-
gins (e.g., being touchedby someoneelse, trying to move a fingeror toe,
praying) are also remarkably consistent in both earlier documented accounts
and contemporary case studies.
The stable features in the nightmare experience, as well as some of the var-
iable culture-specific elaborations, are evident in the following account of an
experience in Laos.5 A Hmong man who left Laos in 1975 and who now lives
in Santa Ana, California, where he is one of the directors of a self-help orga-
nization for Laotian refugees, relates the following experience:

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Adler, SuddenDeathamongHmongImmigrants 57

when I went hunting ... I slept in the jungle and an old man wearing a cloak came to me and
told me that "Oh, now you aregetting, you're getting stronger. I want to see, I want to try how
strong you are." Then he, he simply squeezedmy neck very hard, and I could not do anything.
Finally,my friendwho slept next to me turnedover and touched me. That's why I was able to
move my arm, my legs Before that, I couldn't move, couldn't breathe.I think most of the
people who die in their sleep might have a similarnightmare. [CT]

The "peoplewho diein theirsleep"thattheHmonginformantrefersto are

Hmong victims of SUNDS. Because of the lethal nature of the syndrome,
information regarding the moments preceding an attack can ordinarily only
be gainedfromrelativesandfriendsof thestricken.Of allthepeoplewho have
been victims of SUNDS, the only known survivor of what must be termed a
"SUNDS attack"is Ge Xiong, a Hmong immigrant currentlyliving in central
California.His wife awoke one night to find him lying on his back, not breath-
ing, andcompletelyunresponsive.Sheimmediatelytelephonedanemergency
number, and paramedicsarrivedin time to resuscitatehim. Not surprisingly,
Ge Xiong can remembernothing of the immediate events surroundingthe al-
most-fatalattack,but, by way of comparison,he offersthefollowingdescrip-
tion of a nightmarehe hadpreviouslyexperienced:"youwantto speak,you
are dumb; you want to call out, you cannot; you feel you are dying,
dying .. ." (Lemoine and Mougne 1983:18). In this and other previous ex-
periences,Ge distinctlyrecallsbeingunderthe attackof a nocturnalspiritthat
appearsin eitheranimalor humanformandpressesdown on the chestof the
TraditionalHmong belief interpretsthe nightmareexperienceGe Xiong re-
counts as the visit of the nocturnalpressing spirit known as dabtsog.A clearer
example of the other-worldly nature of this type of visitation is found in the
work of JosephJay Tobin andJoan Friedman.The two researchers
gatedthe caseof VangXiong, a Hmong refugeewho had experiencednoc-
turnal encounters that the researchersreferredto, perhaps misleadingly, as
"spiritpossession."Vang,who movedto ChicagoafterfleeingLaoswith his
wife and child in 1978, had a series of nightmaresimmediately upon moving
into his apartment.

The first night he woke suddenly, short of breath, from a dreamin which a cat was sitting on
his chest. The second night, the room suddenly grew darker,and a figure, like a largeblackdog,
came to his bed and sat on his chest. He could not push the dog off and he grew quickly and
dangerouslyshort of breath. The third night, a tall, white-skinned female spirit came into his
bedroom from the kitchen and lay on top of him. Her weight made it increasinglydifficult for
him to breathe. .. . He attemptedto turn onto his side, but found he was pinned down. After
fifteen minutes, the spiritleft him. [Tobin and Friedman1983:440]

This description offers another example of how the seemingly unique Hmong
experience is actually a culture-specific manifestation of the universally expe-
rienced physiological state that produces the "traditional" Nightmare attack.
In interpreting the account, Tobin and Friedman make the plausible deduction

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58 Journalof AmericanFolklore104(1991)

thatVangmaybe a survivorof SUNDS. The difficultywith theirfinalanal-

ysis, aswell aswith theanalysesof mostinvestigatorswithno trainingin folk-
lore,resultsfroma lackof familiaritywith classicmanifestations
of theNight-
difficulties"canbeseen"assymptomsof theanxiety,depression,andparanoia
thatthreatenall victimsof traumaandextremestress,"they pointto impor-
tantbackgroundfactors,but misreadwhatarein factthe classicsymptomsof
a Nightmareattack(1983:442).
Anotherrelevantinvestigationwas conductedby JacquesLemoineand
ChristineMougne(1983).Afterinterviewing29 familiesof Hmongmenwho
haddiedof SUNDS, the researchers concludedthat"theonly clueto emerge
from our discussions. . . was a dream,forewarningdeath"(1983:9).Here,
again, lack of familiaritywith the symptomsof the traditionalnightmare
causesresearchers to lump togethera varietyof nocturnalexperiences(e.g.,
bad dreams,night terrors,nightmares)and interpretthem as premonitory
dreams;an assessmentthatalso disregardsmanyvictims'convictionthatthe
attackoccursin a wakingstate(Hufford1982;TobinandFriedman1983).
Althoughthereareinsightsto be gainedfrom previousinvestigations,the
mostimportantlinkforunderstanding the likelycauseof the Hmongsudden
deathsis foundin anintriguingcasedefinitionpresentedin the FinalReportof
theSUNDS Planning (Holtanet al. 1984)at SaintPaul-RamseyMedical
Centerin St. Paul, Minnesota.The reportemphasizesthe need to consider
SUNDS-relatedeventsandto observeclosely

persons who fit the demographiccharacteristicsof SUNDS and who have transientnocturnal
events with the following symptoms:
1) a sense of panic or extreme fear
2) paralysis(partialor complete)
3) a sense of pressureon the chest
4) a sense that there is an alien being (animal,human, or spirit) in the room
5) a disturbancein sensation (auditory,visual, or tactile). [Holtan et al. 1984:11]

Thislist of five conditionsof SUNDS-relatedeventsclearlyis consistentwith

the characteristicsof the nightmareas it is knownin countlessfolk traditions.
Sincethesymptomslistedby Holtanet al. areidenticalto thoseof a Nightmare
attack,the possibilitythatSUNDS amongthe Hmongis triggeredby sucha
confrontation mustbe considered.Also, sincethe Hmong, likeotherpeoples
the world over, attribute such an attack to one of the demonic figures of their
belief tradition, the investigation must take Hmong beliefs into account.
Potent traditional activators may very well exert an influence on Hmong
well-being that is not explained by the Western biomedical understanding of
illness and death. A study published by Bruce Bliatout in 1982 offers indis-
pensable insights into Hmong religion and its role in health, illness, and death
(Bliatout 1982). One particularly promising idea among the hypotheses that
Bliatout sets forth is that "Hmong traditional beliefs have a role in SUNDS":

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Adler, SuddenDeathamongHmongImmigrants 59

Hmongelderscitemanyexamplesof mysteriousdeathswhichtheybelievewerecausedby ogres

or evil spirits. Although Westernmedicalpractitionersmay ridiculethese concepts, generations
of belief in supernaturalpowers can causeill health and death. [Bliatout 1982:53]

After analyzingdataon 45 Hmong who had died of what appearedto be

SUNDS, Bliatoutsuggeststhatat least39 of the caseshadsome basis(deter-
minedby reconstructing both the victims'religionat time of deathandprior
religion)for beliefin andfearof the powerof evil spirits(1982:66-67).
Hmong traditional religion comprisesa complex arrayof supernatural
beings:gods, spiritsof places,householdspirits,maliciousspirits,andspirits
of the dead(Chindarsi1976).Humanitycanlive happilyonly by living har-
moniouslywith these myriadspirits.Much of the Hmong religiouseffort,
therefore,is aimed at pleasingor appeasingancestorspirits, who remain
aroundthelivingandwhoseprotectionis activelysought(Bernatzik1970;Be-
tweenTwoWorlds 1985;Quincy1988).As one Hmongmanexplainedto me:
it is believedthatthe ancestorsareto be fed, um, regularly,especiallyduringthe New Year time.
There are only two times that the ancestorshave to be fed: one is, uh, after you, you harvest
your rice field, before you eat those, we call the "new rice," the new season's rice, you should
first feed the ancestors, and the second time is New Year time . . . if, if you don't feed your
ancestors,uh, regularly,they may come back to you and, um, ask for something, they may ask
for, uh, even your life. [LV]

Hmongtraditioninsistson maintainingcertainreligiouspractices,includ-
ing spirit-feedingrituals(usuallyinvolvingthe sacrificeof a chicken,pig, or
cow); violatingthese normscan incurthe wrathof spirits(Chindarsi1976;
Quincy1988).Ancestorspiritsmaydemandretributionthemselvesor simply
desertthenegligentperson,who is thenleft opento anevil spiritattackin the
formof a nightmare:"Um, the peoplewho, uh, diedin theirsleephadeither
oneor two timesof nightmareduringtheirlifetime,andif it happenagainand
nobodyhelpthe person,they die"(CT).
The symptomsof the Hmong evil spiritattackparallelthoseof the night-
mare.The peculiarimpressionof semiwakefulnessis describedby a male
Hmongrefugeein SantaAnawho hasexperiencedthenocturnalattackas the
feelingof being"kindof half-asleepandhalf-awake"(LV).The senseof im-
mobilityand the panicor extremefeartypicalof Nightmareattacksis also
evidentin Hmong descriptionsof nocturnalencounterswith evil spirits.
Lastly,the featureof the nightmareoccurringwhen the victimis in a supine
position is evident in this Hmong explanation: "[old people] told us that evil
spirits can easily get to your body if you sleep on your back, so we are in-
structed to sleep on our sides only" (CT).
Both Hmong SUNDS and the nightmare are better understood with the
assistance of concepts from laboratory sleep research. As DavidJ. Hufford de-
scribes in The Terror That Comes in the Night (1982), current scientific thought
on sleep phenomena also offers one explanation for the pervasiveness of the
nightmare through history and across cultures.

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60 Journalof AmericanFolklore104(1991)

Somnologistsdistinguishbetweentwo majordivisionsof sleep:activesleep

(knownas REMbecauseof its characteristic rapideye movements)andquiet
sleep(non-REM NREM). REM sleepis characterizedby brainwaves re-
semblingthose wakefulness. In to
contradistinction the wakingstate,how-
ever,thebodyis paralyzed,apparentlyto keepthe sleeperfromactingout his
or herdreams(Dement,Frazier,andWeizman1984).
Inrareinstances,thisnormalmuscleinhibitionor atoniaoccursduringpar-
tial wakefulness,eitherduringthe periodof fallingasleep(hypnagogic),or,
less frequently,the periodof awakening(hypnopompic).This conditionis
knownas "sleepparalysis,"a stagein whichthe body is asleep,but the mind
is not.6Often sleep paralysisis accompaniedby hypnagogichallucinations,
whichconsistof complexvisual,auditory,andsomatosensoryperceptionsoc-
curringin the period of falling asleepand resemblingdreams(Hartmann
Sleepparalysisandhypnagogichallucinations areproductsof "sleep-onset
REM,"a REMstagethatoccursearlier than normal,when the individualis
still partiallyconscious(Hartmann1984;Hufford1982;Parkes1985).Sleep-
onsetREMaccountsfor the subjectiveimpressionof wakefulness,the feeling
of paralysis,and,as a result,the tremendousanxietythatmarkthe nightmare
experience.The senseof oppressionor weighton the chestandthe attendant
featureof lyingin a supinepositioncanbe explainedby the factthatwhenthe
sleeperis lyingon his or herback,theatonicmusclesof thetongueandesoph-
aguscollapsethe airway.The relaxedmusclesnot only hinderbreathing,but
actuallycreatea sensationof suffocation,strangulation,or pressureon the
chestof the terrifiedsleeper(Kellerman1981;Dr. EmeryZimmerman,per-
Thus, recentlaboratoryfindingsin the areaof sleepphenomenareiterate
folk distinctionsregardingthe nightmareas differentfrom othersleep phe-
nomena.As Huffordwrites:
The situationis one in which folk observation is ahead of scientificobservation. Without sleep
laboratoriesand without polygraphs, folk traditionapparentlymaintainedan awarenessof the
distinctionbetween REM intrusionsinto wakefulness and REM occurringin its proper places.
The easewith whichfolk traditionisolatesthe nightmareexperience,how-
ever,is in markedcontrastto the continuingconfusionthatcharacterizescur-
rentscientificinvestigationsinto the phenomenon.Perhapsthe most difficult
probleminvolvesdistinguishingthe specificnightmareincidentfrom other
sleep disorders, particularly the night terror, Pavor nocturnus.The terms night-
mareand night terrorare often used interchangeably and are incorrectly assumed
to refer to the same experience. Even among researchers who have considered
a possible connection between SUNDS and certain "dreams" of the Hmong
(e.g., Lemoine and Mougne 1983; Melles and Katz 1988; Tobin and Friedman
1983), progress is impeded by the lack of consistent use of an accurate char-
acterization of the nightmare.

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Adler, SuddenDeathamongHmongImmigrants 61

The confusionis besteliminatedby consideringrecentfindingsin sleepre-

searchin orderto contrastthe two differentphenomena.The nightmareis a
productof sleep-onsetREM, when REMatypicallyintrudesinto stage 1 of
NREMsleep.Night terrors,by contrast,arespontaneousawakeningsduring
the firstthirdof thenightfromstage3 or 4 NREMsleep.Oftenoccurringin
childhood,night terrorsare initiatedby a loud scream.The victim is ex-
tremelyfearful,but,in contrastto thenightmare,usuallynothingof thedream
contentcanbe recalledthenext morning.(Distinctionsbetweenthe two phe-
nomenaarefurtherelaborateduponin Dement,Frazier,andWeizman1984;
A pointedexampleof the misunderstanding of the nightmarephenomenon
is evidentin a commentmadeby Roy Baron,anepidemiologistattheCenters
for DiseaseControlin Atlanta,Georgia.Baronhad beenleadinga govern-
ment-sponsored nationwideinvestigationinto the possiblecauseof SUNDS.
He remarks:"Virtuallyeverycasewe haveencounteredwas a peacefuldeath
wheretherewereno screamsandnone of the thrashingaboutone would ex-
pect from nightmares."Baronalso points out that almostevery American
seemsto haveextremenightmares,at leastoccasionally,yet the ideaof dying
fromone is inconceivable(Monagan1982:38).He confusesthe classicnight-
marebothwithincidentsof nightterrorandordinarybaddreams.Itis evident
fromBaron'scommentsthatlackof familiaritywith the identifyingfeatures
of thenightmarecanleadto misunderstandings whichdirectresearchersand,
in thiscase,alsofederalfunding,awayfroma successfulinvestigationinto the
causesof SUNDS.
theeventsleadingto theNightmareattack,thephenomenonmustalsobe con-
sideredwithinthe contextof Hmong history,includingthe refugeeexperi-
ence, in orderto see how an ordinarilynonlethalsomaticresponsemay be
transformed intoa deadlyculturalactivator.TheHmongarea partlysinicized,
semimigratory people,who in recentcenturieshaveinhabitedthe higheral-
titudesof southernChina,and the northernregionsof Laos, Thailand,and
Vietnam(Hendricks,Downing,andDeinard1986:xv).Forthousandsof years
theHmonglivedin Chinaas nomadsandmountainpeople,butin the middle
of the 19thcenturythousandsbeganfleeingto LaosandotherSoutheastAsian
countriesto escapethe harshruleof the Manchudynasty.The Chinesecon-
temptuouslycalledthe Hmong Miao,"barbarians"; andin Laos,wherethey
lived as farmers, they are called Meo, with the same connotation. The people
themselves, however, have always preferred the term Hmong, which means
"free people" (Garrett 1974).
In the West, the Hmong have been more widely known than other Laotian
ethnic groups because of their involvement during the war in Vietnam that
spread to Laos and Cambodia. Thousands ofHmong were funded directly and
secretly by the U.S. Central Intelligence Agency to combat the Communist
Pathet Lao. By the end of the civil war in 1975, the Hmong suffered casualty

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62 Journalof AmericanFolklore104(1991)

ratesproportionallyten timeshigherthanthoseof Americanswho foughtin

Vietnam(Cerquone1986);it is estimatedthatnearlyone-thirdof the Laotian
Hmongpopulationlost theirlives in the war (Quincy1988).
Whenthe Laotiangovernmentchangedhandsafterthe departureof Amer-
icantroopsin 1975,largegroupsof Hmong were forcedto flee Laosrather
thanchance"re-education" campsor possibledeathunderthe new Commu-
nist regime(Quincy 1988). Many Hmong died from hunger,disease,and
drowningstrying to reachasylumin the refugeecampsof Thailand(Dao
1982).Those peoplewho survivedthe treacherouscrossingof the Mekong
Riverfelt the contradictionof reliefat reachingasylumandthe difficultyof
life in a refugee camp.7
Finally,afterarrivingin America,the Hmong findthemselvesin a country
vious socialsupportsystemis greatlyweakened(Muecke1983).A striking,
butnot uncommon,exampleis foundin ChongSaoYang,a 62-year-oldfor-
merfarmerandsoldier,who movedto SanDiego fromLaos.As he explains:

In our old country, whatever we had was made or brought in by our own hands We are
not born on earthto have somebody give us food. Here, I'm sure we're going to starve, because
since our arrivalthereis no penny I can get that is money I earnfrom work. I've been trying very
hardto learnEnglish, and at the same time look for ajob. But no matterwhat kind ofjob, even
ajob to clean people's toilets, still people don't trust you or offer you such work. I'm not even
worth as much as a dog's stool. Talking about this, I want to die right here so I won't see my

MostHmongknowlittleEnglishandhaveskillsinappropriate in the contem-

poraryAmericaneconomy;thosewho cannotfindjobs areforcedto depend
on welfare(UnitedStatesDepartmentof HealthandHumanServices1985).
Nao ChaiHer was the respectedheadof a Hmong villageof morethan500
peoplein Laos. Livingin San Diego, he sharesa three-bedroomapartment
with20 relatives:

We arejust like the baby birds who stay in their nests, opening their mouths, waiting only for
the mother bird to bring the worms. When the government doesn't send the cash on time, we
even fearwe'll starve. I used to be a real man like any other man, but not any longer. The work
I used to do, I can't do here. I feel like a thing which drops in the fire but won't burn and drops
in the river but won't flow. [Whitman1987:19]

In the attempt to minimize their disadvantages, many Hmong have sought

to adapt rapidly to American urban life, attenuating the practice of their tra-
ditional beliefs and rituals in the process. Hasty conversions to Christianity,
denials of the role of shamans, and the abandonment of spirit-appeasing rituals
represent a few of the changes many Hmong have made in an effort to accom-
modate themselves to their new situation (Beghtol 1988; Between Two Worlds
1985; Desan 1983; Hendricks, Downing, and Deinard 1986).

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Adler, SuddenDeathamongHmongImmigrants 63

The apparentdisruptionof traditionalHmongculture,as well aswhatBurt

Feintuchrefersto as "thestressrelatedto the traumaof culturaldislocation"
(Feintuch1988:5),formpartof theanswerto animportantquestionregarding
theroleof the nightmarein SUNDS; namely,if the nightmareis ordinarilya
universal,transient,nonpathological phenomenon,how canit be responsible
for triggeringa fataldisorderamongHmongrefugees?One likelypossibility
is thatthetraumaticdisturbances in thepreviousHmongway of lifehavedis-
rupted traditional of
ways avoidingor at leastappeasingtheseangryspiritsor
Nightmares.The Hmong areexperiencingpersonaltraumaandculturaldis-
orientationin rapidsuccession.In threecountries-their placesof origin, of
refuge,andof resettlement-theHmonghavebeenforcedto undergoa seem-
inglyendlessseriesof traumaticexperiences(Muecke1983)thatappearto have
contributed to the alterationor cessationof variousreligiouspractices.Inves-
tigatorsof SUNDS pointout thatthe disappearance of traditionalbeliefsand
ritualshashadanadverseeffecton Hmongwell-being,andthusparadoxically
drawessentiallythe sameinferenceas the Hmong themselveswhen they at-
tributethe syndrometo theirtraditionalspirits.One researcheremphasizes
thatincidentsof stress,sickness,anddeathindicatethatwhilethe Hmong re-
taintheirtraditional beliefs,theyhavelost or abandonedtheirreligiousleaders
andritualresponses:"Thisleavesthe Hmong with seriousanxietiesbut no
way to resolvethosetensions"(Desan1983:46).
Not allHmongin the UnitedStates,however,openlyretaintheirprevious
religiousbeliefs;manyHmong haveconvertedto Christianity(BetweenTwo
Worlds 1985).Inhis studyof SUNDS, Bliatoutconcludesthat"itdidnot seem
thatreligiouspreferencewas an indicatorof suddennocturnaldeath.Sudden
nocturnaldeath struck both Christiansand ancestorworshippersalike"
(1982:89).Thisfindingdoesnot negatethehypothesisthatHmongtraditional
religiousbeliefsplay an importantrole in the onset of SUNDS, but rather
pointsto an areafor furtherinvestigation.8 Outwardconversionis not neces-
sarilya reliableindicatorof internalconviction.In Philadelphia in 1983, for
example, several hundred Hmong refugees were associated with various
Christianchurches,but, asDesanreports,the "majorityof ministers. . . sug-
gest thatmost of the refugeesattendbecauseof a desirefor community,not
A way to makesenseout of why bothChristianconvertsandHmongwho
followtheirtraditionalreligiondieof SUNDS is foundin ananalysisby Lauri
Honkoin "Memoratesandthe Studyof FolkBeliefs"(1961).Two of the rel-
evant concepts presented are: cultural experience model (the learned tradition
that each individual brings to a supranormal event) and cultural explanatory
model (the interpretations of others that are formed after the event and con-
form to the collective tradition). Using Honko's scheme, one could say that
the support of the Hmong cultural experience models and explanatory models
has been suspended at a time when it is needed more than ever.
The change in traditional means of coping with supranormal incidents for
Hmong outside their homeland provides an explanation for the assertion made

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64 Journalof AmericanFolklore104(1991)

by some Hmong refugees that there were no SUNDS-related deaths in Laos

priorto their forced departure(Lemoine and Mougne 1983:9).Also, although
the informantsI have interviewed to date may not constitute a representative
group, none had been aware of SUNDS occurring in Laos. In their country
of origin, Hmong Nightmare attacksoccurredin a culturalsetting that appar-
ently was preparedto deal with them; victims had collective assistancein the
form of experienceand explanatorymodels of traditionalHmong culture.
The type of collective support previously availableto the Hmong may have
takena variety of forms: broad exposure to folk narrativessuch as legends and
memoratesdetailing the supranormalexperiencesof other community mem-
bers, having one's own supranormalexperiencessubjectedto the opinions and
interpretationsof the local shamanand others, and having readilyavailableand
socially sanctionedcommunity ritualsto prevent the unwanted incident from
occurring or, failing this, to remedy an existing situation. I suggest that the
insularcommunities that characterizedHmong life in Laos fostered traditional
culturalmodels whose presence alleviated, but whose subsequent loss pro-
vokes, feelings of pressureand distress associatedwith negative supranormal
Although the Hmong in the United States are in the process of adaptingto
new conditions, many may not yet have the resources in their new cultural
context to ease tremendous stress and anxiety. As Jacques Lemoine reports:
"the strangestthing is that many of the [SUNDS] cases we investigated were
people who had alreadyadaptedor were adaptingthemselves. They had given
up their traditionalprotection .. ." (1986:347).This may be one reason that
the attacksexperiencedin the United Statesareso devastating.The suspension
of traditionalsupport in America partiallyexplains how the Nightmare attack
can change from a transientnocturnalexperienceto a fatal encounter.
Another question that arises logically at this point is: if the Nightmare,
which appearsto be a universalphenomenon, is found to play a role in Hmong
SUNDS in the United States, does it also have an effect on other culture
groups in this country or elsewhere in the world? Severalinvestigations have
been conductedof both aJapanese(pokkuri)and a Filipino (bangungut) sudden
nocturnal death. In 1959, Masayoshi Sugai described a syndrome among
young, previously healthy Japanese men who "died suddenly during sleep
with a groan as if having a dreadfuldream with agonal deep respirationsand
stretching of limbs" (Sugai 1959). Since this report, fatalities in Japan with
such characteristicshave been grouped under the name pokkuri.
Another syndrome which seems to be related to SUNDS was investigated
by Dr. Nils P. Larsen, a Honolulu pathologist who examined Filipino victims
of bangungutin Hawaii in 1955. Larsen proposed excessive fear during sleep,
due to a nightmare (read: bad dream), as the cause of death. The only Filipino
man who had survived what appeared to be a "nightmare death" remarked
that the friends who had awakened him had saved him from death at the hands
of a little man who was strangling him in his sleep (Larsen 1955:142).

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Adler, SuddenDeathamongHmongImmigrants 65

Traditionsof Nightmare attacks do exist in both of the cultures (Japanese

and Filipino) in which these sudden nocturnal deaths occur. The question is
whether these geographicallyisolated cases have been shaped significantly by
any of the same factors responsible for the syndrome among the Hmong. It
remains to be seen whether SUNDS is, in fact, a culture-bound syndrome,
and, if so, how it may come to be found in a place far removed from the area
in which the syndrome is part of the socioculturalreality (Simons and Hughes
1985:31).Furtherinvestigationinto the possible role of the nightmareas a trig-
ger for these other disordersclearlyis warranted.
Lastly, of all the questions which arisewith regardto SUNDS, the one that
is perhapsthe most puzzling is: why have all but one of the deathsbeen male?9
Because of the gender-specificnature of the disorder, researchon the differ-
ences between male and female Hmong social roles is important. For Hmong
in the United Statesthe man's role in traditionalreligious practices, as well as
in sustainingthe family, has become increasinglymore difficult. Denise Grady
explainsthat, unlike other refugees from Indochina,

the Hmong were isolated, mountain-dwellingfarmers,scarcelyexposed to Westernculture.The

burdenof family responsibilitieswas on the men. In the United States, they areoftenjobless and
strandedin cities. It is probablyno coincidencethat at least one of the Hmong who died in his
sleep had despairedover how he was going to support his family. [1982:32]

Much of the sexual inequalitybetween men and women that characterizedlife

in Laos (Cooper 1983) is evident in immigrant families: the Hmong living in
the United States still maintaina strongly male-dominatedsociety (Meredith
and Rowe 1986).
Researcherswho focus on the stress of displacement,immigration, and re-
settlementfor the Hmong often make distinctions based on gender. Lemoine
and Mougne (1983) hypothesize that the traumathat Hmong men, in partic-
ular, have undergone frequently has resulted in a loss of self-respect, as well
as the feeling of lack of control over their own lives, severe depression, and a
loss of will to live under such anxious circumstances.Joseph Westermeyer, a
psychiatrist at the University of Minnesota, notes that the overwhelming
number of Hmong deaths occurs in males and sees a possible correlationbe-
tween this fact and the observation that "preliminarytabulationof a mental
health survey conducted among the Hmong in Minnesota . . . indicates a
higher self-report of depression and other symptoms among men" (Wester-
meyer 1981:952). Differences in levels and types of stress along gender lines
are also evident in the findings of Tobin and Friedman who explain that
"Hmong men would be more susceptible to feelings of guilt, since in their
culture it is the man's role to protect his family and homeland, and to feelings
of lingering trauma, since the men, as soldiers, usually had more direct contact
with death" (1983:447).
Another factor that may contribute to the preponderance of male deaths
from SUNDS is the notion of ambivalence about having survived the escape

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66 JournalofAmericanFolklore104(1991)

fromLaos.The stresswhichcomesfromtheseconflictingfeelingsis revealed

by TobinandFriedmanin theirapplicationof insightsgainedfromstudiesof
WorldWarII Holocaustsurvivorsto the plightof the Hmong refugees.The
two researchersexplainthat this dilemma,often referredto as "survivor
guilt," appearsto be presentin the thoughtsof male Hmong immigrants:
"WorkingwithHmong... refugees,we oftenhear,'Ishouldhavestayedand
foughtanddied,'and'I shouldn'tbe alivewhen bettermen thanme, like my
elderbrother,aredead'" (TobinandFriedman1983:443-444).Survivorguilt,
togetherwith the traumaof other crisesof acculturationand resettlement,
formsthe psychologicaland sociologicalcontextwithin which the Hmong
Psychologicalstressmayalsoactas aninstigatorof sleepparalysisandhyp-
nagogichallucinations. Sleep-onsetREMappearsto havea muchhigherrate
of occurrenceamong understress.A fixedpercentageof REMis
necessaryfor healthy,normalsleep,andif the usualpatternis disrupted,sub-
sequentsleepwill includea higherpercentageof REMascompensation(Hish-
ikawa1976).Theneedfor thistypeof sleepcanbecomeso greatthattheREM
phasewill be enteredalmostimmediately,while the sleeperis still semicon-
scious,andwill oftencausea nightmare.DonaldWard,who hasdocumented
scoresof Nightmareassaultsin California,has noted that a combinationof
emotionalstressandextremefatigueis invariablya factorin theseencounters
ing that deep sleep may bring abouttheir deaths,set their alarmclocks to
awakenthemeverytwenty or thirtyminutes(Holtanet al. 1984).Paradoxi-
cally,this type of sleepdisruptionmay actuallycausesleep-onsetREM and
The variousformsof stressthatcharacterize Hmong refugeelife may ac-
tuallyhavea directeffecton incidentsof SUNDS. The resultsfrom a recent
studyof SoutheastAsianrefugeesattheUniversityof California,Irvine,"sug-
gest thatpsychologicalstresscanbe an importantfactorin the development
of life-threateningventriculartachyarrhythmia"(Brodskyet al. 1987:2067).
Thesuddenstressof a Nightmareattackcompoundedwithexistingandsevere
psychologicaltensionmay thus provokethe fatalphysiologicaldisorderof
Not onlythemeansfordiscoveringtheetiologyof SUNDS, butalsometh-
ods for preventingthe disorder,may comefromtheHmongthemselves.Re-
cently, the Hmong have undertaken a second exodus, this time within the
United States. In a self-directed migration that "has left refugee resettlement
officials baffled and embarrassed" (Thompson 1986:47), thousands ofHmong
are moving out of fast-paced urban areas, away from factories and freeways,
to rural regions such as central California and agrarian areas of the Midwest
(Finck 1986).
Research conducted during the initial phase of the move yielded disappoint-
ing findings. Although the Hmong exodus to the Pacific Coast is a tribute to

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Adler, SuddenDeathamongHmongImmigrants 67

humanresourcefulness andhasoftenresultedin reunitinglong-separated fam-

ilies,statisticsrevealed"upto 90%unemployment... a highsuiciderate;and
violentassaultsby BlacksandHispanicswho regardthe refugeesas rivalsfor
shrinkingpublicassistancefunds"(Thompson1986:48).It remainsto be seen,
however,whetherthis migrationfrom stressfulenvironmentsto areasmore
liketheirhomelandwill eventuallyprovideboththeopportunityandthesup-
port for the Hmong to practicetraditionsthat are particularlyunsuitedto
Americanurbanareasand whether,with thesechangesand the intervening
yearsof adaptationto theirnew situation,the Hmong will finallybe freeof
the Nightmarespiritswho tormentandkillthemin theirsleep.
Fornow, however,it appearsthatmuchmay be gainedby a dialoguebe-
tweenHmongandresearchers familiarwith the symptomsof the nightmare.
Thereis alsoaneedto bridgethegapbetweenHmongtraditional healingprac-
ticesandUnited Statesmedicineby eliminatingthe conflictsthatarisefrom
misunderstanding andmistrustbetweenhealthprofessionalsandrefugeepa-
tients(Beghtol1988;Hurlich,Holtan,andMunger1986).FromHmong re-
sistanceto postmortemexaminationson religiousgroundsto SUNDS re-
searchers' insensitivityto the power of belief,the awarenessandknowledge
of bothsidesmustbe increased.
Becauseof the comparative,interdisciplinary, "populist"approachthat
characterizes folklorestudies,folkloristsarein a uniquepositionto offerin-
sight into the effectsof belief on variousaspectsof well-being, including
health.A singularpremiseguidingWesternbiomedicinehasbeenits commit-
ment to a fundamentaloppositionbetween mind and body, the so-called
Cartesiandualism.The Cartesianlegacy"to clinicalmedicineandto the nat-
uralandsocialsciencesis a rathermechanisticconceptionof the body andits
functions,and a failureto conceptualizea 'mindful'causationof somatic
states"(Scheper-Hughes andLock1987).
The biomedicalparadigm,with its tendencyto characterize and treatdis-
ordersas eitherwholly organicor wholly psychological,furtherobscuresthe
roleof such"nonscientific" factorsas beliefsin affectinghealth.In a 1983ar-
ticleentitled"Beliefas Pathogen,BeliefasMedicine:'VoodooDeath'andthe
'PlaceboPhenomenon'in Anthropological Perspective,"HahnandKleinman
assertthat"thesignificanceof... beliefsin diseasecausationandcureis the
sameas thatof microorganisms and medicinals;given certainconditionsof
host and environment,pathology or healing consistentlyfollows belief"
The study of the power of belief is well within the realm in which the folk-
lorist's intellectual tools are particularly effective and can render important in-
sights. There is a broad continuum ranging from voodoo death and sudden
death (what Hahn and Kleinman refer to as "ethnomedical pathogenesis") at
one end to placebo healing, faith healing (M. Jones 1972), and healing through
imagery (Achterberg 1985) or narrating (M. Jones 1976) at the other. From the
study of beliefs that may sicken and kill to those that may heal, there is much

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68 Journal of American Folklore 104(1991)

forfolkloriststo investigate.Manyfolkloristicconcepts,suchaslegends,per-
rectlyrelevantto studiesthatseek to investigatenew andemergingconcep-
tualizationsof theway humanbeingsactin illnessandhealth.Folkloristicshas
muchto offerotherfieldsof inquiry,includingbiomedicine,thatwill contrib-
ute to the advancement of knowledgeandunderstanding of humanbehavior.

The hypothesisset forth in this articlerepresentsthe culminationof preliminaryresearchinto the Night-
mare, as it is known in folk tradition,and its relationto Hmong SUNDS. Portions of an earlierversion of
this articlewere presentedat the 1988 AmericanFolkloreSociety meeting in Cambridge,Massachusetts,and
the 1989 SouthernCaliforniaAcademy of Sciences meeting in Pomona, California. I would like to thank
Donald Wardfor his initialinspirationand continuedassistance,MichaelOwenJones for his ongoing creative
insights and encouragement,and Carole Browner, Yoram Bilu, and David Hufford for their enthusiasmas
well as comments on earlierversions of this article. Specialthanks are due to the Hmong men and women
who spoke with candorand trust on the painfulsubjectof SUNDS.
'The disorderis also known by the acronym SUDS, Sudden Unexplained Death Syndrome. I feel that
both the unpredictablenatureof the syndrome and the fact that 98% of the deaths occurredbetween 10:00
P.M.and8:00A.M.(Parrishet al. 1987)warrantthe inclusionof both the words "unexpected"and "nocturnal"
in the label. Thus, Sudden UnexpectedNocturnalDeath Syndrome is a more accuratedescriptionof the dis-
order. My use of the term SUNDS is consistent with that of the SUNDS Planning Project at Saint Paul-
2Autopsieshave revealedonly irregularitiesassociatedwith acuteheartfailure.Certainspecialpostmortem
cardiacstudieshave revealedother cardiacdefects (conductionsystem abnormalitiesand cardiomegaly[Kir-
schner,Eckner,and Baron 1986;Otto et al. 1984]). These cardiacdefectsarenot manifestduringthe victims'
lives, however, and "the event which provokes the fatal arrhythmiahas never been explained"(Melles and
Katz 1988).
3Theword mara,from which "nightmare"is derived, can be tracedto a proto-Indo-Europeanroot that
most likely referredto a nocturnalpressing spirit (Kluge 1960). The Old English nihtmara,which is the an-
tecedentto the modernword "nightmare,"andthe GermanMahr(m.) or Mahre(f.) (Old High GermanMara)
arerelatedexamplesof this root (Hoops 1916:172;Kluge 1960:454).
41am indebtedto David J. Hufford for his characterizationof the nightmarein The TerrorThatComesin
theNight(1982). Although I have alteredhis configurationslightly (basedon the resultsof my own fieldwork
in Jerusalem[1987-88] and Los Angeles [1986-87]), Hufford's criteria,which are unique in the literatureon
the subject, remain the foundation of the minimal requirementsfor the nightmare experienceas I present
5Theinterviews cited in the text were conducted during the months ofJanuary throughJune of 1987 in
Hmong communities in Orange County, California. (Additional fieldwork has subsequentlybeen under-
takenamong Hmong living in Stockton, Sacramento,and Fresno, California.)In order to protect the ano-
nymity of the informants,all quotationsfrom these interviews are followed by the initialsof the informant
in parentheses.
6Althoughin the biomedicalliteraturesleep paralysisis commonly associatedwith victims of narcolepsy,
this phase of sleep has a significantrate of occurrenceamong nonnarcolepticsas well, as has recently been
convincinglydemonstrated(Hishikawa1976;Hufford 1976, 1982;Ness 1978).
7Thereare only two publishedreports to date on the possibility of SUNDS in SoutheastAsia; both are
basedon interviews with Hmong in the Ban Vinai refugee camp in Thailandand are written by Ronald G.
Munger(1986, 1987). My preliminaryreview of the materialindicatesthatthe 16 reporteddeathsmay indeed
have been instancesof SUNDS, but, due to the vaguenesswith which victim's "sleep disturbances"are de-
scribed,it is difficultto assess the relevanceof Munger'sfindings to my own research.Although (out of 16
incidentsof sudden unexpecteddeath during sleep in which the victim was not previously ill) Mungerpro-

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Adler, SuddenDeathamongHmongImmigrants 69

vides detailedinformationon only four cases. The discussionof one of these casescontainsuseful information
on what appearsto be a Nightmare attack. The wife of one victim describes"dreams"her husbandhad had
previouslyin which a female spirit, known as poj ntxoog,would appear:"The subjecttold his wife that the
poj ntxoogwould sometimes visit during sleep and sit on his chest. Breathingduring these episodes was very
difficult .. ." (1986:388).Interviewsconductedwith Hmong in Ban Vinai confirmedthe characterizationof
poj ntxoog as an evil spirit who may take away the souls of the living, thus causing illness and death, and
whose evil must be protectedagainstby the performanceof shamanisticceremonies.
8Bliatout'sstatedintentin conductinghis investigation"was to open avenuesfor alternatetypes of research
on the subject of Hmong Sudden Unexpected Nocturnal Death Syndrome" (1982:v). Although Bliatout
states that, based on this investigation, he was unable to prove definitively that his hypothesis regarding
Hmong religiousbeliefsis correct,he did find "manyindicationsthata fairlylargegroup of Hmong, probably
both Christianand non-Christian, have anxieties caused by not performing traditionalreligious practices.
This probablycontributedto raisingthe stresslevel in many of the suddennocturnaldeathcases" (1982:92).
Bliatoutconcludesthat he did indeedfind supportfor his hypothesisthat seriousreligiousconcernscan affect
Hmong individualsby greatlyraisingthe level of stressand triggering"mentalhealthproblems, healthprob-
lems, and suddennocturnaldeath"(1982:93).
9Onlyone Hmong woman has died of SUNDS to date. A Hmong informanthypothesizedthat she might
have been the headof her householdand hence the one held accountableby the spirits (CT).
'oHmongSUNDS and other disorderswhich appearto be forms of nightmaredeath are reminiscentof
what is frequentlyreferredto as "voodoo death." In 1942, WalterCanon publisheda paper describingin-
stancesof mysterious,sudden,apparentlypsychogenicdeath,from manypartsof the world. He suggests that
intenseemotionalstresscreatessympathicoadrenaloverdrive, which canresultin suddendeath. The unifying
featurein all of the caseshe describesis the elementof beliefonthe partof the victims (Cannon1942). Hmong
SUNDS may be relatedto Cannon's voodoo deathinsofaras belief is capableof affectingthe state of health
or illness of the humanbody.

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