Congress Reviews Nist Report Research Needs to Support Immediate Occupancy Building Performance

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Nat Hazards Rev. Writer manuscript; available in PMC 2020 Aug 26.

Published in terminal edited grade as:

Nat Hazards Rev. 2020; 21(1): https://doi.org/ten.1061/(asce)nh.1527-6996.0000334.

PMCID: PMC7448611

NIHMSID: NIHMS1573032

Social and Economic Components of Resilient Multi-Chance Building Design

Katherine J. Johnson, Ph.D., Juan F. Fung, Ph.D., Therese P. McAllister, Ph.D., P.E., Steven L. McCabe, Ph.D., P.Due east., Siamak Sattar, Ph.D., and Christopher L. Segura, Jr., Ph.D.

Katherine J. Johnson

Earthquake Hazard Mitigation Policy Annotator, National Institute of Standards and Applied science, Gaithersburg, MD

Juan F. Fung

Economist, National Found of Standards and Technology, Gaithersburg, MD

Therese P. McAllister

Community Resilience Group Leader and Program Director, National Constitute of Standards and Technology, Gaithersburg, Dr..

Steven L. McCabe

Earthquake Engineering Group Leader and Manager of the National Convulsion Take a chance Reduction Plan, National Institute of Standards and Technology, Gaithersburg, Physician

Siamak Sattar

Enquiry Structural Engineer, National Institute of Standards and Applied science, Gaithersburg, Md.

Christopher L. Segura, Jr.

Research Structural Engineer, National Institute of Standards and Technology, Gaithersburg, MD

Abstract

In 2017, U.S. damages from natural gamble events exceeded $300B, suggesting that current targets for edifice performance practise not sufficiently mitigate loss. The significant costs borne by individuals, insurers, and government exercise not include impacts from social disruption, deportation, and subsequent economic and livelihood effects. In 2016, Congress mandated the National Institute of Standards and Engineering science (NIST) develop a written report (NIST SP 1224) describing the research needs, implementation activities, and engineering principles necessary to improve the operation of residential and commercial buildings subjected to natural hazards. An Immediate Occupancy Functioning Objective (IOPO) could assist preserve building and social functions mail service event, minimizing concrete, social, and economic disaster. The stakeholder-informed NIST report sets along items needed for multi-hazard building pattern that can back up enhanced resilience controlling. This paper highlights the social and economical considerations that crave additional inquiry, particularly with regard to feasibility and potential impacts from an IOPO. These topics must be considered prior to and throughout the IOPO technical development and community implementation processes to ensure better outcomes afterward natural hazard events.

Introduction

In the concluding FY2017 appropriation, the The states Senate mandated that the National Constitute of Standards and Technology (NIST) create a report detailing steps to develop an Firsthand Occupancy Functioning Objective (IOPO). NIST was directed to place engineering principles, research, and implementation activities needed for a new "safety building operation objective for commercial and residential backdrop...[because]...electric current building codes often do not provide the necessary protection confronting natural hazards, particularly with regard to enabling immediate occupancy after a significant convulsion, hurricane, tornado, overflowing, or other natural disaster." (U.S. Senate, 2016). This asking seeks to improve "the resiliency of buildings, homes, and infrastructure" (U.S. Senate, 2016) for the American public.

Communities, owners, and residents would benefit from buildings that maintain structural integrity, a building envelope that is intact, and internal systems that proceed to part after a natural risk event, thereby avoiding lengthy and costly repairs or rebuilding, as well as the need for long term evacuation of building occupants. The goal of building codes is to protect lives by reducing the likelihood of structural plummet for a blueprint-level issue (every bit planned for in the codes), and to provide some level of property protection. In mod buildings, loss of life and structural plummet from natural run a risk events are exceptional, just societal needs are quickly outpacing this performance level. Buildings with improved resilience to multiple hazards could lessen costs and significant disruption.

A new IOPO will demand to accost the post-obit topics: building design considerations (advances in engineering, designing, or retrofitting individual buildings and changes to building code provisions); community considerations (the role of buildings within context); economical and social considerations (feasibility and potential impacts of improved performance); and acceptance and adoption considerations (activities required for implementation). The role of lifelines in supporting IOPO is recognized in the study but not addressed in detail, given the assignment by the Senate. In addition, the report does not specify whether an IOPO would be voluntary or mandatory. Each topic is developed in NIST'southward report: "Enquiry Needs to Support Immediate Occupancy Building Performance Objective Following Natural Take chances Events" (NIST SP 1224). The report was developed by NIST and included input from a collaborative stakeholder process hosted by NIST in 2017 and 2018.

Three meaning report takeaways are: (1) a focus on buildings lone would not produce IO operation; (2) social, economic, and community considerations should inform desired building performance; and (3) developing performance criteria for buildings requires pregnant stakeholder input. In this paper nosotros focus on the social and economic aspects of takeaway (2). We are motivated by the challenge of defining edifice functionality around user needs and a building'southward role in the community. IOPO development requires a unique combination of engineering science and social science inquiry. Developing the applied science attribute of the IOPO is challenging, just is understood relatively well, considering contempo advancements in implementation of operation-based design. Yet, the social and economic aspects of the IOPO development, as well as the interaction between social, economic, and applied science aspects, remain challenging and are less understood. Failure to include social and economic considerations equally a complement to the technical and technology components of performance objective development will result in an IOPO that does run across the needs of communities, where buildings have rich and varied context and purpose. Therefore, this paper's goal is to outline important considerations of our society and economy that should influence our focus in developing technical and engineering specifications for an IOPO. Although many of these may not typically be part of the building engineering and design procedure, they are integral to ensuring an constructive performance objective that can provide resilience to natural hazard events. Please see NIST SP 1224 for more information on the three other topics of the report, which should be considered alongside this information.

Motivation

Each geographic region in the The states faces a unique combination of natural hazards (see Fig. ane for significant weather and climate disasters in the continental U.S. in 2017). These can cause extensive impairment and disruption to buildings, loss of life, injury, belongings damage, displacement of residents and businesses, and take long-lasting economical and social effects that impact local communities and the spirit of the nation (NOAA 2018). The economic costs, borne by individuals, governments, and insurance companies, can exist substantial. In 2017, the U.Southward. suffered $300B in natural gamble damages from weather and climate events (Mooney and Dennis 2018). In 2016, one-half of all insurance payouts around the globe ($67.5B) went to the United States (Mooney and Dennis 2018). The merely year costlier (in adjusted dollars) was 2011, with the devastating Tohoku earthquake in Japan (Munich Re 2018). Earthquakes are not included in NOAA's reports of conditions and climate disasters, and fortunately the U.Southward. has not experienced a major damaging earthquake since 1994. However, the estimated annualized cost of damage to U.S. building stock from earthquakes is calculated to be $half-dozen.1B per year (FEMA 2017), and this increasing threat should be included to more accurately assess gamble. Development of a new IOPO to improve resilience for buildings can help lessen costs beyond all natural hazards, whether geologic or climatic and frequent or exceptional. In addition, by protecting buildings and infrastructure from failure, we tin reduce curt-and-long term displacement, adverse health effects, and disruption to social order acquired past impairments to government, schools, and businesses. By ensuring access to housing and resumption of local businesses following a hazard effect, communities tin can employ IO buildings to mitigate and recover from natural hazards and to reduce vulnerability and long-term negative consequences.

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Regional Variation of Pregnant 2017 Conditions and Climate Disasters

Source: NOAA 2018

Operation of Electric current Buildings

Building operation during a natural run a risk result and functionality afterward depend on multiple factors including: original design, electric current condition, and capacity to resist hazards (east.g., magnitude of hazard compared to hazard design level). The factors are influenced by building age; maintenance; budget and retrofit; location; building code and zoning specifications; lawmaking enforcement; skill and proficiency of engineers, contractors, and construction workers; quality of materials used; as well as physical and environmental forces impacting the building.

Considering buildings meet just the standards enforced when designed, they may non perform well during natural hazard events due to historic period, or because a hazard was non part of design or was not adequately characterized by the lawmaking. Electric current building codes practise non more often than not address functionality afterward a risk event, except for special structures such as hospitals. Functionality depends not only on the building itself just likewise on the condition of supporting infrastructure and the availability of utilities (e.g., power and h2o) supplied to the edifice. Additionally, outside cladding (e.thousand., windows and doors) and interior not-structural systems (e.thou., sprinklers and communication systems) or components (e.g., heating and air workout equipment) oft have varying pattern requirements and may sustain damage leading to partial or total loss of building function. The lack of integration between performance goals for structural, outside, and interior systems ways that even if the structural system performs well, the building may not be available for its intended employ following an upshot.

While some buildings (e.g., hospitals) are designed with increased performance requirements, the anticipated performance for the entire building is difficult to predict. Ensuring building integrity and functionality after a natural take a chance event requires comprehensive pattern criteria, evolution of supporting tools and procedures, and customs support. In the case of existing buildings, IOPOs may require application of innovative assessment techniques and retrofit technologies. A new IOPO would address this gap between current and desired performance of buildings, expanding the awarding of existing IOPOs across critical buildings to other buildings important to residents, businesses, and communities.

Goal for IO Operation Objectives

New IOPOs would provide edifice pattern and retrofit criteria that preserve the integrity of edifice cladding, structural frames, and interior systems, and in plow support continued functionality. Development of performance objectives is a complex procedure requiring definition of acceptable levels of damage calibrated across hazards to enable better standardization of desired performance levels. Subsequently a design-level chance event, IO buildings should sustain minimal loss of role, repairs would be minor, and occupancy largely unaffected. IO performance levels could improve resilience and quality of life by reducing harm and allowing continued access to jobs, housing, and community services, therefore reducing economic losses to local communities.

IOPOs would be a major endeavor involving both public and private sectors in research and implementation activities. IOPO evolution requires improved technology design approaches, construction techniques, and mayhap significant changes in building development, local edifice approval processes, and maintenance/monitoring processes. The development of IOPOs will as well require communities to make up one's mind whether and which buildings should be subject to enhanced performance levels requirements. In doing then, communities tin can optimize hazard planning to suit their economic and social needs.

Discussion of Economical and Social Considerations

Both positive and negative effects to society and the economy relative to the price of IO construction or retrofits need to be characterized. Anticipating problems related to feasibility or impacts tin help the successful development and implementation of IOPOs. Feasibility considerations include the knowledge and steps required to make a new IOPO reality. Impacts cover potential concerns and effects that firsthand occupancy buildings have for stakeholders. These considerations demand attending alongside the development of engineering principles and design standards to ensure that an IOPO volition accept the maximum possible benefit for communities.

Economical Feasibility

This topic covers a range of issues related to initial and long-term costs, directly and indirect benefits of IOPOs for new and existing buildings, also as the role of financing mechanisms for construction, repairs, or retrofit. Its telescopic is express to costs, benefits, and financing for stakeholders of an individual building. The relationship between costs and benefits will inform community-level policy decisions (such as subsidy recipients and amounts) to support implementation of IOPOs.

Costs

Cost estimates, including blueprint, materials, and labor costs, are needed for both new construction and existing buildings. Costs need to be compared for a range of designs and natural hazards and to discover a balance between total cost and design alternatives. Another central challenge is to place who bears those costs as developers and building owners base of operations decisions primarily on initial costs, and full consideration of impacts may lead to different outcomes.

Long-term costs, incorporating maintenance and operating costs over the life of an IO edifice, besides as losses resulting from hazard events, may be equally important to building owners, occupants, and managers if buying is a long-term plan. Developers with a curt time horizon will likely concentrate on first costs. The costs associated with how adoption of an IOPO affects the lifespan of a edifice and the maintenance required to maintain expected functionality also need to exist assessed.

To support these goals, a range of tools is needed to quantify the costs of an IOPO for a range of natural hazards. An example is a tool that can judge the deviation in construction, maintenance, and recovery costs between a new building subject to current-code requirements and a new building subject field to an IOPO.

Benefits

Another key challenge is to identify and quantify direct and indirect benefits to various edifice stakeholders. Developers may non benefit from building to an IOPO, unless owners and tenants are willing to pay more for an IO building. Owners who exercise non occupy their building may benefit from reduced losses, including rent, post-obit a run a risk outcome. The reduced likelihood of concern intermission from loss of building function could make IOPOs bonny every bit an investment for business owners. Tenants may be willing to pay more than for reduced likelihood of displacement. Improved IO building operation with continuous functionality following a hazard effect can provide dissimilar benefits to occupants and building owners.

Direct and indirect benefits directly related to improved IO building performance need to be identified and quantified (east.g., reduced losses from a hazard consequence and the potential for lower life-cycle costs [LCCs: For a definition and a discussion of costs typically included in LCCs see: https://www.gsa.gov/node/81412.], result of an IOPO building on property values, and thus rental rates). As with costs, identifying who benefits is of import. Brusk-term benefits and co-benefits are likely to be attractive to building owners and occupants. Decision makers need tools to simultaneously evaluate the direct and indirect costs and benefits of an IOPO building.

Financing

Finally, research is needed on the function of financing in linking costs and benefits across stakeholders. Lenders, insurers, and investors play a direct role in financing initial costs. While loan principal is determined by initial costs, it may be possible to incorporate LCC-related reductions into mortgage rates. Whether and how IO buildings can affect mortgage rates, insurance rates, and other forms of return on investment will inform both individual stakeholders' cess of the internet benefit of IO buildings and development of policies and incentives for promoting adoption of IO buildings.

Economic Impacts

This topic covers effects on the local, regional, and national economy from a building, or grouping of buildings, designed or retrofitted for an IOPO. These effects may be thought of as positive or negative externalities (impacts borne by others rather than edifice owners or developers) imposed on society by a building-level decision. IO buildings may benefit residents, occupants, or communities, but may too confer burdens such every bit increased rents. Consideration of economic impacts across a wide range of stakeholders beyond the individual-edifice level should be linked closely with issues related to social feasibility and impacts discussed in the following sections.

Households

A key challenge is to place the economic furnishings of IO buildings on households. Edifice failure following a hazard event can result in loss of housing and jobs. An IOPO has the potential to mitigate such losses. In the absence of a take a chance issue, notwithstanding, an IOPO has the potential to touch on households in other ways. For instance, higher holding values due to IO buildings tin lead to college holding taxes and rents and, consequently, deportation of lower-income populations. As some other example, IO buildings may attract new businesses, stimulating urban growth and increasing task opportunities. Research on the potential impacts of IO buildings on population change, migration patterns, and population density is needed.

Businesses

A 2d primal challenge is to identify the furnishings of IOPOs on businesses. Suspension of building functionality after a natural run a risk consequence can outcome in supply-chain disruptions, decreases in productivity, or business concern downtime. IO buildings have the potential to affect businesses in other means in the absence of a adventure event, besides. For case, higher rents can displace minor-business organisation owners or urban growth can attract more businesses, improving local economic productivity. Research is needed to determine how an IOPO tin protect business organization operations and inventory to reduce losses; affect both expected and unexpected losses resulting from downtime; and how impacts vary by sector (e.k., service sectors versus manufacturing sectors).

Gild

The economical effects of IO building functioning on social institutions needs to be characterized for both hazard and non-adventure conditions. For example, higher property values due to IO buildings may increase the local taxation base of operations, potentially affecting provision of services such as public education. However, migration patterns resulting from higher property values affect who benefits from such improvements.

Research should identify how IO edifice functioning can back up economic stability at the local, regional, and national levels following a chance event. This includes defining IOPO contributions to improving the synergy between household and business organization recovery. Economic stability tin stimulate local economic growth and national commerce and trade.

Finally, it is of import to identify and compile the range of positive and negative externalities from an IO building on the local, regional, and national economic system, before and after implementation. A range of potential environmental furnishings of IOPOs should be considered, including: straight impacts (such as changes in demand for construction materials), indirect impacts (such as higher energy consumption to maintain indoor air quality), and environmental costs to society (evaluated using life-cycle assay).

Social Feasibility

The ability of determination makers to implement IOPOs will vary widely due to other factors that support or constrain willingness to invest in IO buildings. Chief among these are desires and preferences stakeholders have for the performance of buildings, knowledge of a building's predictable functioning, perception of take chances, and obstacles to decision making. These need to exist better assessed to support the social feasibility of implementing IOPOs.

Desires and Preferences

What building owners, occupants, and communities need and desire from buildings should influence IOPOs. Goals for structural performance and functionality may vary based on the building'southward typical occupants, role, or part (such as a daycare eye or a police station). Desired performance may change in a take chances scenario (due east.chiliad., a gas station may become far more critical during hurricane evacuation). Qualitative and quantitative stakeholder input is needed to identify desired IOPOs for hazard events, the effects of IOPOs on social systems and the community, and performance benefits that will support customs resilience.

Expected Edifice Performance

How IO building performance can benefit communities varies with current building design requirements. People may overestimate edifice resilience and incorrectly believe that buildings will not exist damaged if they were designed to the building lawmaking. For example, many buildings perform well structurally during current of air events, but may sustain damage to the exterior cladding. Days after the 2010 Maule earthquake in Chile, a new high-rise apartment edifice was evacuated and demolished because of structural damage barely perceptible to non-experts (NIST 2014). A ameliorate agreement of total building performance (for new and existing buildings) is needed to inform IOPO needs and desires. Estimates of condom and recovery benefits of IO buildings should exist created to help with controlling. Methods for tracking the operation of IO buildings (and in adventure perception), and sharing this information with others considering IO adoption, will be necessary.

Perception of Risk

The public may not have adequate knowledge of how natural hazards will touch buildings and, consequently, their family and community. Risks from natural hazards vary with location and hazard type, charge per unit of occurrence, and magnitude of the upshot, making assessment and agreement of risks challenging. In addition, lack of experience with natural adventure events, or feel with minor events, may mislead people into a false sense of security. They may besides overestimate the availability and effectiveness of disaster relief and recovery back up services. Research is needed to quantitatively and qualitatively define take a chance from the stakeholder perspective; develop strategies to help communities understand risk; assess tolerances for loss of building services (ability, water, heat, etc. that tin can vary widely, particularly in areas of high population density) and social functions (employment, schools, governance, etc.); and effects of edifice downtime. For example, simulation modeling could provide tailored guidance on event bear on and inform determination-making.

Obstacles to Determination Making

Individuals or groups that decide on implementing IOPOs may face obstacles to decision-making. Individuals may lack or accept express power to effect change (east.one thousand., a parent has limited bureau to provide their child a seismic sea wave-prophylactic schoolhouse). Other priority needs such as immediate health, finances, or family issues may take precedence. Similarly, the initial costs associated with IOPOs may limit their use in pattern or retrofit or create conflicts in priority betwixt multiple parties (e.yard., reluctance to change the historic character of buildings, or pre-adamant design of housing developments or concatenation stores). Additional study is needed to develop tools to navigate barriers to constructive individual and community decision-making.

Social Impacts

Understanding the effects of IOPOs is of import to avoid or minimize negative outcomes, support stakeholder wellbeing, and maximize benefits from potential positive outcomes. Indirect social impacts can include those afflicted past secondary or unintended consequences such as impacts on social functions, organizations, and institutions, and vulnerable populations. This research may require re-conceptualizing aspects of planning, design, and recovery for IO building pattern.

Social Institutions

Natural run a risk events can disrupt social wellbeing and cohesion at multiple scales. Social institutions such equally government, hospitals, schools, and customs centers support communities in crisis. Critical health intendance services such as pharmacies or urgent care are oft located in commercial buildings. Parents may have to leave the community and relocate their families to detect work if businesses are airtight or if schools aren't open, and this migration can negatively impact local and regional economies. Organizations such as churches and customs centers support community recovery activities. Enquiry is needed to appraise which groups of buildings support social institutions and provide key roles and services. Many of these buildings may require college performance levels to ensure community performance, cohesion, and shelter post-event. This inquiry can help communities, building owners, and individuals to ameliorate prioritize and make decisions related to IO edifice performance.

Vulnerable Populations

Vulnerable populations (those with fewer resources, social uppercase, mobility, or power to influence modify) may do good from IO buildings. Communities could prioritize services for vulnerable populations, for example by improving admission and operation of mental wellness and long-term intendance facilities (eastward.g., see Allen 2017), or past ensuring that large low-income housing developments are more resilient. Alternatively, IO buildings could increment existing inequalities, by raising prices for housing and pushing lower-income residents out of neighborhoods. Isolation and lack of resources reduces the capacity of vulnerable populations to anticipate, cope, respond, and recover from natural hazard events. Research is needed to identify, characterize, and address the particular needs of these populations in relation to IO building design and implementation.

Decision

IO buildings are intended to provide shelter and services and to operate post-event in a "business every bit usual" style. They are also places of enjoyment, productivity, and social interaction. Hazard events can lead to failures in buildings and infrastructure, leading to injury, displacement, and adverse health effects, and impair the performance of services, such as schools, government, and businesses. By improving building prophylactic and functionality for hazard events, IO edifice performance would minimize disruption and economical impact to communities. In addition, information technology would lessen the social, psychological, and health consequences to individuals across the nation.

The research topics and implementation activities suggested in this newspaper originate from a stakeholder-driven process organized past NIST at the request of Congress. They present the key economical and social considerations relating to both the feasibility of IOPO evolution too equally the potential impacts of IO buildings. These considerations will need to be addressed aslope and in coordination with the technical and applied science aspects of IOPO development. As research for IOPOs progresses, multiple stakeholders will need to be involved to address the direct and indirect benefits and consequences that may occur with the adoption of IOPO for buildings.

ACKNOWLEDGMENTS

Expert Contributions: NIST acknowledges the extensive input and support of the practiced steering committee members who assisted in developing the NIST Immediate Occupancy Project Report (NIST SP 1224) from which this newspaper was developed. Their subject-matter expertise, variety of perspectives, and critical input were essential to the comprehensive nature of the topics addressed. In improver, the authors would like to acknowledge the participation of over 80 stakeholders at our January 2018 briefing related research and implementation needs for IOPO development. Steering committee and participant fourth dimension and effort are greatly appreciated.

Technical and Analytical Contributions: NIST acknowledges the contribution of the Science and Engineering science Policy Constitute (STPI) to this paper. STPI supported the development of the NIST SP 1224 written report and organization of the workshop under contract with NIST. STPI is a federally funded research and evolution eye of the Institute for Defense Analyses (IDA) chartered by Congress to provide rigorous and objective analysis of science and technology policy issues for the Office of Science and Technology Policy and other offices and councils inside the executive branch of the U.Due south. government and federal agencies.

Reviewer Contributions: Authors are likewise grateful for detailed review, advice and suggestions of Matthew Heyman, Jason Averill, Howard Harary, Jazalyn Dukes, and Doug Thomas.

Footnotes

DISCLAIMERS

ASCE Disclaimer:

Any statements expressed in these materials are those of the individual authors and do non necessarily represent the views of ASCE, which takes no responsibleness for whatsoever argument made herein. No reference fabricated in this publication to whatever specific method, product, procedure, or Service constitutes or implies an endorsement, recommendation, or warranty thereof by ASCE. The materials are for general information simply and practise not represent a standard of ASCE, nor are they intended as a reference in purchase specifications, contracts, regulations, statutes, or any other legal document. ASCE makes no representation or warranty of any kind, whether expressed or implied, concerning the accuracy, abyss, suitability, or utility of any data, apparatus, product, or process discussed in this publication, and assumes no liability therefor. This information should not exist used without first securing competent communication with respect to its suitability for whatsoever generai or specific application. Anyone utilizing this information assumes all liability arising from such use, including but non limited to infringement of any patent or patents.

NIST Disclaimer:

The content presented in this paper should be understood as considerations identified by expert stakeholders for further research and evolution in concert with the development of an IOPO. This information should not be taken every bit policy communication or a argument of NIST'due south position or interests with regard to this topic. NIST SP 1224 provides information nearly steps that could be taken to develop more robust multi-chance firsthand occupancy functioning. NIST was non charged with making recommendations virtually the desirability, practicality, or government or private sector resources that would exist needed to bear out these actions. Therefore, if a determination is fabricated to give immediate occupancy greater attending, additional work edifice upon considerations introduced in this paper and in the NIST SP 1224 would be necessary.

Contributor Data

Katherine J. Johnson, Convulsion Risk Mitigation Policy Annotator, National Institute of Standards and Technology, Gaithersburg, MD.

Juan F. Fung, Economist, National Institute of Standards and Engineering science, Gaithersburg, MD.

Therese P. McAllister, Community Resilience Group Leader and Program Manager, National Institute of Standards and Technology, Gaithersburg, MD.

Steven 50. McCabe, Earthquake Engineering Group Leader and Director of the National Earthquake Hazard Reduction Plan, National Constitute of Standards and Engineering science, Gaithersburg, MD.

Siamak Sattar, Research Structural Engineer, National Institute of Standards and Applied science, Gaithersburg, Physician.

Christopher L. Segura, Jr., Research Structural Engineer, National Plant of Standards and Technology, Gaithersburg, Dr..

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7448611/

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