High-Definition Occupational Therapy: HD OT

Florence Clark

doi:10.5014/ajot.2010.64602

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Editorial | November 2010

High-Definition Occupational Therapy: HD OT

Florence Clark

Author Affiliations

Article Information

American Journal of Occupational Therapy, November/December 2010, Vol. 64, 848-854. doi:10.5014/ajot.2010.64602

Abstract

This article was taken from Dr. Florence Clark’s address given at the AOTA Annual Conference & Expo, held in Orlando, Florida, April 29–May 2, 2010.

Fellow practitioners, scientists, educators, and students: I am so honored to address you for the first time as President of the American Occupational Therapy Association (AOTA). I am thrilled to have the opportunity to work with you as we get closer to attaining the Centennial Vision and the profession of occupational therapy’s 100th anniversary.

Florence Clark, PhD, OTR/L, FAOTA

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Now, if any of you are unfamiliar with the Vision statement, here it is: “By the year 2017, we envision that occupational therapy is a powerful, widely recognized, science-driven, and evidence-based profession with a globally connected and diverse work force meeting society’s occupational needs” (AOTA, 2007, p. 613).

We really got started on the Centennial Vision playing field 7 years ago. Do you realize it’s now half-time? That leaves us 7 years to score more touchdowns! Just like any good team would do, we have to assess our performance in the first half. I would say we’re doing an excellent job of implementing our game plan.

AOTA membership is up 15%. Our scientists are receiving more federal funding than ever; we have built important alliances with other professional associations, such as the National Association of Home Builders and AARP; we can boast about significant triumphs in the advocacy arena; we are being wowed by the enthusiasm our students have for our profession; and we have our brand, “Living Life To Its Fullest™.” But now, as we move into the third quarter of our game, I want all of us—students, scientists, educators, and practitioners—to bring our game into high definition (HD) so that everyone will see occupational therapy clearly!

Thanks to the hard work you did with my predecessors, Dr. Penny Moyers Cleveland, Dr. Carolyn Baum, and Dr. Barbara Kornblau, we are positioned to put occupational therapy in HD. This will be the overarching goal of my presidency. Together, we can bring occupational therapy into crystal-clear high definition for our clients, our fellow health care providers, policymakers, and the American public. But more on that in a little bit.

If your household is anything like mine, you’ve had the great “gadget debate.” One member loves to get the latest piece of electronic wizardry, while another thinks the old 8-track tape player sounds just fine. In my house, my husband, John, likes the latest technology. I’m the opposite. However, when I started preparing for this speech in November, I began reading magazines with titles like Home Theater 2010 Buyers Guide. I really wanted to get my head around the capabilities of HD technology. Unbeknownst to me, John saw these types of materials lying around and became a little panicked. But he was too polite to tell me. He thought I was going to splurge on the purchase of a high-definition home theater for our condo as a surprise holiday gift. In most families, this surprise would be welcome. But in our home, the very notion of getting a home theater made John wonder if I had lost my mind!

The holidays came and went, and John was relieved that the home theater never arrived. One day he broached the question: Why on earth I had been reading those magazines? I said, “Because for the second half of the Centennial Vision, we needed to put occupational therapy in high definition, and I simply needed to learn everything I can about it.” John was relieved; his wife was still the same woman he had married 19 years ago—still the occupational therapy–obsessed woman who hardly read or did anything that in some way did not connect to our wonderful profession!

All of my reading about HDTV convinced me that the Centennial Vision is the key that will help us bring our profession into high definition. In the remaining 7 years we must stay on course. We must make our scope of practice and what we do with clients clear. We must make the most of opportunities for doing more to meet societal needs before they disappear, and we must avoid becoming embroiled in internal conflicts that can derail us from Centennial Vision priorities.

Thankfully, we are already well on our way toward meeting these challenges. Because of Presidents Kornblau, Baum, and Moyers Cleveland—and, of course, the many others who rallied in support of and contributed to the Centennial Vision—all the pieces are now coming together to form one consistent, coherent, and comprehensive picture of occupational therapy. We now have in place the necessary platform for broadcasting occupational therapy in high definition.

So what are we going to do during the next 3 years of my presidency to bring occupational therapy into high definition? First, don’t misunderstand me. I am proud of all that we accomplished in the past before we had the Centennial Vision, and I have been awestruck by our accomplishments over the past 7 years. Together, we have achieved great things for our profession. But we were limited by the circumstances of the times. The implementation of the Centennial Vision has given us the ability to now do so much more!

Think of it this way: The TVs we had several years ago were fine. They showed everything in color and beat the drab black-and-white set my family had in the 1950s. And thanks to cable TV, we don’t have to do what my parents did—stand on one foot with the rabbit ears in one hand and a pie pan in the other to bring in a clear picture.

But just as HDTV has taken television watching to a whole new level of clarity and visibility, so, too, do we have the opportunity to better secure occupational therapy’s place in meeting society’s needs through high-definition occupational therapy: HD OT. In taking this next step, we will make the picture of our profession even clearer, and we will become more confident because HD OT can solve [several types of problems related to picture clarity].

Fuzziness

How many times have we had to explain that the word “occupation” has meaning well beyond a person’s job? Or deal with cloudy descriptions of what people think we do?

Narrow Screen

In the days when you could get the biggest analog TV out there, that square screen was still only able to show you a limited percentage of the picture. The wide screen of high definition gives us the ability to show so much more. Occupational therapy doesn’t belong on a small, square screen. Occupational therapy on the small screen, rather than HD, is like watching Avatar (Landau & Cameron, 2009) on that old normal screen rather than in a 3D IMAX. You sort of get the story, but it’s not that impressive and you miss detail and depth. I believe that in high definition, occupational therapy, with its breadth, depth, and complexity, will finally be correctly understood by the public and by policymakers.

Poor Resolution

Another great thing about HDTV is that it brings about high resolution. In HDTV, the more detailed the image [is], the sharper the image will appear. Clarity of the picture depends on the number of contrasting individual picture elements. In HD OT, we are not jacks of all trades and masters of none. Nor are we cookie-cut clones of one another. [All practitioners] are different in what we attend to, depending on our client’s particular needs, our areas of expertise, and our experience. For example, one of us focuses on low-vision training, another on sensory integration, and yet another on home modifications. But we are all united by our overarching aim of helping our clients do better, or even flourish, in their worlds of activity and throughout the life course.

Our distinct approaches in the many areas of occupational therapy practice can come together to form a unified image. High definition has the ability to capitalize on contrast and to bring diverse elements into high resolution. It brings all of us together in a brand new way. What’s great about the resolution in HDTV is that you can clearly see the faces of people in the background. Occupational therapy practitioners do the same and see in detail the people in the background of our clients’ lives. We see the families, coworkers, and friends who give them support and help them achieve. And because we see them in detail, our interventions often include them.

Lack of Clarity

Of course, the opposite of narrowness is broadness. And high definition certainly emphasizes the broadness of our profession. Some may see this broadness as a problem in defining who we are as occupational therapy scientists, educators, and practitioners. I do not. Broadness is not the problem; lack of clarity in being able to see the whole picture is the problem—and HD OT will bring us the clarity we need for describing the broad nature of our profession.

Take a look at this famous movie clip from The Sound of Music (Wise, 1965). Notice how the opening shows us the entire mountainside. Thanks to high definition, we can see that the sky is blue and the landscape has different shades. The picture is broad, but we have detail.

Because of the educational preparation all of us received as occupational therapy practitioners, our picture is also broad and detailed. We don’t always talk about it in this way, but we do have those images in our head as we draw upon our science and use our creative imaginations in our work with clients. It’s been called the “underground practice,” but now it’s time to drill down deeply and blast it to the surface. It’s time to take our unique training, science, and services and bring them above ground.

Let’s start with our brand. As part of the Centennial Vision we adopted the brand “Occupational Therapy: Living Life To Its Fullest.” But what do we mean by this? And do we enable people to live life to its fullest better than other health professions?

My research on HD answered these two questions. To start, Living Life To Its Fullest first captures that occupational therapy is laser focused on helping people continue to meaningfully participate in their worlds of work, play, and social engagement. Second, it targets helping clients secure the futures they desire no matter how devastating the circumstances that have befallen them. Our claim to the brand is absolutely justified, because as occupational therapy practitioners, the professional education we receive uniquely prepares us to enable our clients to achieve these ends. We should be proud of this education and never give it short shrift.

First, ours is the only health care professional curriculum that provides science-based, detailed, and complex understandings of how lives are lived out each day in the real world, both with and without disability. This is called the science of everyday living. By our training, we are committed to a holistic perspective. Like certain other professionals, we enter lives at dramatic times when much is at stake. However, only our practitioners are trained to analyze and address the likely repercussions of devastating events on the person’s future.

Second, our educational preparation, as for all professions, is responsible for how we practice. Its high-definition components give us the knowledge and skills to be able to figure out what it will take to enable particular people not only to improve function but also to simultaneously combat depression or other mental health concerns; avoid social isolation; and be able to stay healthy, be happy, and remain productive.

Third, our educational program content is complicated. It needs to be, because the far-reaching aims of our service provision also are complicated. To achieve them requires attending to a wide constellation of interlocking concerns related to the person with his or her attributes, the context in which the person’s life is playing out, the activities he or she needs or wants to do, the provision of significant experiences that can be transformative, and the person’s future possibilities. Therefore, no matter what intervention approaches we use, our work is always nested, at least in our heads, within our comprehensive, science-based understanding of participation and the “how to” for improving future prospects for our clients.

Engineers repair collapsed physical structures like bridges and buildings; we rebuild fragile and broken lives. Just like engineers, we must master multifaceted, widely varying educational content. Rebuilding lives requires a solid preparation not only in biomedical conditions but also, more important, in the science that explains participation, the factors that influence it, and its relationship to health.

In HD OT, rebuilding lives begins with collaboration with our clients. We need to know what the person we are working with is thinking about. We must pay close attention to [the client’s] stories for prioritizing treatment goals. In the process, we often become friends, companions, or confidantes.

Rebuilding lives requires attending to the social, cultural, physical, economic, and political context in which the person’s life is playing out. It may reveal an immediate, urgent need for a home modification, driving instruction, or repair to a piece of adaptive equipment that can be lifesaving, or it may signal the need for a particular culturally sensitive and complex intervention approach.

And, of course, rebuilding lives requires knowing how to motivate people to reengage in life, albeit initially, perhaps in very small steps. It entails shifting our concentration from a few valued occupations to the wider screen that deals with fixing ever-changing and threatening life situations. For in rebuilding lives in high definition, a wide array of activities create the experiences out of which suffering is lessened, hope is strengthened and, as Mary Reilly (1962) said, the mind and will are energized to positively affect health.

In HD OT, when it’s time to part with a client, we experience the satisfaction in knowing that the better person–environment fits we may have put in place or the specific clinical outcomes we may have obtained are likely to be enduring and that as a consequence, our clients will continue to move forward in their lives in profound ways. This is high-definition occupational therapy practice. And only occupational therapy education prepares one to do it.

Beyond providing broadness with clarity, high definition also takes pieces of the picture that were in the background and clearly brings them into the foreground. How does this pertain to our science? It’s time for us to take the impressive evidence-based research that justifies the need for our profession and its services and bring it from the background to the foreground. We can never know every study, but everyone should know the most important studies in our profession and the most relevant ones in their own area of practice.

We all know that our practice is complex, our educational programs are complex, and even our research is complex. The good news is that HD can handle complexity. How many of you remember when the local news anchor would wear a tightly patterned necktie or perhaps a plaid sport coat? The pattern would drive the old cameras nuts and, as a result, the viewers saw unclear, wobbly patterns on their screen where neckties and sportcoats should have been. That’s not a problem anymore. High definition can handle complexity.

As practitioners, scientists, and educators, we appreciate and tackle complexity. In fact, I believe those who choose to pursue occupational therapy arrive on Day 1 of their professional program equipped with an extremely high aptitude for complex, real-world problem solving. Just as people with artistic talent obtain fine arts degrees, those with superior practical intelligence pursue occupational therapy degrees. This aptitude, along with our training, translates into really loving the kind of complex work we do. Think of how simple it may seem to sketch a bird. But by third grade, we pretty much know who can and who can’t. Like artistic composition, our clinical reasoning takes both talent and training. Now, we need to convince others that what we do, despite appearances, is complicated.

Of course, one of the main bonuses of HDTV is that with all the clarity and size, viewers feel like they are right in the middle of the movie’s action. It gets intense. I saw Avatar (Landau & Cameron, 2009) twice: once on a regular screen and the second time in HD 3D IMAX. What a difference in intensity! In high definition, we bring this intensity into our work with our clients. We are not “extras,” doing a quick, walk-on part in the crowd scene. Rather, we are like independent film makers. In the stories of our clients’ lives, we are co-producers and codirectors with them. We do setting and costume design. As if that’s not enough, we become actors, playing a supporting role in our client’s quest to have a life worth living.

For the past 93 years, occupational therapy practitioners have been co-producing such films, and they were in 3D long before there were IMAX theaters. Granted, none of this work will get you a studio contract, but it does enrich your life, your clients and, ultimately, our profession.

For all the advances in picture quality, there’s more to the picture than what we see. In HD OT, crisp sound has to accompany the crystal-clear picture. The branding process has helped, but we must push ourselves to talk about our work and promote our practice and our profession. All of these components—wide screen, showing complexity, sound—are the technical parts of high definition and can be used to create a brilliant picture of our profession.

So this high-definition gizmo may look nice in our living rooms, but what shows are we watching? Without the right content, the great picture we have on is of little use. I don’t get to watch much television, but when I do, I am amazed that we get all the cable channels one could ever want—and still, there’s nothing on!

There was a time when Americans could view—at the most—five television stations. There were three networks, public television, and usually a local independent station. Characters such as Fonzie and Cliff Huxtable became national icons because everyone watched the same shows. If you need to know who “the Fonz” or Cliff Huxtable is, ask any occupational therapy practitioner over the age of 40! Technology has changed all that. Dozens upon dozens of channels bring us very specific information. If your viewing interests are cooking and golf, you could easily fill up your TV time with just those two channels.

By the same token, our profession could fill up 24 hours per day of programming on its own Living Life To Its Fullest channel. Just imagine, Captain Erik Johnson, whom we met at the opening ceremony, could star in “Support Our Troops” and highlight his work on the frontlines of the war in Afghanistan helping our soldiers deal with combat stress. Laura Gitlin could star in the “Living Life To Its Fullest” show for caregivers of parents with dementia. Jane Case-Smith could host “Overcoming Autism” and showcase her important work in evidence-based reviews of occupational therapy. The Mary Warren show could be projected so that people with low vision issues could see it without eye strain. The list could go on and on. For that matter, each one of us could find a home on our high-definition cable channel!

I am speaking metaphorically, but our profession does have the substance that could sustain such a project. Some fields have lots of visibility but lack breadth and substance. We have both breadth and substance, but we need greater visibility. To increase our visibility, we are planning some specific initiatives in the areas of practice, science, education, diversity, public awareness, and advocacy that will put us in high definition.

Practice is central to our high-definition picture—and I mean every kind of occupational therapy practice. Some of us use the Model of Human Occupation (MOHO; Kielhofner, 2007), some of us do hand therapy, some of us do sensory integration therapy, and some of us do Lifestyle Redesign therapy. But we all do occupational therapy.

High-definition occupational therapy practice always considers the broad picture, even if it’s in the background or in our mind’s eye and not overtly visible in a specific therapeutic encounter. Close-ups are perfectly legitimate. In fact, as I see it, they are critical in one of the outstanding areas in which many of you practice: hand therapy.

Fortunately, high definition allows us to present broad pictures with clarity while retaining the capability to focus in on close-ups. Check out this oldie but goodie clip from the movie Ferris Bueller’s Day Off (Chinich & Hughes, 1986). As occupational therapy practitioners, we typically zoom in and then back out, and high definition will enable us to retain our clarity because it is complex and sharp but also has detail. As part of my presidency, we will take pride in the variation that characterizes our practice, feeling good about the complexity of our work and appreciating that some of us concentrate on close-ups and others of us on the wide screen. We can share in our collective vibrancy, and this collective vibrancy will position us to expand our capacity to meet society’s occupational needs. We must work to increase our presence in service provision for wounded warriors and veterans reintegrating into their communities. We need to work hard to secure occupational therapy positions in medical homes, prevention, telemedicine, and bundled care. These areas are the centerpieces of the health care reform bill [Patient Protection and Affordable Care Act of 2010], these are areas where funding streams will grow exponentially, and these are new areas of practice where we should be front and center.

Our educational programs prepare the future occupational therapy work force and are critical for positioning us to be at the forefront of health care reform. To achieve high definition in education, we first have to use some tools that have been produced as a Centennial Vision initiative to guide curriculum development, including the two model curriculum documents (AOTA, 2008, 2009) and the Blueprint for Entry-Level Education (AOTA, 2010). Use them!

Our curricula must include the content that will enable new generations of practitioners to confidently meet emerging societal needs in mental health, work and industry, aging, disability and rehabilitation, technology, and health and wellness as well in the health care reform priority areas. And in HD OT, our important work begins on Day 1 in acute care.

There is an increased demand for our practitioners every year. The members of my cohort, the Baby-Boom Generation, are now older people, and Generation X is not too far behind us. Our wounded soldiers return from war every day, and the autism epidemic is still here. To meet all the challenges before us, we must endorse top-notch standards and best practices in occupational therapy education. We must ensure that core science and competencies that align with the Centennial Vision are taught in every educational program. We must make sure that the occupational therapy doctorate is widely supported. It is key to leveling the playing field in the competitive environment of health care reform. And we must encourage practitioners in potential fieldwork sites to do all they can to institute internship programs. High-definition occupational therapy education requires an abundance of fieldwork opportunities so that our graduates are mentored and developed by our seasoned professionals who are on the front lines of practice.

Each student we graduate who becomes a practitioner can be thought of as a pixel contributing to our high-definition picture. Think of this detailed picture like a [Georges] Seurat painting. Individual pixels of color, which are clear and vibrant in their own right, come together to form lines of the painting, and those lines come together to form a clear, vibrant picture.

High definition also requires us to more strongly link science, academic education, and clinical education. In both clinical and academic settings, our students need to be groomed as confident, evidence-based practitioners. Clinical educators need to support academic education, and faculty in academic programs need to be respectful of and responsive to the needs of practice. Our students should not be struggling in divided families where their fieldwork educator is telling them one thing and their academic faculty, something else. Let’s all become comrades and get on the same page.

Our academic programs need to be supported to function as hubs of power in research, education, and practice integration, and our program directors need to be asked to work at building strong alliances. They are in command stations; they can have widespread influence through their many networks. We will call upon them to mobilize their faculty, students, alumni, fieldwork educators, corporate donors, clinical communities, and state associations to become the foot soldiers for implementing the Centennial Vision.

Our science must also be in high definition. We will begin by building an easily accessible repository of the science our practitioners need to know about, generated both within and outside our discipline, which supports the need for our practice and demonstrates its effectiveness and cost-effectiveness. We need to make sure that the outstanding research pertinent to our field is squarely placed in high definition on all of our radar screens.

For example, we all should know about Susan Murphy’s work in arthritis, Carolyn Baum and Tim Wolf’s discoveries on the impact of stroke on participation, Mary Lawlor and Cheryl Mattingly’s work on cultural barriers in health care, and Grace Baranek’s work on sensory processing in autism. Our science is a cornerstone for building high-definition occupational therapy. This research will need to be used to make our legitimacy crystal clear and to demonstrate the ways in which we do what our competitors can’t.

We also need to establish mechanisms for supporting the development of career scientists. To start, existing National Institutes of Health (NIH) and National Institute on Disability and Rehabilitation Research training programs need to be vigorously promoted. We will accelerate our science by networking with potential extramural funding agencies at the NIH so that they have a clear sense of the unique contribution our scientists can make in furthering their research priorities. We need to ensure that we are at the table when requests for proposals of relevance to occupational therapy are written.

Our picture also needs heightened public awareness. The branding initiative has been a success, but we can’t let the phrase Occupational Therapy: Living Life To Its Fullest be the end point; it must be a beginning.

Each of us has to tell our stories of the specific ways that we help people live life to its fullest. Thanks to advances in technology, there are more channels than ever for spreading our story. We can use community message boards, YouTube, e-mail lists, local media Web sites, Twitter, and Facebook, to name a few. Each time you help spread our message and show how we help people to live life to its fullest, you are fulfilling a key part of the Centennial Vision to make sure that our profession is widely recognized.

Let’s hold more virtual events. This year, when our government affairs division needed case studies to support a change in policy, you supplied them through our AOTA online social networking arm, OT Connections. Your stories were the grist for our advocacy mill.

I want to call upon each of you to really get your stories out in plain and simple language. When you do this, project confidence and put yourself in the spotlight. Now, research shows that there seems to be only a weak relationship between projected confidence and expertise. People we call superstars project confidence and have expertise, but there are lots of folks with limited expertise who nevertheless project confidence. Some people refer to them as “hot air.” In Texas, where John comes from, the phrase “all hat and no cattle” is used. Unfortunately, many of these people seem to rise to prominence. Other people have expertise, substance, and inner belief in one’s self but do not project confidence.

If you are one of our inwardly confident and expert practitioners, I call on you to step up to the plate, tell your story, and cast yourself as a colorful pixel in occupational therapy’s new high-definition image. In my presidency, I want to provide you with tools to make doing so easy.

Your individual efforts count. Through them, we will grow more widely recognized. Last year, Julie Bissell, an occupational therapy practitioner, contacted a freelance writer connected to National Public Radio (NPR) and pitched a story. Her one phone call resulted in NPR’s coverage of the need for more men in recession-proof occupational therapy, and 22 million people learned about occupational therapy in one evening. HD OT will be achieved if each of you takes a step as simple as Julie’s. It only took one call to put occupational therapy in high definition on NPR.

Speaking of men, I want to emphasize that to bring occupational therapy into high definition we will need to increase diversity in our profession. Each pixel in high definition is of a different shade and color, and different colors combine to make new colors. One of the key ingredients for a high-definition picture is diversity. Today, our profession is not diverse enough, and we will need to support initiatives that will help to remedy the situation. High-definition occupational therapy will be much more sustainable if we have a critical mass of diverse occupational therapy practitioners, educators, and researchers representing the composition of all Americans.

Growing more widely recognized and diverse will add to our power in advocacy. You know the issues. If we’re not trying to make sure that occupational therapy services are funded in whatever the final federal health care bill turns out to be, we’re fighting turf wars at the state level to protect our scope of practice. If we’re not fighting to extend the Medicare therapy cap, we’re fighting state Medicaid cuts.

I am so proud of what we have accomplished together in advocacy as individuals and as an association. AOTA itself is a key component in high-definition occupational therapy, and it must remain that way. Once again, let’s think of each one of us as a pixel in the picture. Now, let’s imagine that the state associations are the lines and everyone comes together to make the high-definition picture. For widescreen advocacy, students, practitioners, scientists, and educators must join both AOTA and their state associations.

Both the state associations and AOTA are only as strong as the members who join and participate in them. We now have more avenues than ever for each member to get involved with [his or her] association, and we want to increase these opportunities. We want an ongoing dialogue where members attend events, join online communities of practice, volunteer for ad hoc task groups, and read our magazine to facilitate productive interactions with our state association and AOTA leadership.

However, even if you don’t have time to participate, your membership is still sorely needed. Do you realize AOTA has the capacity to triple its membership? That’s because occupational therapy has 133,000 practitioners, and AOTA has 40,000 members. That’s 30%. As a comparison, in the United Kingdom, 80% of practitioners are members of their professional association. Tripling our membership will increase the resources to address advocacy, public awareness, research capacity, best practice, and the other Centennial Vision priorities.

The flow of information is key. The more information that we have flowing, the faster we can respond to change and the more relevant we can remain to everyone. By doing this, we can achieve the parts of the Centennial Vision that call for a powerful and globally connected workforce.

Each of these areas we’ve been discussing—practice, education, science, public awareness, diversity, and advocacy—help bring our profession into high definition, but each individual sitting in this audience or reading a transcript later has a role to play.

Remember, I said that we are not extras in this movie. We are co-producers entitled to our own fancy trailer! We have to awaken ourselves to the potential of this power and go grab it.

Then, once we awaken to use this power, we have to use it for good. We have to transform the world of occupational therapy. We must change our culture by insisting that membership in state associations and AOTA is necessary for everyone. The more members we have, the more collective power we have.

None of these tasks will be easy, but the more of us who engage in building a better profession and achieving our Centennial Vision, the clearer our high-definition picture will be.

The actor Christopher Reeve (1996), who after his spinal cord injury became a powerful advocate for rehabilitation research, said it best: “So many of our dreams first seem impossible. Then they seem improbable. And then, when we summon the will, they soon become inevitable.” Let’s use HD OT to the make goals of the Centennial Vision inevitable.

References

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