Why does left/right leaning matter? Also, why should this be solved through relay segregation, rather than shared follow lists, use of hashtags (and, if we ever get them working, Reddit-like communities)?

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The basic follow functionality of Nostr is outbox-model-powered follow lists, that doesn't need to be solved. But follow lists don't protect from reply spam, and they don't solve the need that some people have for seeing feeds of content from people they don't follow. Relay-based users and content curation and pubkey whitelisting do.