Should we be worried about artificial intelligence?

Not really, but we do need think carefully about how to harness, and regulate, machine intelligence.

By now, most of us are used to the idea of rapid, even accelerating, technological change, particularly where information technologies are concerned. Indeed, as consumers, we helped the process along considerably. We love the convenience of mobile phones, and the lure of social-media platforms such as Facebook, even if, as we access these services, we find that bits and pieces of our digital selves become strewn all over the internet.

More and more tasks are being automated. Computers (under human supervision) already fly planes and sail ships. They are rapidly learning how to drive cars. Automated factories make many of our consumer goods. If you enter (or return to) Australia with an eligible e-passport, a computer will scan your face, compare it with your passport photo and, if the two match up, let you in. The “internet of things” beckons; there seems to be an “app” for everything. We are invited to make our homes smarter and our lives more convenient by using programs that interface with our home-based systems and appliances to switch the lights on and off, defrost the fridge and vacuum the carpet.

Robots taking over more intimate jobs

With the demise of the local car industry and the decline of manufacturing, the services sector is expected to pick up the slack for job seekers. But robots are taking over certain roles once deemed human-only.

Clever though they are, these programs represent more-or-less familiar applications of computer-based processing power. With artificial intelligence, though, computers are poised to conquer skills that we like to think of as uniquely human: the ability to extract patterns and solve problems by analysing data, to plan and undertake tasks, to learn from our own experience and that of others, and to deploy complex forms of reasoning.

The quest for AI has engaged computer scientists for decades. Until very recently, though, AI’s initial promise had failed to materialise. The recent revival of the field came as a result of breakthrough advances in machine intelligence and, specifically, machine learning. It was found that, by using neural networks (interlinked processing points) to implement mathematically specified procedures or algorithms, machines could, through many iterations, progressively improve on their performance – in other words, they could learn. Machine intelligence in general and machine learning in particular are now the fastest-growing components of AI.

The achievements have been impressive. It is now 20 years since IBM’s Deep Blue program, using traditional computational approaches, beat Garry Kasparov, the world’s best chess player. With machine-learning techniques, computers have conquered even more complex games such as Go, a strategy-based game with an enormous range of possible moves. In 2016, Google’s Alpha Go program beat Lee Sedol, the world’s best Go player, in a four-game match.

Allan Dafoe, of Oxford University’s future humanities institute, says AI is already at the point where it can transform almost every industry, from agriculture to health and medicine, from energy systems to security and the military. With sufficient data, computing power and an appropriate algorithm, machines can be used to come up with solutions that are not only commercially useful but, in some cases, novel and even innovative.

Should we be worried? Commentators as diverse as the late Stephen Hawking and development economist Muhammad Yunus have issued dire warnings about machine intelligence. Unless we learn how to control AI, they argue, we risk finding ourselves replaced by machines far more intelligent than we are. The fear is that not only will humans be redundant in this brave new world, but the machines will find us completely useless and eliminate us.

The University of Canberra's robot Ardie teaches tai chi to primary school pupils.
The University of Canberra’s robot Ardie teaches tai chi to primary school pupils.

If these fears are realistic, then governments clearly need to impose some sort of ethical and values-based framework around this work. But are our regulatory and governance techniques up to the task? When, in Australia, we have struggled to regulate our financial services industry, how on earth will governments anywhere manage a field as rapidly changing and complex as machine intelligence?

Governments often seem to play catch-up when it comes to new technologies. Privacy legislation is enormously difficult to enforce when technologies effortlessly span national boundaries. It is difficult for legislators even to know what is going on in relation to new applications developed inside large companies such as Facebook. On the other hand, governments are hardly IT ingenues. The public sector provided the demand-pull that underwrote the success of many high-tech firms. The US government, in particular, has facilitated the growth of many companies in cybersecurity and other fields.

Governments have been in the information business for a very long time. As William the Conqueror knew when he ordered his Domesday Book to be compiled in 1085, you can’t tax people successfully unless you know something about them. Spending of tax-generated funds is impossible without good IT. In Australia, governments have developed and successfully managed very large databases in health and human services.

The governance of all this data is subject to privacy considerations, sometimes even at the expense of information-sharing between agencies. The evidence we have is that, while some people worry a lot about privacy, most of us are prepared to trust government with our information. In 2016, the Australian Bureau of Statistics announced that, for the first time, it would retain the names and addresses it collected during the course of the 2016 population census. It was widely expected (at least by the media) that many citizens would withhold their names and addresses when they returned their forms. In the end, very few did.

But these are government agencies operating outside the security field. The so-called “deep state” holds information about citizens that could readily be misused. Moreover, private-sector profit is driving much of the current AI surge (although, in many cases, it is the thrill of new knowledge and understanding, too). We must assume that criminals are working out ways to exploit these possibilities, too.

If we want values such as equity, transparency, privacy and safety to govern what happens, old-fashioned regulation will not do the job. We need the developers of these technologies to co-produce the values we require, which implies some sort of effective partnership between the state and the private sector.

Could policy development be the basis for this kind of partnership? At the moment, machine intelligence works best on problems for which relevant data is available, and the objective is relatively easy to specify. As it develops, and particularly if governments are prepared to share their own data sets, machine intelligence could become important in addressing problems such as climate change, where we have data and an overall objective, but not much idea as to how to get there.

Machine intelligence might even help with problems where objectives are much harder to specify. What, for example, does good urban planning look like? We can crunch data from many different cities, and come up with an answer that could, in theory, go well beyond even the most advanced human-based modelling. When we don’t know what we don’t know, machines could be very useful indeed. Nor do we know, until we try, how useful the vast troves of information held by governments might be.

Perhaps, too, the jobs threat is not as extreme as we fear. Experience shows that humans are very good at finding things to do. And there might not be as many existing jobs at risk as we suppose. I am convinced, for example, that no robot could ever replace road workers – just think of the fantastical patterns of dug-up gravel and dirt they produce, the machines artfully arranged by the roadside or being driven, very slowly, up and down, even when all the signs are there, and there is absolutely no one around. How do we get a robot, even one capable of learning by itself, to do all that?

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Cyberbullying Wreaks Havoc on Teens’ Mental Health

A new study confirms the emotional harm caused by cyberbullying in adolescents, particularly the most vulnerable youth.

The study showed significant increases in depression and anxiety among adolescent psychiatric inpatients and outpatients who were recent victims of cyberbullying.

“We found what some of the other literature has shown, with higher levels of depression and anxiety in victims of cyberbullying. This was shown in two different settings, inpatient and outpatient, and in two different states, New York and Florida,” co–first author Samantha Saltz, MD, from University of Miami Miller School of Medicine in Florida, told Medscape Medical News.

“When we do a psychiatric interview, we ask all of our patients about physical abuse, we ask about sexual abuse, we ask about neglect, but we don’t specifically ask about bullying and cyberbullying, and nowadays, those kinds of victimizations actually may be more prevalent than other kinds of abuse. We just might not be identifying it,” said Saltz.

The study was presented here May 5 at the American Psychiatric Association (APA) 2018 annual meeting.

High Anxiety, Depression

With co–first author, Nils Westfall, MD, also from University of Miami Miller School of Medicine, the investigators examined associations of recent cyberbullying with depression and anxiety among 51 adolescent psychiatric inpatients (mean age, 15 years) and 50 adolescent psychiatric outpatients (mean age, 14 years).

The vast majority of adolescent inpatients (94%) and outpatients (100%) had ready access to electronic social media via a phone or computer and reported recent use of online social media, “making them very vulnerable to cyberbullying,” Westfall told Medscape Medical News. Inpatients used a wider variety of online social media than outpatients. Such media included Facebook, instant messaging, and online chat rooms.

The prevalence of recent cyberbullying was higher in inpatients than outpatients (23% vs 10%) and among girls (29% female inpatients and 15% female outpatients). Female inpatients were 4.6 times more likely to be a victim of cyberbullying than their male peers, and female outpatients were 3.4 times more likely to be a victim than their male peers.

The most common mode of cyberbullying was phone texting.

“It’s important to look not just at social media use but specific types of social media, because the risk of being cyberbullied may differ a lot by the type of social media teenagers are using,” Westfall said. “For prevention purposes and trying to address this problem, it would be good to know where people are actually being cyberbullied.”

Among both inpatients and outpatients, being cyberbullied was associated with about a 1.5 standard deviation (SD) increase in depressive symptoms and about a 1 SD increase in anxiety on standard scales.

Among outpatients, levels of total anxiety, panic, generalized anxiety, and school-related anxiety were significantly greater by roughly two to three times, and there was a strong trend toward greater levels of separation anxiety among cyberbullying victims compared to nonvictims.

Given how common cyberbullying is and its associations with worsening mental health, simple age-appropriate screening instruments for cyberbullying are needed. Such screening may facilitate prevention efforts and improve care, the researchers say.

“We would encourage all psychiatrists, especially child psychiatrists, to incorporate cyberbullying into their general interview. Social media is now a big part of adolescents’ social life. It absolutely should be asked in primary care as well,” said Saltz.

Major Problem

Reached for comment, Shannon Bennett, PhD, clinical site director of the Youth Anxiety Center at New York–Presbyterian Hospital and clinical psychologist at New York–Presbyterian Hospital and Weill Cornell Medicine, said this study “adds useful statistics” about the frequency of reported recent cyberbullying in both inpatient and outpatient youth and the association with depression and anxiety.

Bennett cautioned that these data do not explain causal relationships between cyberbullying and reported anxiety and depression symptoms. “More research is needed to understand the role of cyberbullying in youth reports of anxiety, depression, and traumatic stress in both inpatient and outpatient contexts,” she noted.

“Cyberbullying is a significant problem,” said Bennett, “particularly for youth who are already vulnerable because of mental health symptoms, prior trauma experience, or history of inpatient and/or outpatient treatment. Clinicians should ask their patients about experiences of cyberbullying.”

To address the problem, schools and youth agencies “must continue to make youth aware of the negative consequences of bullying, whether in person or online, through awareness campaigns and activism, and also denote safe spaces for youth to disclose and discuss their experiences of bullying,” said Bennett. “Clinicians can partner with parents and schools when bullying is reported by a patient in order to protect the child and assess the personal and psychological consequences of the bullying experience,” she added.

Earlier this week, First Lady Melania Trump launched an awareness campaign called Be Best, which is aimed at combating cyberbullying and teaching children the importance of social awareness, self-awareness, positive relationship skills, and responsible decision making.


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Motherless, designer baby specter increases

Two developing reproductive technologies — one that could facilitate motherless babies and another that could open the door to so-called designer babies — have drawn warnings from Christian ethicists.

In one experiment, researchers at the UK’s University of Bath altered unfertilized mouse eggs so they took on properties like “ordinary” cells, such as skin cells, the BBC reported. Then they created mouse embryos by fertilizing the altered eggs with sperm cells, leading scientists to speculate that two human men, or even one man, may one day be able to conceive a child with similar technology using sperm and another donated body cell.

A separate experiment in Sweden has achieved genetic modification of “healthy human embryos,” which were then destroyed, NPR reported. Lead researcher Fredrik Lanner said he is seeking to help treat infertility, prevent miscarriages and treat diseases. But critics say the research could lead to genetically made-to-order babies and the introduction of new diseases into the human genepool.

Both experiments have troubling ethical implications, Union University bioethicist C. Ben Mitchell said.

“The biblical ideal for procreation is one man, one woman, in a one-flesh relationship, in which children are received as a gift,” Mitchell told Baptist Press in written comments. “Every violation of that ideal results in human trauma and heartache, whether through adultery, divorce or death.

“The use of reproductive technologies that end up destroying unborn human beings is a clear harm. If we defy the procreative relationship by creating parentless babies, there is likewise clear harm. Even if we could justify the outcome, think of the human carnage on the way to the goal. Countless human beings — generated at the hands of researchers — would die in the process of trying to perfect the techniques. The end does not justify the means when the means are immoral,” said Mitchell, Union’s provost and Graves Professor of Moral Philosophy.

Conception without eggs?

The British experiment, reported Sept. 13 in the journal Nature Communications, is only a first step toward motherless human babies, with researcher Tony Perry calling such a prospect “speculative and fanciful” at present, according to the BBC.

Still, Charles Patrick, a Southwestern Baptist Theological Seminary vice president who holds a Ph.D. in chemical and biomedical engineering, warned of skewing God’s plan for procreation described in Genesis 1-2.

“Just because we can develop a reproductive technology does not mandate that we must develop the technology,” Patrick told BP. “It seems unwise to develop reproductive technologies that preclude the use of sperm or eggs.”

“First, and to be scientifically honest, much of what occurs when a sperm and egg unite continues to be a mystery. There are potential errors with dangerous consequences that may occur when cells are ‘tricked’ into functioning in a manner not natural for them,” he said in written comments. “Second, reproductive technologies that remove either the egg or the sperm open the cultural door further to a genderless society.”

Additionally, creating babies without either egg or sperm cells “would provide childless couples yet another ‘extraordinary means’ distraction from adoption. Adoption is clearly espoused and modeled throughout Scripture,” Patrick said.

R. Albert Mohler Jr., president of Southern Baptist Theological Seminary, said the University of Bath research illustrates society’s quest to redefine “everything about sex and reproduction and marriage and gender.”

The sexual revolution, Mohler said Sept. 22 on his podcast The Briefing, has necessitated “a technological revolution” whose proponents seek reproduction “without marriage, and in this case … without women.”

Genetically made to order?

The Swedish research uses a genetic engineering innovation to “edit” healthy embryos’ DNA for what NPR deemed the first time ever. British scientists have said they will begin similar experiments later this year.

Thus far, at least 12 embryos — which were donated by couples who generated them as part of the in vitro fertilization process — have been modified, and researchers have vowed to destroy all modified embryos no later than their 14th day of life.

Patrick called any “use and destruction of human embryos” unethical because it “does not preserve the worth, dignity and value of human life defined in Genesis 1-2.” Yet “even if there were not a sanctity of life issue, there are other issues to consider in opening the epigenetic black box.”

“For instance, although there is the promise of correcting devastating diseases, there is equally the specter of creating designer babies or other non-therapeutic modifications and of introducing unintended consequences in the human germline,” Patrick said.

“Man was mandated in Genesis to be a steward of creation, and emphasis throughout Scripture is placed on restoring what God originally purposed in His creation. Hence, there is a general biblical warrant for scientific advances and technologies that restore,” he said.

“However, there is not clear biblical permission to manipulate genes toward perfection. Gene editing cannot reverse what sin and resulting human depravity wrought to God’s perfected creation. There is a flesh-spirit aspect that gene editing does not and cannot incorporate,” Patrick said.

Mohler wondered aloud Sept. 23 in The Briefing, “How long will it be before the bumper sticker on the back of the SUV says, ‘My child is genetically enhanced?’ … That day might after all not be so far in our future.”

Driving Under the Influence of Cannabis,An Increasing Public Health Concern

Driving is a complex task that requires integrity of sensory, motor, and cognitive function. The driving task may be compromised by factors related to the vehicle, the driving environment, and the driver. Driver impairment is a major cause of motor vehicle crashes and commonly results from alcohol intoxication.1 Cannabis is the most frequently detected illicit drug among drivers involved in motor vehicle crashes, often in combination with alcohol.2 Evidence from experimental and epidemiological studies indicates that cannabis also impairs driving performance and increases crash risk.1,2 The prevalence of cannabis use is expected to increase following recent legalization of medical and recreational use in several countries worldwide and the introduction of a legal cannabis industry.3 As a result, driving under the influence of cannabis has become an increasing public health concern.

Experimental laboratory studies have repeatedly demonstrated that the primary component of cannabis (ie, of Δ9-tetrahydrocannabinol [THC]) impairs the motor performance (eg, reaction time, tracking) and cognitive function (eg, attention, decision making, impulse control, memory) needed for safe driving in a dose-related manner.1,2 Performance impairments are maximal during the first hour after smoking and decline over 2 to 4 hours after cannabis use.2

Standard deviation of lateral position (SDLP), a measure of “weaving” or road tracking control as measured in on-road driving tests in actual traffic, appeared to be one of the most sensitive measures to detect THC-induced driving impairment. A study in 18 participants showed that smoking low (100 μg/kg of THC) and medium (200 μg/kg of THC) doses of cannabis significantly increased SDLP in a dose-related manner. The SDLP further increased when cannabis was combined with a low alcohol dose that produced a blood alcohol concentration (BAC) of 0.04 g/dL.4

In addition, the time spent driving outside of the traffic lane increased exponentially with increasing SDLP (r = 0.94) and was maximal (1.1%, about 40 seconds during the 1-hour driving test) following combined use of cannabis and alcohol. Mean increments in SDLP associated with cannabis use were equivalent to changes in SDLP previously observed in drivers performing the on-road test with a BAC of 0.05 g/dL, the level of legal impairment in many European countries. Blood alcohol concentrations at or above this level have been associated with a substantial increase in crash risk.1 Cannabis in combination with alcohol produced a mean increase in SDLP that was equivalent to that associated with a BAC greater than 0.10 g/dL, which is greater than the level of legal impairment in the United States.

Findings from on-road studies indicating that cannabis alone and combined with alcohol impairs road tracking have been replicated in driving simulator studies,1,2 supporting their validity and reliability. On-road and driving simulator studies also have shown that cannabis produces dose-related impairments of distance keeping and reaction time that added to those of alcohol when given in combination1,2 In these studies, drivers were aware of their driving impairment. Consequently, they invested more effort, drove at a greater distance from other vehicles, and slightly adjusted their speed.1 Yet, drivers were unable to compensate for the adverse effects of cannabis on lateral position because road tracking performance is a highly overlearned, habitual, and automated process that operates outside of conscious control.

Other laboratory studies have explored the possibility that the impairing effects of THC might be substantially reduced after repeated use owing to tolerance but provided little empirical evidence for this assumption. Cognitive and psychomotor impairments were blunted in (some) regular cannabis users but were nevertheless evident across multiple performance domains.5 An on-road driving study involving 24 participants6 demonstrated that acute administrations of dronabinol (10 mg and 20 mg), a synthetic THC prescribed to treat anorexia in wasting diseases and emesis in patients with cancer and chronic pain, increased SDLP and reaction time in occasional as well as heavy (daily and near daily) cannabis users. Increments in SDLP were comparable with impairments associated with BACs of 0.08 to 0.10 g/dL in occasional users. The magnitude of driving impairment was generally less among heavy users but still comparable with a BAC of 0.05 g/dL, particularly after the higher dose of THC.

Epidemiological findings on the role of THC in vehicle crashes show that cannabis use among drivers is associated with a moderate (about 1.2- to 2.0-fold) increase in crash risk,2 less of an effect than might have been predicted from experimental research. Various studies have shown that the combined use of cannabis and alcohol is associated with greater crash risk than the use of either alone.1 A significant problem with epidemiological studies is that (blood) samples for drug screening are often taken 3 to 4 hours after a crash. Concentrations of THC in these samples are usually very low (around 1 ng/mL) and not representative of the event because THC concentrations decline very rapidly after smoking. Moreover, low THC blood concentrations are not necessarily an indication of recent use but may also reflect past use in nonimpaired drivers. Most epidemiological studies therefore have been unable to estimate crash risk of drivers during the acute intoxication phase of cannabis use. Those that did collect blood samples closer to the crash event typically reported higher associations (odds ratios of 2-14) between cannabis use and crash risk at THC concentrations above 5 ng/mL.7

Scientific evidence on the association between cannabis use and driving impairment contrasts with public attitudes toward driving under the influence of cannabis. Regular cannabis users often admit to driving under the influence of cannabis and wrongfully believe that cannabis does not affect their driving performance or that they can compensate for cannabis-associated impairment.2 Consuming cannabis with or without alcohol is a common occurrence that causes substantial risk to intoxicated drivers and road users in general. In a policy brief by the World Health Organization, driving under the influence of cannabis was estimated to be responsible for slightly more than 8700 road traffic deaths worldwide in 2013.8 This is still far less than the number of deaths due to alcohol-impaired driving in the same year (slightly more than 188 000) but does underscore the importance of developing evidence-based policy and legislation to counteract the safety risks posed by driving under the influence of cannabis.

It Is Time for Women (and Men) to Be BraveA Consequence of the #MeToo Movement

It is telling that TIME Magazine’s Person of the Year honor was shared by “the silence breakers,” 61 women and men, from familiar actors to ordinary people, who came forward to report sexual assault and harassment, mostly in the workplace.1 Their stories are powerful and, sadly, not at all unfamiliar.

From the perspective of a female surgeon, one of the first female chairs of surgery, and now as one of a handful of female medical center chief executive officers and medical school deans, it appears that US society is on the cusp of a change in addressing sexual harassment and abuse.

Change often starts with the familiar basics: policies, education, and training. The harassment policy at Wake Forest Baptist Medical Center is clear and direct: Respectful behavior in the workplace is nonnegotiable. All staff members are responsible for making the medical center a safe, inclusive place where every individual feels valued, respected, and able to do his or her best work. There are no excuses and no exceptions to allow or enable anything less.

Similar policies are in place in hospitals across the country with similar important language: Discrimination or harassment of any employee or student based on sex, race, color, religion, national origin, sexual orientation, gender identity, age, or disability will not be tolerated. But policies are not always practiced and incidents are not always reported, due to fear of retaliation or harm to career advancement.

Health care workers in the United States are not alone with respect to sexual harassment. Around the world, there are reports of harassment, disrespect, and bullying in health care and science. In some countries, these behaviors border on unsafe. In a recent study, 83% (100/120) of physicians, nursing, and support staff at Bahrain Defense Force Hospital emergency departments, at 1-year follow-up, reported experiencing verbal abuse (78%), followed by physical abuse (11%), and sexual abuse (3%).2 In another recent study involving a survey of 137 residents at a children’s hospital in Mexico, 32% reported bullying and 82% reported harassing behaviors.3 Being female and younger than 29 years of age were reported as factors significantly associated with workplace bullying.3

If current methods and policies to prevent harassment and bias in health care are not working, what can leaders and others do to address this, especially if staff members do not feel there is someone they can talk with openly? Some organizations have set up an independent intermediary or outside organization with a hotline to report inappropriate actions or conversations and to manage the matter through to resolution. Other health care systems require staff to take real-time or virtual training to learn how to address being bullied or what to do when they see someone else being disrespected.4

Policies and training are well meaning and necessary, but gender bias and harassment must be eliminated. It is an issue that affects all of society. In the enormous public response to publicity around harassment and gender bias—across multiple industries and organizations over the last several months—society has decided: This is wrong.

Medical training teaches physicians to step up and say something. Physicians learn to say “I have a concern” when they need to stop before a surgical procedure for the safety of the patient. Today, surgeons see this play out every day, but in previous years, that was not the case. No one spoke in the operating room, except the surgeon. Now, anyone can speak up, and should do so, when necessary.

Physicians need to take this process, built upon safety, and encourage those in medicine to be brave and to speak out when they are, or witness someone else who is, being harassed or disrespected. Every physician, female or male, should feel empowered and encouraged to speak up, without fear, if she or he ever experiences or observes behavior that betrays the values central to a person’s identity. Every physician, female or male, should be brave enough to say, “This behavior makes me feel uncomfortable” or “I feel disrespected” to anyone who is inappropriate or disrespectful.

When it comes to respect, everyone must speak the same language and understand the same definitions. How physicians treat each other and other members of the health care organization creates the workplace culture and affects the health care environment, regardless of the person and his or her academic rank or clinical role; regardless of the clinical, administrative, or supporting duties and responsibilities; and regardless of the location, from operating rooms to board rooms. More importantly, leaders must ensure that issues brought to their attention involving disrespect of others, sexual harassment, or other unprofessional behaviors are immediately recognized, addressed, and resolved.

The medical and research communities are taking notice. Many recent publications,5,6 journal articles, and commentaries have addressed the issue of gender bias and harassment in medicine, including one that suggested 2018 would be the “year of reckoning for gender equality,” as well as the “year of reckoning for women in science.”7 Similarly, a committee of the National Academies of Science, Engineering, and Medicine will deliver a consensus report in 2018 on sexual harassment of women in science, engineering, and medicine and its effect on career advancement.

Medicine is at a tipping point. For the first time, in 2017, the number of women entering medical schools outnumbered men.8 With these students come different perspectives and active voices. This millennial generation knows that discrimination and harassment are not right. But for the young people of this generation, as well as people of the generations that preceded them and who work in academic medical centers, health care institutions, and other settings, now is the time for mutual respect, for utmost civility, and for women (and men) to be brave in putting an end to sexual harassment and abuse.

It’s Official: A British Man Has Contracted The First Case of Untreatable ‘Super-Gonorrhea’

It’s not a great feeling to know that you scared your doctors. Unfortunately for a man in the UK, he recently did so: he displayed a case of gonorrhea that so dramatically resisted treatment that it chilled his physicians.

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That’s partially because gonorrhea isn’t the best thing to leave untreated. But another reason: this case is a harbinger of a looming crisis.

Gonorrhea is an infection caused by a bacteria. Usually antibiotics can kill it.

But after some time, the bacteria evolves to become resistant to that treatment. It also happens to be one of the world’s most common STDs, with 78 million new cases every year.

Approximately 30 percent of all gonorrhea infections are resistant to at least one antibiotic, according to the Centers for Disease Control and Prevention (CDC).

We’ve known this was coming. In 2017, the WHO raised a worldwide alarm about the rising spread of resistance to older and cheaper antibiotics. Some countries with better monitoring systems, the UN agency said in a statement, found cases of resistance to all known antibiotics.

This case is one of the first of its kind.

The man is reported to have visited a clinic earlier this year, and was given a combination of two antibiotics, azithromycin and ceftriaxone, that was known to be effective in getting rid of the disease.

After the cocktail failed to wipe out the infection, the patient is now being treated with injections of a stronger antibiotic called ertapenem and will be tested again next month, PHE said in a report.

As reported by The Guardian, the UK government agency Public Health England (PHE) revealed that the patient who caught the highly resistant strain had a female partner in the country, but might have been infected during a trip in Southeast Asia.

Authorities are tracking down the man’s partners to try and contain the spread of the disease.

“These cases may just be the tip of the iceberg, since systems to diagnose and report untreatable infections are lacking in lower-income countries where gonorrhea is actually more common,” said Teodora Wi, a human reproduction expert with WHO, in a 2017 press release.

New antibiotics are hard to come by. They are expensive to produce, and resistance evolves fast, thanks to their extensive use in agriculture and farming.

And we’re already feeling the effects. Superbugs claim the lives of up to 50,000 people every year in Europe and the U.S. alone, according to the UK’s Review on Antimicrobial Resistance. Globally, drug resistant infections kill at least 700,000 people every year.

Those deaths are mostly due to resistance to cheap, widely-available antibiotics.

What makes this gonorrhea case notable? So far it has resisted treatments previously considered very effective. Doctors are treating the patient with more powerful antibiotics in the hope they might finally work.

Until we have more effective treatments for gonorrhea and other antibiotic-resistant infections, the only way to avoid catching a potentially untreatable STI is the same that prevents a treatable one: protected sex.

So if you needed an extra reminder to stay safe in the boudoir, well, here you go.

People Aren’t as Safe From Lead as Thought: Study

Long-term, low-level lead exposure may be linked with more than 256,000 premature deaths from heart disease in middle-aged and older Americans each year, according to a new study.

The researchers analyzed data from 14,300 people in the United States, covering nearly 20 years. All participants had a medical exam and a blood test for lead at the start of the study.

The findings revealed a link between low-level exposure and increased risk of premature death. Lead exposure has been associated with hardened arteries, high blood pressure and coronary heart disease, according to the researchers.

“Our study estimates the impact of historical lead exposure on adults currently aged 44 years old or over in the USA, whose exposure to lead occurred in the years before the study began,” said study lead author Dr. Bruce Lanphear. He’s a professor at Simon Fraser University in British Columbia, Canada.

Historical exposure occurs from lead present in the environment because of past use in fuel, paint and plumbing. There’s also ongoing exposure from foods, emissions from industrial sources and contamination from lead smelting sites and lead batteries, the researchers explained.

“Today, lead exposure is much lower because of regulations banning the use of lead in petrol, paints and other consumer products so the number of deaths from lead exposure will be lower in younger generations,” Lanphear said.

But efforts to reduce environmental lead exposure is still vital, he said.

“Our study calls into question the assumption that specific toxicants, like lead, have ‘safe levels,'” Lanphear said. Rather, he said, it “suggests that low-level environmental lead exposure is a leading risk factor for premature death in the USA, particularly from cardiovascular disease.”

The findings were published online March 12 in The Lancet Public Health journal.

Stemming the risk requires a range of public health measures, Lanphear said in a journal news release, such as “abating older housing, phasing out lead-containing jet fuels, replacing lead-plumbing lines and reducing emissions from smelters and lead battery facilities.”

Dr. Philip Landrigan, a professor at the Icahn School of Medicine at Mount Sinai in New York City, wrote an editorial published with the study.

“A recurrent theme in lead poisoning research has been the realization that lead has toxic effects on multiple organ systems at relatively low levels of exposure previously thought to be safe,” Landrigan wrote. “A key conclusion to be drawn from this analysis is that lead has a much greater impact on cardiovascular mortality than previously recognized.”

Opioids: A Crisis Decades In the Making

In 1980, Jane Porter and Hershel Jick published in a prominent medical journal the results of their study of pain among hospital patients.

These simple words about patients who took opioids would be used — and misused – for decades:

“We conclude,” the doctors wrote in a letter to the editor, “that despite widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction.”

Nearly four decades later, Jick said he regrets that he and Porter ever published their work. But they are hardly to blame for what would come.

Pain, Pills, and Death

An estimated 100 million Americans live with long-term pain. For decades, medicine’s overwhelming response has been prescription opioids like hydrocodone and fentanyl. Retail pharmacies dispensed more than 214 million opioid prescriptions in 2016. That’s more than 66 prescriptions for every 100 people and more prescriptions than any other country in the world.

In 2015, a reported 2 million Americans ages 12 and older were addicted to prescription pain relievers. In 2015 and 2016, nearly 117,000 Americans died from opioid overdoses. That’s more than the number of U.S. soldiers killed in the Korean, Vietnam, Iraq, and Afghanistan wars combined.

The numbers are so massive, they’re hard to comprehend. They have led dozens of cities and states, joined by the U.S. Justice Department, to sue opioid manufacturers and distributors as the federal government tightens regulations on opioid prescribing and calls the epidemic a public health emergency.

And it started with the mistaken idea that opioids were not addictive.

There’s plenty of blame to go around, from companies that used questionable marketing to make opioids the go-to for pain treatment, to the doctors who failed to change their habits even as patients’ bodies piled up, to the insurance companies that may not cover alternatives to opioids.

Because the drugs are so addictive, some patients, too, played a role in the crisis. Lax regulation and tracking allowed some to “doctor shop”: If one doctor refused to prescribe opioids, there’s another just down the street who might.

War on Pain

In their 1980 study, Jick and Porter wanted to find out whether hospital patients who received narcotics for acute pain for a short time became addicted to them. They reviewed the medical records of about 39,000 hospital patients. Nearly 12,000 of them received opioids while they were in the hospital. Four developed addiction to them. They reported their findings in a letter to the editor in the New England Journal of Medicine.

The patients that Porter and Jick observed “weren’t being treated with chronic opioid therapy for chronic pain, so the observation had no bearing at all on the risk of developing addiction” with chronic use, says Daniel Tobin, MD, medical director of Adult Primary Care at Yale-New Haven Hospital in New Haven, CT. He focuses on long-term pain management and opioid safety. “But this letter to the editor became doctrine.”

A study found that Porter and Jick’s five-sentence letter was cited 608 times in support of opioids. In 80% of those citations, the authors did not note that the patients received the drugs in the hospital.

A 1986 study in the journal Pain, which observed 38 patients, concluded again that opioid addiction was extremely rare.

“If we were talking about (blood pressure) medication, doctors would want rigorous evidence from long-term trials. We were ready to use opioids more freely before we had that data. I’d say physicians should take some of the responsibility,” says William Becker, MD, a core investigator in the Pain Research, Informatics, Multimorbidities & Education (PRIME) Center of Innovation at the VA Connecticut Healthcare System in West Haven, CT.

The ‘Fifth Vital Sign’

Around the same time, the medical community started paying more attention to the treatment of pain.

In the 1980s, the HIV epidemic called the medical profession’s attention to the under treatment of pain. “It triggered a worldwide outcry about the underutilization of opioids in the treatment of pain and how doctors needed to do a better job of treating chronic pain,” says Walter Ling, MD, a psychiatrist and founding director of the Integrated Substance Abuse Programs at the University of California-Los Angeles.

In 1996, increasing concern about untreated pain led the American Pain Society, a group of health care professionals and scientists that promote changes in public policy and medical practice to reduce pain-related suffering, to declare pain the “fifth vital sign.” That suggests it’s just as important for health care professionals to evaluate and address pain in every patient visit as it is to address the four common vital signs: temperature, pulse, breathing rate, and blood pressure.

While patients’ perception about their own pain is important, there is no test or instrument to verify it.

“Of course, pain is not a vital sign. There’s no objective test for it,” Tobin says. “We only have patients’ self-reports.”

That same year, Purdue Pharma released a new opioid prescription medication called OxyContin. In the 1998 OxyContin promotional video “I Got My Life Back,” targeted at doctors, a doctor explains that opioid painkillers are the best pain medicine available, they have few if any side effects, and fewer than 1% of people who use them get addicted.

OxyContin, originally sold in 80 milligram tablets, was appropriate, its label said, “for the management of moderate to severe pain where use of an opioid analgesic is appropriate for more than a few days.”

“The drug companies were ‘educating’ the doctors,” Ling says. “But there’s a very thin line between educating doctors and promoting your product.”

At the same time, drug reps were everywhere. They traveled from clinic to clinic, promoting their drugs while offering doctors gifts such as travel and lodging at expensive medical conferences in exchange for a visit to their booth. “They were literally throwing money at us,” says Joji Suzuki, MD, a psychiatrist who specializes in substance abuse at Brigham and Women’s Hospital in Boston. “These were the Wild West days when drug reps had free rein.”

Other Options Cheaper, Safer

Opioid painkillers aren’t the only pain medications available. They were just more aggressively marketed. Studies have shown that over-the-counter ibuprofen or a combination of ibuprofen and acetaminophen may treat pain better than opioids. Topical creams, certain antidepressants called SNRIs, and nerve pain medications such as gabapentin can ease chronic pain in some people, too. Other therapies, like yoga, acupuncture, physical therapy, and exercise, have also shown benefit for some.

While opioid manufacturers were “educating” doctors, American medical schools offered little or no training in the management of long-term pain. In 2010, only 1 in 5 American medical schools had any formal instruction on the topic. Among those, some schools required fewer than 5 hours of instruction. “In the absence of adequate education, pharmaceutical manufacturers stepped into the void with the message that long-term opioids were unquestionably safe and effective,” Becker says.

In 2003, the FDA warned the company its advertisements and promotional materials, which claimed OxyContin was less addictive than other opioids, were breaking federal law.

“The combination in these advertisements of suggesting such a broad use of this drug to treat pain without disclosing the potential for abuse with the drug and the serious, potentially fatal risks associated with its use, is especially egregious and alarming in its potential impact on the public health,” the agency wrote.

In 2007, the company agreed to pay $634 million to settle criminal and civil charges over its “long-term illegal scheme to promote, market and sell OxyContin,” according to an FDA press release issued at the time.

Today, Purdue Pharma publicly supports state and federal programs to fight the opioid epidemic, including encouraging prescribers to consult prescription-drug-monitoring program databases and repeating the CDC’s call to shorten the duration of first opioid prescriptions. The drug company distributed the CDC’s guidelines to prescribers and pharmacists when they were first released.

“Our industry and our company have and will continue to take meaningful action to reduce opioid abuse,” the company says in a statement. The company says it supports efforts to limit the length of first prescriptions of opioids and vows to continue research into new, non-opioid pain medications.

But the horse was already out of the barn before the FDA’s warning to Purdue Pharma in 2003.

Both the Veterans Administration and the Joint Commission, the independent organization that accredits American hospitals, had also declared pain the fifth vital sign. Health care professionals took notice when, soon after, a doctor was fined $1.5 million for under treatment of pain in an 85-year-old patient who died of lung cancer. “Under treatment of pain became a form of malpractice, of medical abuse,” Ling says.

By 2006, the Centers for Medicare and Medicaid Services launched a patient-satisfaction survey that would affect how much reimbursement hospitals got. Among other questions, the survey asked patients whether their pain was well managed.

“It behoved hospitals to push opioids as much as they could to keep patients happy,” Becker says.

A Way Forward?

Though opioid prescribing is still high, it peaked in 2010 and has continued to fall. In 2014, there was a steeper decline in opioid prescriptions after new laws took effect that required patients to see their doctor every time they wanted a refill of certain painkillers, Jones says.

The requirement made it a little harder for people to get opioids, and it may have raised doctors’ awareness of how much of the medication their patients were taking.

As of October 2017, in response to comments from doctors, the U.S. Department of Health and Human Services no longer considers hospitals’ pain management scores on patient satisfaction surveys in its reimbursement decisions for Medicare and Medicaid patients. The agency also plans to take another look at pain management survey questions and may revise them, says Jones.

These policy changes are intended to cut prescribing but not end access to the drugs altogether. “There are patients who do benefit from opioids,” says Daniel Tobin, MD, medical director of adult primary care at Yale-New Haven Hospital in New Haven, CT. He focuses on long-term pain management and opioid safety. “For those patients who benefit without evidence of harm, you don’t need to just take it all away. I would hate to see the pendulum swing too far.”

But there is some evidence that the proverbial pendulum has already begun to swing too far, according to a recent article in The New England Journal of Medicine. “The increase in opioid-related mortality fueled by injudicious prescribing and increasing illicit use of both prescription and illegal opioids has led some clinicians to simplify their lives by discontinuing prescribing of opioid analgesics,” the authors of the article write.

The authors say that halting opioid prescribing altogether would cause patients to suffer and could push some to seek out illegal opioids, like heroin, on the street.

“We need to find a middle ground,” says Tobin, “where we’re being deliberate and careful about prescribing.”

medicine cabinet

The fast-melting Arctic is already messing with the ocean’s circulation, scientists say


Between the Labrador and Irminger Seas: the southern tip of Greenland, photographed during a GEOMAR survey in 2016.

Scientists studying a remote and icy stretch of the North Atlantic have found new evidence that fresh water, likely melted from Greenland or Arctic sea ice, may already be altering a key process that helps drives the global circulation of the oceans.

In chilly waters on either side of Greenland, the ocean circulation “overturns,” as surface waters traveling northward become colder and more dense and eventually sink, traveling back southward toward Antarctica at extreme depths. This key sinking process is called convection. But too much fresh water at the surface could interfere with it, because with less salt, the water loses density and does not sink as easily.

In the new research, Marilena Oltmanns and two colleagues at the GEOMAR Helmholtz Center for Ocean Research in Kiel, Germany, found that following particularly warm summers in the remote Irminger Sea, convection tended to be more impaired in winter. In some cases, a layer of meltwater stayed atop the ocean into the next year, rather than vanishing into its depths as part of the overturning circulation, which has sometimes been likened to an ocean “conveyor belt.”

“Until now, models have predicted something for the future … but it was something that seemed very distant,” said Oltmanns, the lead scientist behind the research, which was published this week in Nature Climate Change.

“But now we saw with these observations that there is actually freshwater and that it is already affecting convection, and it delays convection quite a lot in some years,” she continued.

One caution is that this is an observational study, not a prediction for the future — and Oltmanns said “nobody really knows” how much freshwater is enough to significantly slow or shut down the circulation, which is technically called the “Atlantic meridional overturning circulation,” or AMOC. Still, it suggests that key processes that have raised long-standing concern are already happening.

To collect the data, Oltmanns and her team ventured by ship out into the Irminger Sea to the southeast of Greenland. There, they read data from ocean moorings that take measurements of the character of the waters in key regions of ocean convection. The researchers now have a 13-year record to draw upon from this area.

In winter, cold air chills the northward-flowing surface water in this region enough to cause it to become denser and sink. But meltwater interferes with and delays this process because, lacking salinity, it is less dense and less prone to sink.

In the high meltwater years, the ocean is also just warmer overall, the study found. That also delays the onset of convection, because it is harder for the ocean surface layer to lose enough heat to sink, Oltmanns said.

Either way, these processes create a situation in which meltwater may not sink entirely below the surface — instead, it can linger. This then creates the possibility that, lasting through the winter, it could join with even more meltwater the following summer.

The study found that in one year, 2010, 40 percent of fresh meltwater managed to linger in the Irminger Sea over winter and into the next year.

“It means that if there is less time for convection, there is less time to remove the freshwater from the upper layer,” Oltmanns said. “And in spring, the new freshwater comes. And it is possible that there is a threshold, that if there is a lot of freshwater that stays at the surface, and mixes with the new freshwater from the new summer, it suddenly doubles, or increases a lot, and the next winter, it’s a lot more difficult to break through.”

Again, it’s important to underscore that there are no predictions in this study about when these processes would reach such a threshold or cause a major switch to a new regime. Climate change simulations have generally found that while global warming should indeed weaken the Atlantic overturning circulation, that should play out gradually — but scientists acknowledge that these simulations are not necessarily complete.

That’s why data gathering, as in the current study, also matters a great deal.

“As we explore the crucial impact of freshwater discharge from Greenland and other venues on the ocean circulation, this paper represents an important piece in the puzzle,” said Marco Tedesco, a Greenland expert at the Lamont-Doherty Earth Observatory of Columbia University, who was not involved in the study.

The research highlights the growing attention being paid to the crucial ocean circulation in question, which is responsible for bringing warm ocean water northward and, therefore, warming higher latitudes and Europe, in particular. It has long been considered a potential weak spot in the climate system because of the possibility that a change here could trigger dramatic changes in a short time.

Scientists have reported the circulation is in a weakened state and has been since 2008. The reduction in strength has been by about 15 percent, David Smeed, a scientist who studies the strength of the circulation at Britain’s National Oceanography Center in Southampton, told The Washington Post this year.

But what’s behind changes this region is less clear, with some scientists saying that we’re already seeing the role of climate change, others saying that what’s going on in the North Atlantic is mainly the reflection of a cyclical phenomenon affecting the oceans and atmosphere — and many suggesting it’s a combination.

“These decadal variations are likely superimposed on a longer declining trend related to increasing greenhouse gases,” said Tom Delworth, an expert on the North Atlantic with the National Oceanic and Atmospheric Administration, in an email to The Post this year. “However, in terms of explaining AMOC behavior over the coming decades, the relative role of increasing greenhouse gases may well increase relative to natural variability.”

That sounds pretty gradual — but the new study is saying the change doesn’t necessarily have to be.

“There might be a threshold that is crossed, and it’s harder to get back to where we were before,” Oltmanns said. “It’s possible.”

Curbing Gun Violence

HMS internal medicine physician discusses gun reform and health care

AR-15 rifles.

Having undergone her training as a medical student on the South Side of Chicago, Chana Sacks thought she understood the ramifications of gun violence.

Then, in December 2012, during Sacks’ residency at Massachusetts General Hospital, a harrowing personal experience reframed her understanding of gun violence in the most painful of ways. Her cousin’s 7-year-old son, Daniel, was gunned down at Sandy Hook Elementary School in Connecticut. For Sacks, now a Harvard Medical School instructor, gun violence became an aching personal reality.

Sacks powerfully captured this scarring—and transformative—experience in a 2015 commentary for The New England Journal of Medicine.

Now, an internal medicine physician at Mass General, Sacks has formed the MGH Gun Violence Prevention Coalition. She co-leads the effort with Peter Masiakos, HMS associate professor of surgery and director of the pediatric trauma service at Mass General, and Paul Currier, HMS assistant professor of medicine and a pulmonary and critical specialist at Mass General, along with Kim Sheppard Smith, a registered nurse.

For this group, the Feb. 14 shooting in Parkland, Florida, that left 17 dead is the latest tragic reminder that their work is more urgently needed than ever.

Sacks sat down with Harvard Medicine News to discuss the state of gun violence research, policy and more.

HMN: Nearly 33,000 people die of firearm injuries in the United States each year and more than 67,000 are injured by gun violence. What does this mean to you as a physician and a scientist?

Sacks: These numbers are staggering and tragic because these deaths and injuries are preventable. While the stats are stark, they actually underestimate the magnitude of the problem, because this is not just about body counts. There were 3,000 students at the school in Parkland and, while thankfully most were not physically injured, those students and faculty and staff and parents and family friends are all facing long-lasting emotional sequelae. It’s important to remember that while mass shootings like this tragedy in Parkland capture the country’s attention, gun violence is a daily reality across the country for many people and many families whose pain never makes the news.

“These numbers are staggering and tragic because these deaths and injuries are preventable.” — Chana Sacks

My colleagues across every discipline—from emergency medicine, trauma surgery, rehabilitation, psychiatry, social work and other specialties—witness the devastation of gun violence firsthand. We all see the devastation of entire families when one person comes in shot.

As a clinician, I thought I understood this issue. I thought I knew what it meant. Then, when Daniel was killed, gun violence became a haunting personal reality.

HMN: Going back to cold clinical numbers, can we put them in a public health context?

Sacks: Thirty-three thousand people die each year from gun violence—that’s the same number of people dying from liver disease, and about the same number of people dying from sepsis. As clinicians, we are taught how to deal with these other causes of death that threaten our patients. I have sat through lectures on those topics, pored over well-conducted research studies funded by the National Institutes of Health. Not a single lecture, no emphasis in the curriculum, hardly any federal research funding for gun violence, which is taking just as many lives. We’re not taught how to approach it.

HMN: If you had a wish list of things to do to curb gun violence, what would the list include?

Sacks: One of the critical things we have to do to address gun violence is to reframe it as the public health and medical issue that it is. Then, we will have the power to approach it in a way that can lead to real solutions. Addressing firearm-related injuries will take a constellation of strategies. Reducing deaths from gun suicides demands a very different approach from one making sure a 5-year-old doesn’t get his hands on a gun and accidentally shoot his sister. We need to develop an understanding of the different pathways that lead to different types of gun violence. We would never expect one treatment to cure every type of heart disease. Whether it’s cardiovascular illness or gun violence, once we understand them we can devise targeted treatments.

At the same time, there are things we already know.  The common link in these tragedies is easy access to firearms. We know that access to firearms is an independent risk factor for suicide and homicide. We know that stronger firearm policies in general and stronger laws regulating permits and background checks are associated with decreased firearm homicides. We know that states with the most firearm legislation have the lowest rates of gun suicide and homicide. We know that in most mass shootings, the shooter gave warning signs that either weren’t recognized or weren’t acted upon. We know that too many guns in this country are not safely stored.

We know from the firsthand accounts of emergency room physicians, trauma surgeons and radiologists who treat gunshot victims that certain semi-automatic rifles spew lethality like no other, causing often irreparable organ damage, the kind once seen only on the battlefield.

We have important, actionable knowledge already, but still, many questions remain unanswered because of the lack of federal research funding. Speaking of a wish list, repealing the federal legislation first passed in 1996 that effectively shut down funding for gun violence research is a first order of business.  When data are absent, people get to choose their own anecdotes and treat them as fact. We cannot develop sound policy from gestalt alone. We have to test interventions and evaluate what works in a measurable way.

HMN: Much has been made of the mental health component in the gun debate. Can you address this?

Sacks: Tackling the mental health aspect of gun violence is, without doubt, critical, but it’s one component in a complex dynamic. There is a risk that people with mental illness get scapegoated in the national conversation. The fact is that people with mental illness are more likely to be victims of crime rather than perpetrators. Painting gun violence as a mental health problem alone is reductive and is exploited by some people who are very good at distracting from the real evidence-based ways of moving forward.

HMN: The human toll of gun violence appears immeasurable. Let’s talk about dollars and cents.

Sacks: The medical costs and loss of productivity alone are estimated to cost tens of billions of dollars a year. When costs of psychological trauma, litigation, the economic impact of lower property values and the closing of businesses in areas of cities that are seen as dangerous are factored in, some estimates reach $100 billion a year or more. The ripple effects spread quickly.

HMN: What is the role of clinicians in informing the public conversation on gun violence?

 Sacks: Our first obligation is to our patients in the clinic, in the hospital, in the emergency room. We must ask about gun safety and firearms in the home. Beyond the walls of the hospital, we have an obligation to speak out about what we witness on a daily basis. We must demand policy change because gun injuries and gun deaths are, at their core, medical. Gun violence affects every discipline in medicine in a really far-reaching way: emergency medicine doctors and nurses, trauma surgeons, primary care doctors dealing with the longer term sequelae, rehabilitation specialists, infectious disease doctors who take care of patients with spinal cord injuries and neurogenic bladder who get recurrent infections, mental health specialists, social workers and so on.

HMN: If gun violence is at its core a public health issue with cultural and political dimensions, how do we disentangle one from the others?

Sacks: I don’t know that they are easily disentangled. But an organized movement demanding substantive change is growing. There are many different groups saying the same thing—enough is enough. The Parkland students are really making a difference, leading with their powerful voices.

Responsible gun owners, of whom there are millions, have a big role to play in this conversation, and many of them are part of the effort for sensible gun reform. This goes to show it’s not “us” versus “them,” although this framing may be politically expedient for some.

But ultimately, we do have to bring the political and cultural discussion back to the core question of how to reduce morbidity and mortality from firearms and how to keep our communities safe. We are talking 33,000 deaths a year from gun violence—what could be more medical than that?