Academic literature on the topic 'Old United States Naval Hospital (New York, N.Y.)'

Abstract This study is a secondary analysis of the Outcome and Assessment Information Set (OASIS) and administrative billing records of 6,153 adults ≥ 65 years old who received home health (HH) from a not-for-profit HH agency in upstate New York in CY 2017. We evaluated the association between the use of home health services (HH) with the hazard of unplanned facility admissions among Medicare patients with and without Alzheimer’s disease and related dementia (ADRD). Outcome was time from HH start of care to an unplanned facility admission of any type, including the hospital, nursing home, or rehabilitation facility. Independent variables included weekly intensity (visits/week, hours/week) of each discipline, including skilled nursing (SN), physical therapy (PT), occupational therapy (OT), social work (SW), and home health aide (HA), separately. ADRD was identified by diagnosis (ICD-10 codes) and cognitive impairment (M1700, M1710, M1740 [OASIS]). In multivariable Cox Proportional hazard models that adjusted for time-varying effects of HH intensity, receiving the highest intensity of SN (3.3 visits of 2.78 hours per week) and PT (2.5 visits of 2 hours per week) was related to up to a 54% and 86% decrease, respectively, in the hazard of unplanned facility admission among patients with ADRD (n=1,525), and decreases of 56% and 90% respectively among patients without ADRD (n=4,628). This is the first study in the United States showing that receiving a sufficient amount and appropriate mix of HH services was associated with substantially reduced risk of unplanned facility admission among patients with ADRD by up to 86%.

BackgroundTotal knee arthroplasty (TKA) is a procedure rarely performed in patients under 21 years old. However, the number of patients <21 undergoing TKA in the United States (US) is unknown. In one of the largest US studies of an institutional arthroplasty registry, only 19 TKAs were performed in patients <21 out of ~30,000 primary TKAs over 34 years1. While a few national or multi-national studies have been performed outside the US, these studies have small cohorts (~100), making it difficult to determine the indications for TKA in this age group.ObjectivesWe identified the number of patients <21 years of age who underwent TKA in a US nationwide dataset. Additionally, we determined the epidemiological characteristics of patients undergoing TKA, including their age, sex, race, indications for surgery, and in-hospital mortality.MethodsWe analyzed the Kids’ Inpatient Database, which is a national weighted sample of all inpatient hospital admissions in the US in patients <21 years old from ~4,200 hospitals in 46 states. We included all admissions from 2000-2016 with a primary procedural code of TKA determined by ICD-9 and 10 codes. Descriptive statistics such as means and percentages, along with 95% confidence intervals were calculated using appropriate sample weights.ResultsThe total number of TKAs performed in patients <21 years old from 2000 to 2016 was 1,331 (Table 1). The majority of TKAs performed (n=936; 70.3%) were for treatment of an oncologic disease. The most common diagnosis was malignant tumor (68.7%), followed by osteoarthritis (7.3%) and inflammatory arthritis or juvenile idiopathic arthritis (JIA) (7.0%) (Figure 1). Osteonecrosis accounted for 3.9% of cases, while mechanical complications accounted for 3.3%. Fewer than 2% of cases had an indication of either benign or uncertain tumor, infection, or trauma. The mean age was 14.8 years, and 48.4% of the cohort was female. A higher proportion of the non-tumor cohort was female (57.1%) than the tumor cohort (44.7%). 57.1% of patients in the overall cohort were White, and this proportion was smaller in the tumor group (53.8%) than the non-tumor group (64.9%). No patients died during the inpatient event. 87.8% of TKAs were performed in urban teaching hospitals.Table 1.Characteristics of patients <21 undergoing TKA by diagnosis typeVariableOverallN = 1331Non-tumorN = 395TumorN = 936Age, mean (95% CI)14.8 (14.4, 15.2)15.9 (14.7, 17.1)14.3 (14.1, 14.6)Sex: Female, % (95% CI)48.4 (44.9, 51.9)57.1 (49.1, 64.8)44.7 (41.1, 48.3)Race, % (95% CI) White57.1 (52.3, 61.8)64.9 (55.5, 73.3)53.8 (48.4, 59.2) Black13.1 (10.1, 16.9)16.9 (10.1, 27.2)11.5 (8.7, 14.9) Hispanic19.7 (16.6, 23.3)14.3 (9.9, 20.2)22.0 (18.1, 26.6) Asian or Pacific Islander3.4 (2.1, 5.4)**4.6 (2.9, 7.4) Native American0.9 (0.4, 1.9)**** Other5.8 (4.1, 8.1)2.9 (1.3, 6.4)7.0 (4.8, 10.0)Payor, % (95% CI) Medicare1.4 (0.7, 2.9)4.7 (2.2, 9.7)— Medicaid31.1 (27.5, 35.0)28.0 (21.0, 36.3)32.4 (28.3, 36.7) Private57.8 (53.7, 61.7)60.2 (52.1, 67.8)56.7 (52.2, 61.1) Self-pay3.3 (2.3, 4.9)**4.2 (2.7, 6.2) Other6.1 (4.4, 8.3)5.1 (3.0, 8.6)6.6 (4.5, 9.4)Admission type: elective, % (95% CI)85.9 (81.1, 89.6)81.6 (72.6, 88.2)87.7 (82.2, 91.6)N represents weighted estimateCI = Confidence Interval** Per HCUP guidelines, cell sizes ≤10 have been omitted to protect patient confidentialityFigure 1.Most common primary diagnoses for TKA in patients <21 years oldThe most common primary diagnosis of 1,331 patients <21 undergoing TKA. Bars represent 95% Confidence Intervals. JIA = juvenile idiopathic arthritis.ConclusionTKA is a rarely-performed procedure for patients <21 years old in the US; it is mainly performed in urban teaching centers and has excellent in-hospital survival rates. 70.3% of these procedures are performed for tumors—the vast majority of which are malignant. Also, even with the advent of better treatment options for JIA and inflammatory arthritis, TKA is still performed frequently in this population indicating that better clinical management is needed.References[1]Martin JR et al. Adolescent total knee arthroplasty. PMCID: PMC5484984AcknowledgementsThis work was supported by the Kellen Scholar Award supported by the Anna Marie and Stephen Kellen Foundation Total Knee Improvement Program. The authors would like to acknowledge the Healthcare Cost and Utilization Project Data Partners that contribute to Healthcare Cost and Utilization Project: Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, District of Columbia, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, Wyoming.Disclosure of InterestsJ. Alex Gibbons: None declared, Cynthia Kahlenberg: None declared, Deanna Jannat-Khah Shareholder of: AstraZeneca, Cytodyn, and Walgreens, Susan Goodman Consultant of: UCB, Grant/research support from: Novartis, Peter Sculco Consultant of: Intellijoint Surgical, DePuy Synthes, Lima Corporate, Zimmer Biomet, and EOS Imaging, Grant/research support from: Intellijoint Surgical and Zimmer Biomet, Mark Figgie Shareholder of: HS2, Mekanika, and Wishbone, Consultant of: Lima and Wishbone, Bella Mehta Paid instructor for: Novartis

Review Metformin Inhibits Autophagy, Mitophagy and Antagonizes Doxorubicin-Induced Cardiomyocyte Death Jennifer Van 1, Younghee Hahn 1, Brett Silverstein 1, Cairong Li 2, Fei Cai 2, Jia Wei 3, Lokesh Katiki 1, Puja Mehta 1, Katherine Livatova 1, Jaclyn DelPozzo 1, Tamayo Kobayashi 1, Yuan Huang 1, Satoru Kobayashi 1, and Qiangrong Liang 1, * 1 Department of Biomedical Sciences, New York Institute of Technology, College of Osteopathic Medicine, Old Westbury, New York 10001, United States 2 Clinical Medical College, Hubei University of Science and Technology, Xianning 332306, China 3 Department of Cardiology, the Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an 710000 , China * Correspondence: qliang03@nyit.edu Received: 28 November 2022 Accepted: 12 January 2023 Published: 17 February 2023 Abstract: The antidiabetic drug metformin has been shown to reduce cardiac injury under various pathological conditions, including anticancer drug doxorubicin (DOX)-induced cardiotoxicity, which makes metformin a prime candidate for repurposing. However, the mechanisms that mediate the cardioprotective effects of metformin remain highly controversial. In this study, we tested a prevailing hypothesis that metformin activates autophagy/mitophagy to reduce DOX cardiotoxicity. FVB/N mice and H9C2 cardiac myoblasts were treated with metformin, respectively. Autophagy/mitophagy was determined by Western blot analysis of microtubule-associated protein light chain 3, form-II (LC3-II), a well-established marker of autophagic vesicles. Although metformin had minimal effects on basal LC3-II levels, it significantly inhibited the accumulation of LC3-II levels by the lysosomal protease inhibitors pepstatin A and E64d in both total cell lysates and mitochondrial fractions. Also, dual fluorescent autophagy/mitophagy reporters demonstrated that metformin slowed the degradation rate of autophagic cargos or mitochondrial fragments in the lysosomes. These surprising results suggest that metformin inhibits rather than stimulates autophagy/mitophagy, sharply contrasting the popular belief. In addition, metformin diminished DOX-induced autophagy/mitophagy as well as cardiomyocyte death. Together, these results suggest that the cardioprotective effects of metformin against DOX cardiotoxicity may be mediated by its ability to inhibit autophagy and mitophagy, although the underlying molecular mechanisms remain to be determined.

Cyborgs already walk among us. (“Cures to Come” 76) This essay was begun as a reaction to a Hallmark Hall of Fame television movie called Sweet Nothing in My Ear (2008), which follows the lives of two parents, Dan, who is hearing (played by Jeff Daniels), and Laura, who is deaf (Marlee Matlin), as they struggle to make a decision about whether or not to give their 11-year-old son, Adam (late-deafened), a cochlear implant. Dan and Laura represent different perspectives, hearing and deaf perspectives. The film dramatizes the parents’ conflict and negotiation, exposing audiences to both sides of the cochlear implant debate, albeit in a fairly simplistic way. Nevertheless, it represents the lives of deaf people and gives voice to debates about cochlear implants with more accuracy and detail than most film and television dramas. One of the central scenes in the film is what I call the “activation scene”, quite common to cochlear implant narratives. In the scene, the protagonists witness a child having his implant activated or turned on. The depiction is reminiscent of the WATER scene in the film about Helen Keller, The Miracle Worker, employing a sentimental visual rhetoric. First, the two parents are shown seated near the child, clasping their hands as if in prayer. The audiologist, wielder of technology and therefore clearly the authority figure in the scene, types away furiously on her laptop. At the moment of being “turned on,” the child suddenly “hears” his father calling “David! David!” He gazes angelically toward heaven as piano music plays plaintively in the background. The parents all but fall to their knees and the protagonist of the film, Dan, watching through a window, weeps. It is a scene of cure, of healing, of “miracle,” a hyper-sentimentalised portrait of what is in reality often a rather anti-climactic event. It was certainly anti-climactic in my son, Michael’s case. I was taken aback by how this scene was presented and dismayed overall at some of the inaccuracies, small though they were, in the portrayal of cochlear implants in this film. It was, after all, according to the Nielsen ratings, seen by 8 million people. I began to wonder what kinds of misconceptions my son was going to face when he met people whose only exposure to implants was through media representations. Spurred by this question, I started to research other recent portrayals of people with implants on U.S. television in the past ten years, to see how cochlear implant (hereafter referred to as CI) identity has been portrayed by American media. For most of American history, deaf people have been portrayed in print and visual media as exotic “others,” and have long been the subject of an almost morbid cultural fascination. Christopher Krentz suggests that, particularly in the nineteenth century, scenes pairing sentimentality and deafness repressed an innate, Kristevan “abject” revulsion towards deaf people. Those who are deaf highlight and define, through their ‘lack’, the “unmarked” body. The fact of their deafness, understood as lack, conjures up an ideal that it does not attain, the ideal of the so-called “normal” or “whole” body. In recent years, however, the figure of the “deaf as Other” in the media, has shifted from what might be termed the “traditionally” deaf character, to what Brenda Jo Brueggeman (in her recent book Deaf Subjects: Between Identities and Places), calls “the new deaf cyborg” or the deaf person with a cochlear implant (4). N. Katharine Hailes states that cyborgs are now “the stage on which are performed contestations about the body boundaries that have often marked class, ethnic, and cultural differences” (85). In this essay, I claim that the character with a CI, as portrayed in the media, is now not only a strange, “marked” “Other,” but is also a screen upon which viewers project anxieties about technology, demonstrating both fascination fear. In her book, Brueggeman issues a call to action, saying that Deaf Studies must now begin to examine what she calls “implanting rhetorics,” or “the rhetorical relationships between our technologies and our identity” and therefore needs to attend to the construction of “the new deaf cyborg” (18). This short study will serve, I hope, as both a response to that injunction and as a jumping-off point for more in-depth studies of the construction of the CI identity and the implications of these constructions. First, we should consider what a cochlear implant is and how it functions. The National Association of the Deaf in the United States defines the cochlear implant as a device used to help the user perceive sound, i.e., the sensation of sound that is transmitted past the damaged cochlea to the brain. In this strictly sensorineural manner, the implant works: the sensation of sound is delivered to the brain. The stated goal of the implant is for it to function as a tool to enable deaf children to develop language based on spoken communication. (“NAD Position”) The external portion of the implant consists of the following parts: a microphone, which picks up sound from the environment, which is contained in the behind-the-ear device that resembles the standard BTE hearing aid; in this “hearing aid” there is also a speech processor, which selects and arranges sounds picked up by the microphone. The processor transmits signals to the transmitter/receiver, which then converts them into electric impulses. Part of the transmitter sits on the skin and attaches to the inner portion of the transmitter by means of a magnet. The inner portion of the receiver/stimulator sends the impulses down into the electrode array that lies inside the cochlea, which in turn stimulates the auditory nerve, giving the brain the impression of sound (“Cochlear Implants”). According to manufacturer’s statistics, there are now approximately 188,000 people worldwide who have obtained cochlear implants, though the number of these that are in use is not known (Nussbaum). That is what a cochlear implant is. Before we can look at how people with implants are portrayed in the media, before we examine constructions of identity, perhaps we should first ask what constitutes a “real” CI identity? This is, of course, laughable; pinning down a homogeneous CI identity is no more likely than finding a blanket definition of “deaf identity.” For example, at this point in time, there isn’t even a word or term in American culture for someone with an implant. I struggle with how to phrase it in this essay - “implantee?” “recipient?” - there are no neat labels. In the USA you can call a person deaf, Deaf (the “D” representing a specific cultural and political identity), hearing impaired, hard of hearing, and each gradation implies, for better or worse, some kind of subject position. There are no such terms for a person who gets an implant. Are people with implants, as suggested above, just deaf? Deaf? Are they hard of hearing? There is even debate in the ASL community as to what sign should be used to indicate “someone who has a cochlear implant.” If a “CI identity” cannot be located, then perhaps the rhetoric that is used to describe it may be. Paddy Ladd, in Understanding Deaf Culture, does a brilliant job of exploring the various discourses that have surrounded deaf culture throughout history. Stuart Blume borrows heavily from Ladd in his “The Rhetoric and Counter-Rhetoric of a 'Bionic' Technology”, where he points out that an “essential and deliberate feature” of the history of the CI from the 60s onward, was that it was constructed in an overwhelmingly positive light by the mass media, using what Ladd calls the “medical” rhetorical model. That is, that the CI is a kind of medical miracle that promised to cure deafness. Within this model one may find also the sentimental, “missionary” rhetoric that Krentz discusses, what Ladd claims is a revival of the evangelism of the nineteenth-century Oralist movement in America. Indeed, newspaper articles in the 1980s and 90s hailed the implant as a “breakthrough”, a “miracle”; even a quick survey of headlines shows evidence of this: “Upton Boy Can Hear at Last!”, “Girl with a New Song in Her Heart”, “Children Head Queue for Bionic Ears” (Lane). As recently as January 2010, an issue of National Geographic featured on its cover the headline Merging Man and Machine: The Bionic Age. Sure enough, the second photograph in the story is of a child’s bilateral cochlear implant, with the caption “within months of the surgery (the child) spoke the words his hearing parents longed for: Mama and Dada.” “You’re looking at a real bionic kid,” says Johns Hopkins University surgeon John Niparko, proudly (37). To counter this medical/corporate rhetoric of cure, Ladd and Blume claim, the deaf community devised a counter-rhetoric, a discourse in which the CI is not cast in the language of miracle and life, but instead in terms of death, mutilation, and cultural oppression. Here, the implant is depicted as the last in a long line of sadistic experiments using the deaf as guinea pigs. Often the CI is framed in the language of Nazism and genocide as seen in the title of an article in the British Deaf News: “Cochlear Implants: Oralism’s Final Solution.” So, which of these two “implanting rhetorics” is most visible in the current construction of the CI in American television? Is the CI identity presented by rendering people with CIs impossibly positive, happy characters? Is it delineated using the metaphors of the sentimental, of cure, of miracle? Or is the CI identity constructed using the counter-rhetorical references to death, oppression and cultural genocide? One might hypothesize that television, like other media, cultivating as it does the values of the hearing hegemony, would err on the side of promulgating the medicalised, positivist rhetoric of the “cure” for deafness. In an effort to find out, I conducted a general survey of American television shows from 2000 to now that featured characters with CIs. I did not include news shows or documentaries in my survey. Interestingly, some of the earliest television portrayals of CIs appeared in that bastion of American sentimentality, the daytime soap opera. In 2006, on the show “The Young and the Restless”, a “troubled college student who contracted meningitis” received an implant, and in 2007 “All My Children” aired a story arc about a “toddler who becomes deaf after a car crash.” It is interesting to note that both characters were portrayed as “late-deafened”, or suddenly inflicted with the loss of a sense they previously possessed, thus avoiding any whiff of controversy about early implantation. But one expects a hyper-sentimentalised portrayal of just about everything in daytime dramas like this. What is interesting is that when people with CIs have appeared on several “reality” programs, which purport to offer “real,” unadulterated glimpses into people’s lives, the rhetoric is no less sentimentalized than the soaps (perhaps because these shows are no less fabricated). A good example of this is the widely watched and, I think, ironically named show “True Life” which appears on MTV. This is a series that claims to tell the “remarkable real-life stories of young people and the unusual subcultures they inhabit.” In episode 42, “ True Life: I’m Deaf”, part of the show follows a young man, Chris, born deaf and proud of it (his words), who decides to get a cochlear implant because he wants to be involved in the hearing world. Through an interpreter Chris explains that he wants an implant so he can communicate with his friends, talk with girls, and ultimately fulfill his dreams of having a job and getting married (one has to ask: are these things he can’t do without an implant?). The show’s promo asks “how do you go from living a life in total silence to fully understanding the spoken language?” This statement alone contains two elements common to the “miracle” rhetoric, first that the “tragic” deaf victim will emerge from a completely lonely, silent place (not true; most deaf people have some residual hearing, and if you watch the show you see Chris signing, “speaking” voluminously) to seamlessly, miraculously, “fully” joining and understanding the hearing world. Chris, it seems, will only come into full being when he is able to join the hearing world. In this case, the CI will cure what ails him. According to “True Life.” Aside from “soap opera” drama and so-called reality programming, by far the largest dissemination of media constructions of the CI in the past ten years occurred on top-slot prime-time television shows, which consist primarily of the immensely popular genre of the medical and police procedural drama. Most of these shows have at one time or another had a “deaf” episode, in which there is a deaf character or characters involved, but between 2005 and 2008, it is interesting to note that most, if not all of the most popular of these have aired episodes devoted to the CI controversy, or have featured deaf characters with CIs. The shows include: CSI (both Miami and New York), Cold Case, Law and Order (both SVU and Criminal Intent), Scrubs, Gideon’s Crossing, and Bones. Below is a snippet of dialogue from Bones: Zach: {Holding a necklace} He was wearing this.Angela: Catholic boy.Brennan: One by two forceps.Angela {as Brennan pulls a small disc out from behind the victim’s ear} What is that?Brennan: Cochlear implant. Looks like the birds were trying to get it.Angela: That would set a boy apart from the others, being deaf.(Bones, “A Boy in the Tree”, 1.3, 2005) In this scene, the forensics experts are able to describe significant points of this victim’s identity using the only two solid artifacts left in the remains, a crucifix and a cochlear implant. I cite this scene because it serves, I believe, as a neat metaphor for how these shows, and indeed television media in general, are, like the investigators, constantly engaged in the business of cobbling together identity: in this particular case, a cochlear implant identity. It also shows how an audience can cultivate or interpret these kinds of identity constructions, here, the implant as an object serves as a tangible sign of deafness, and from this sign, or clue, the “audience” (represented by the spectator, Angela) immediately infers that the victim was lonely and isolated, “set apart from the others.” Such wrongheaded inferences, frivolous as they may seem coming from the realm of popular culture, have, I believe, a profound influence on the perceptions of larger society. The use of the CI in Bones is quite interesting, because although at the beginning of the show the implant is a key piece of evidence, that which marks and identifies the dead/deaf body, the character’s CI identity proves almost completely irrelevant to the unfolding of the murder-mystery. The only times the CI character’s deafness is emphasized are when an effort is made to prove that the he committed suicide (i.e., if you’re deaf you are therefore “isolated,” and therefore you must be miserable enough to kill yourself). Zak, one of the forensics officers says, “I didn’t talk to anyone in high school and I didn’t kill myself” and another officer comments that the boy was “alienated by culture, by language, and by his handicap” (odd statements, since most deaf children with or without implants have remarkably good language ability). Also, in another strange moment, the victim’s ambassador/mother shows a video clip of the child’s CI activation and says “a person who lived through this miracle would never take his own life” (emphasis mine). A girlfriend, implicated in the murder (the boy is killed because he threatened to “talk”, revealing a blackmail scheme), says “people didn’t notice him because of the way he talked but I liked him…” So at least in this show, both types of “implanting rhetoric” are employed; a person with a CI, though the recipient of a “miracle,” is also perceived as “isolated” and “alienated” and unfortunately, ends up dead. This kind of rather negative portrayal of a person with a CI also appears in the CSI: New York episode ”Silent Night” which aired in 2006. One of two plot lines features Marlee Matlin as the mother of a deaf family. At the beginning of the episode, after feeling some strange vibrations, Matlin’s character, Gina, checks on her little granddaughter, Elizabeth, who is crying hysterically in her crib. She finds her daughter, Alison, dead on the floor. In the course of the show, it is found that a former boyfriend, Cole, who may have been the father of the infant, struggled with and shot Alison as he was trying to kidnap the baby. Apparently Cole “got his hearing back” with a cochlear implant, no longer considered himself Deaf, and wanted the child so that she wouldn’t be raised “Deaf.” At the end of the show, Cole tries to abduct both grandmother and baby at gunpoint. As he has lost his external transmitter, he is unable to understand what the police are trying to tell him and threatens to kill his hostages. He is arrested in the end. In this case, the CI recipient is depicted as a violent, out of control figure, calmed (in this case) only by Matlin’s presence and her ability to communicate with him in ASL. The implication is that in getting the CI, Cole is “killing off” his Deaf identity, and as a result, is mentally unstable. Talking to Matlin, whose character is a stand-in for Deaf culture, is the only way to bring him back to his senses. The October 2007 episode of CSI: Miami entitled “Inside-Out” is another example of the counter-rhetoric at work in the form of another implant corpse. A police officer, trying to prevent the escape of a criminal en route to prison, thinks he has accidentally shot an innocent bystander, a deaf woman. An exchange between the coroner and a CSI goes as follows: (Alexx Woods): “This is as innocent as a victim gets.”(Calleigh Duquesne): “How so?”AW: Check this out.”CD: “I don’t understand. Her head is magnetized? Steel plate?”AW: “It’s a cochlear implant. Helps deaf people to receive and process speech and sounds.”(CSI dramatization) AW VO: “It’s surgically implanted into the inner ear. Consists of a receiver that decodes and transmits to an electrode array sending a signal to the brain.”CD: “Wouldn’t there be an external component?”AW: “Oh, she must have lost it before she was shot.”CD: “Well, that explains why she didn’t get out of there. She had no idea what was going on.” (TWIZ) Based on the evidence, the “sign” of the implant, the investigators are able to identify the victim as deaf, and they infer therefore that she is innocent. It is only at the end of the program that we learn that the deaf “innocent” was really the girlfriend of the criminal, and was on the scene aiding in his escape. So she is at first “as innocent” as they come, and then at the end, she is the most insidious of the criminals in the episode. The writers at least provide a nice twist on the more common deaf-innocent stereotype. Cold Case showcased a CI in the 2008 episode “Andy in C Minor,” in which the case of a 17-year-old deaf boy is reopened. The boy, Andy, had disappeared from his high school. In the investigation it is revealed that his hearing girlfriend, Emma, convinced him to get an implant, because it would help him play the piano, which he wanted to do in order to bond with her. His parents, deaf, were against the idea, and had him promise to break up with Emma and never bring up the CI again. His body is found on the campus, with a cochlear device next to his remains. Apparently Emma had convinced him to get the implant and, in the end, Andy’s father had reluctantly consented to the surgery. It is finally revealed that his Deaf best friend, Carlos, killed him with a blow to the back of the head while he was playing the piano, because he was “afraid to be alone.” This show uses the counter-rhetoric of Deaf genocide in an interesting way. In this case it is not just the CI device alone that renders the CI character symbolically “dead” to his Deaf identity, but it leads directly to his being literally executed by, or in a sense, excommunicated from, Deaf Culture, as it is represented by the character of Carlos. The “House Divided” episode of House (2009) provides the most problematic (or I should say absurd) representation of the CI process and of a CI identity. In the show, a fourteen-year-old deaf wrestler comes into the hospital after experiencing terrible head pain and hearing “imaginary explosions.” Doctors Foreman and Thirteen dutifully serve as representatives of both sides of the “implant debate”: when discussing why House hasn’t mocked the patient for not having a CI, Thirteen says “The patient doesn’t have a CI because he’s comfortable with who he is. That’s admirable.” Foreman says, “He’s deaf. It’s not an identity, it’s a disability.” 13: “It’s also a culture.” F: “Anything I can simulate with $3 earplugs isn’t a culture.” Later, House, talking to himself, thinks “he’s going to go through life deaf. He has no idea what he’s missing.” So, as usual, without permission, he orders Chase to implant a CI in the patient while he is under anesthesia for another procedure (a brain biopsy). After the surgery the team asks House why he did it and he responds, “Why would I give someone their hearing? Ask God the same question you’d get the same answer.” The shows writers endow House’s character, as they usually do, with the stereotypical “God complex” of the medical establishment, but in doing also they play beautifully into the Ladd and Blume’s rhetoric of medical miracle and cure. Immediately after the implant (which the hospital just happened to have on hand) the incision has, miraculously, healed overnight. Chase (who just happens to be a skilled CI surgeon and audiologist) activates the external processor (normally a months-long process). The sound is overwhelming, the boy hears everything. The mother is upset. “Once my son is stable,” the mom says, “I want that THING out of his head.” The patient also demands that the “thing” be removed. Right after this scene, House puts a Bluetooth in his ear so he can talk to himself without people thinking he’s crazy (an interesting reference to how we all are becoming cyborgs, more and more “implanted” with technology). Later, mother and son have the usual touching sentimental scene, where she speaks his name, he hears her voice for the first time and says, “Is that my name? S-E-T-H?” Mom cries. Seth’s deaf girlfriend later tells him she wishes she could get a CI, “It’s a great thing. It will open up a whole new world for you,” an idea he rejects. He hears his girlfriend vocalize, and asks Thirteen if he “sounds like that.” This for some reason clinches his decision about not wanting his CI and, rather than simply take off the external magnet, he rips the entire device right out of his head, which sends him into shock and system failure. Ultimately the team solves the mystery of the boy’s initial ailment and diagnoses him with sarcoidosis. In a final scene, the mother tells her son that she is having them replace the implant. She says it’s “my call.” This show, with its confusing use of both the sentimental and the counter-rhetoric, as well as its outrageous inaccuracies, is the most egregious example of how the CI is currently being constructed on television, but it, along with my other examples, clearly shows the Ladd/Blume rhetoric and counter rhetoric at work. The CI character is on one hand portrayed as an innocent, infantilized, tragic, or passive figure that is the recipient of a medical miracle kindly urged upon them (or forced upon them, as in the case of House). On the other hand, the CI character is depicted in the language of the counter-rhetoric: as deeply flawed, crazed, disturbed or damaged somehow by the incursions onto their Deaf identity, or, in the worst case scenario, they are dead, exterminated. Granted, it is the very premise of the forensic/crime drama to have a victim, and a dead victim, and it is the nature of the police drama to have a “bad,” criminal character; there is nothing wrong with having both good and bad CI characters, but my question is, in the end, why is it an either-or proposition? Why is CI identity only being portrayed in essentialist terms on these types of shows? Why are there no realistic portrayals of people with CIs (and for that matter, deaf people) as the richly varied individuals that they are? These questions aside, if these two types of “implanting rhetoric”, the sentimentalised and the terminated, are all we have at the moment, what does it mean? As I mentioned early in this essay, deaf people, along with many “others,” have long helped to highlight and define the hegemonic “norm.” The apparent cultural need for a Foucauldian “marked body” explains not only the popularity of crime dramas, but it also could explain the oddly proliferant use of characters with cochlear implants in these particular shows. A person with an implant on the side of their head is definitely a more “marked” body than the deaf person with no hearing aid. The CI character is more controversial, more shocking; it’s trendier, “sexier”, and this boosts ratings. But CI characters are, unlike their deaf predecessors, now serving an additional cultural function. I believe they are, as I claim in the beginning of this essay, screens upon which our culture is now projecting repressed anxieties about emergent technology. The two essentialist rhetorics of the cochlear implant, the rhetoric of the sentimental, medical model, and the rhetoric of genocide, ultimately represent our technophilia and our technophobia. The CI character embodies what Debra Shaw terms a current, “ontological insecurity that attends the interface between the human body and the datasphere” (85). We are growing more nervous “as new technologies shape our experiences, they blur the lines between the corporeal and incorporeal, between physical space and virtual space” (Selfe). Technology either threatens the integrity of the self, “the coherence of the body” (we are either dead or damaged) or technology allows us to transcend the limitations of the body: we are converted, “transformed”, the recipient of a happy modern miracle. In the end, I found that representations of CI on television (in the United States) are overwhelmingly sentimental and therefore essentialist. It seems that the conflicting nineteenth century tendency of attraction and revulsion toward the deaf is still, in the twenty-first century, evident. We are still mired in the rhetoric of “cure” and “control,” despite an active Deaf counter discourse that employs the language of the holocaust, warning of the extermination of yet another cultural minority. We are also daily becoming daily more “embedded in cybernetic systems,” with our laptops, emails, GPSs, PDAs, cell phones, Bluetooths, and the likes. We are becoming increasingly engaged in a “necessary relationship with machines” (Shaw 91). We are gradually becoming no longer “other” to the machine, and so our culturally constructed perceptions of ourselves are being threatened. In the nineteenth century, divisions and hierarchies between a white male majority and the “other” (women, African Americans, immigrants, Native Americans) began to blur. Now, the divisions between human and machine, as represented by a person with a CI, are starting to blur, creating anxiety. Perhaps this anxiety is why we are trying, at least in the media, symbolically to ‘cure’ the marked body or kill off the cyborg. Future examinations of the discourse should, I believe, use these media constructions as a lens through which to continue to examine and illuminate the complex subject position of the CI identity, and therefore, perhaps, also explore what the subject position of the post/human identity will be. References "A Boy in a Tree." Patrick Norris (dir.), Hart Hanson (by), Emily Deschanel (perf.). Bones, Fox Network, 7 Sep. 2005. “Andy in C Minor.” Jeannete Szwarc (dir.), Gavin Harris (by), Kathryn Morris (perf.). Cold Case, CBS Network, 30 March 2008. Blume, Stuart. “The Rhetoric and Counter Rhetoric of a “Bionic” Technology.” Science, Technology and Human Values 22.1 (1997): 31-56. Brueggemann, Brenda Jo. Deaf Subjects: Between Identities and Places. New York: New York UP, 2009. “Cochlear Implant Statistics.” ASL-Cochlear Implant Community. Blog. Citing Laurent Le Clerc National Deaf Education Center. Gallaudet University, 18 Mar. 2008. 29 Apr. 2010 ‹http:/ /aslci.blogspot.com/2008/03/cochlear-implant-statistics.html›. “Cures to Come.” Discover Presents the Brain (Spring 2010): 76. Fischman, Josh. “Bionics.” National Geographic Magazine 217 (2010). “House Divided.” Greg Yaitanes (dir.), Matthew V. Lewis (by), Hugh Laurie (perf.). House, Fox Network, 22 Apr. 2009. “Inside-Out.” Gina Lamar (dir.), Anthony Zuiker (by), David Caruso (perf.). CSI: Miami, CBS Network, 8 Oct. 2007. Krentz, Christopher. Writing Deafness: The Hearing Line in Nineteenth-Century American Literature. Chapel Hill: UNC P, 2007. Ladd, Paddy. Understanding Deaf Culture: In Search of Deafhood. Clevedon, UK: Multilingual Matters Limited, 2002. Lane, Harlan. A Journey Into the Deaf-World. San Diego: DawnSignPress, 1996. “NAD Position Statement on the Cochlear Implant.” National Association of the Deaf. 6 Oct. 2000. 29 April 2010 ‹http://www.nad.org/issues/technology/assistive-listening/cochlear-implants›. Nussbaum, Debra. “Manufacturer Information.” Cochlear Implant Information Center. National Deaf Education Center. Gallaudet University. 29 Apr. 2010 < http://clerccenter.gallaudet.edu >. Shaw, Debra. Technoculture: The Key Concepts. Oxford: Berg, 2008. “Silent Night.” Rob Bailey (dir.), Anthony Zuiker (by), Gary Sinise (perf.). CSI: New York, CBS Network, 13 Dec. 2006. “Sweet Nothing in My Ear.” Joseph Sargent (dir.), Stephen Sachs (by), Jeff Daniels (perf.). Hallmark Hall of Fame Production, 20 Apr. 2008. TWIZ TV scripts. CSI: Miami, “Inside-Out.” “What Is the Surgery Like?” FAQ, University of Miami Cochlear Implant Center. 29 Apr. 2010 ‹http://cochlearimplants.med.miami.edu/faq/index.asp›.

Photo by 14825144 © Alita Xander | Dreamstime.com ABSTRACT The US government's approach to the War on Drugs has created laws to deter people from using illicit drugs through negative punishment. These laws have not controlled illicit drug use, nor has it stopped the opioid pandemic from growing. Instead, these laws have created a negative bias surrounding addiction and have negatively affected particularly vulnerable patient populations, including pregnant women with substance use disorder and newborns with neonatal abstinence syndrome. This article highlights some misconceptions and underscores the challenges they face as they navigate the justice and healthcare systems while also providing possible solutions to address their underlying addiction. INTRODUCTION Pregnant women with substance use disorder require treatment that is arguably for the benefit of both the mother and the fetus. Some suggest that addiction is a choice; therefore, those who misuse substances should not receive treatment. Proponents of this argument emphasize social and environmental factors that lead to addiction but fail to appreciate how chronic substance use alters the brain’s chemistry and changes how it responds to stress, reward, self-control, and pain. The medical community has long recognized that substance use disorder is not simply a character flaw or social deviance, but a complex condition that requires adequate medical attention. Unfortunately, the lasting consequences of the War on Drugs have created a stigma around addiction medicine, leading to significant treatment barriers. There is still a pervasive societal bias toward punitive rather than rehabilitative approaches to addiction. For example, many women with substance use disorder lose custody of their baby or face criminal penalties, including fines and jail time.[1] These punitive measures may cause patients to lose trust in their physicians, ultimately leading to high-risk pregnancies without prenatal care, untreated substance misuse, and potential lifelong disabilities for their newborns.[2] As a medical student, I have observed the importance of a rehabilitative approach to addiction medicine. Incentivizing pregnant women with substance use disorder to safely address their chronic health issues is essential for minimizing negative short-term and long-term outcomes for women and their newborns. This approach requires an open mind and supportive perspective, recognizing that substance use disorder is truly a medical condition that requires just as much attention as any other medical diagnosis.[3] BACKGROUND The War on Drugs was a government-led initiative launched in 1970 by President Richard M. Nixon with the aim of curtailing illegal drug use, distribution, and trade by imposing harsher prison sentences and punishments.[4] However, it is worth noting that one can trace the roots of this initiative back further. In 1914, Congress enacted the Harrison Narcotics Tax Act to target the recreational use of drugs such as morphine and opium.[5] Despite being in effect for over four decades, the War on Drugs failed to achieve its intended goals. In 2011, the Global Commission on Drug Policy released a report that concluded that the initiative had been futile, as “arresting and incarcerating tens of millions of these people in recent decades has filled prisons and destroyed lives and families without reducing the availability of illicit drugs or the power of criminal organizations.”[6] One study published in the International Journal of Drug Policy in the same year found that funding drug law enforcement paradoxically contributed to increasing gun violence and homicide rates.[7] The Commission recommended that drug policies focus on reducing harm caused by drug use rather than solely on reducing drug markets. Recognizing that many drug policies were of political opinion, it called for drug policies that were grounded in scientific evidence, health, security, and human rights.[8] Unfortunately, policy makers did not heed these recommendations. In 2014, Tennessee’s legislature passed a “Fetal Assault Law,” which made it possible to prosecute pregnant women for drug use during pregnancy. If found guilty, pregnant women could face up to 15 years in prison and lose custody of their child. Instead of deterring drug use, the law discouraged pregnant women with substance use disorder from seeking prenatal care. This law required medical professionals to report drug use to authorities, thereby compromising the confidentiality of the patient-physician relationship. Some avoided arrest by delivering their babies in other states or at home, while others opted for abortions or attempted to go through an unsafe withdrawal prior to receiving medical care, sacrificing the mother's and fetus's wellbeing. The law had a sunset provision and expired in 2016. During the two years this law was in effect, officials arrested 124 women.[9] The fear that this law instilled in pregnant women with substance use disorder can still be seen across the US today. Many pregnant women with substance use disorders stated that they feared testing positive for drugs. Due to mandatory reporting, they were not confident that physicians would protect them from the law.[10] And if a woman tried to stop using drugs before seeking care to avoid detection, she often ended up delaying or avoiding care.[11] The American College of Obstetricians and Gynecologists (ACOG) recognizes the fear those with substance use disorders face when seeking appropriate medical care and emphasizes that “obstetric–gynecologic care should not expose a woman to criminal or civil penalties, such as incarceration, involuntary commitment, loss of custody of her children, or loss of housing.”[12] Mandatory reporting strains the patient-physician relationship, driving a wedge between the doctor and patient. Thus, laws intended to deter people from using substances through various punishments and incarceration may be doing more harm than good. County hospitals that mainly serve lower socioeconomic patients encounter more patients without consistent health care access and those with substance use disorders.[13] These hospitals are facing the consequences of the worsening opioid pandemic. At one county hospital where I recently worked, there has been a dramatic increase in newborns with neonatal abstinence syndrome born to mothers with untreated substance use disorders during pregnancy. Infants exposed to drugs prenatally have an increased risk of complications, stillbirth, and life-altering developmental disabilities. At the hospital, I witnessed Child Protective Services removing two newborns with neonatal abstinence syndrome from their mother’s custody. Four similar cases had occurred in the preceding month. In the days leading up to their placement with a foster family, I saw both newborns go through an uncomfortable drug withdrawal. No baby should be welcomed into this world by suffering like that. Yet I felt for the new mothers and realized that heart-wrenching custody loss is not the best approach. During this period, I saw a teenager brought to the pediatric floor due to worsening psychiatric symptoms. He was born with neonatal abstinence syndrome that neither the residential program nor his foster family could manage. His past psychiatric disorders included attention deficit disorder, conduct disorder, major depressive disorder, anxiety disorder, disruptive mood dysregulation disorder, intellectual developmental disorder, and more. During his hospitalization, he was so violent towards healthcare providers that security had to intervene. And his attitude toward his foster parents was so volatile that we were never sure if having them visit was comforting or agitating. Throughout his hospital course, it was difficult for me to converse with him, and I left every interview with him feeling lost in terms of providing an adequate short- and long-term assessment of his psychological and medical requirements. What was clear, however, was that his intellectual and emotional levels did not match his age and that he was born into a society that was ill-equipped to accommodate his needs. Just a few feet away from his room, behind the nurses’ station, were the two newborns feeling the same withdrawal symptoms that this teenager likely experienced in the first few hours of his life. I wondered how similar their paths would be and if they would exhibit similar developmental delays in a few years or if their circumstance may follow the cases hyped about in the media of the 1980s and 1990s regarding “crack babies.” Many of these infants who experienced withdrawal symptoms eventually led normal lives.[14] Nonetheless, many studies have demonstrated that drug use during pregnancy can adversely impact fetal development. Excessive alcohol consumption can result in fetal alcohol syndrome, characterized by growth deficiency, facial structure abnormalities, and a wide range of neurological deficiencies.[15] Smoking can impede the development of the lungs and brain and lead to preterm deliveries or sudden infant death syndrome.[16] Stimulants like methamphetamine can also cause preterm delivery, delayed motor development, attention impairments, and a wide range of cognitive and behavioral issues.[17] Opioid use, such as oxycodone, morphine, fentanyl, and heroin, may result in neonatal opioid withdrawal syndrome, in which a newborn may exhibit tremors, irritability, sleeping problems, poor feeding, loose stools, and increased sweating within 72 hours of life.[18] In 2014, the American Association of Pediatrics (AAP) reported that one newborn was diagnosed with neonatal abstinence syndrome every 15 minutes, equating to approximately 32,000 newborns annually, a five-fold increase from 2004.[19] The AAP found that the cost of neonatal abstinence syndrome covered by Medicaid increased from $65.4 million to $462 million from 2004 to 2014.[20] In 2020, the CDC published a paper that showed an increase in hospital costs from $316 million in 2012 to $572.7 million in 2016.[21] Currently, the impact of the COVID-19 pandemic on the prevalence of newborns with neonatal abstinence syndrome is unknown. I predict that the increase in opioid and polysubstance use during the pandemic will increase the number of newborns with neonatal abstinence syndrome, thereby significantly increasing the public burden and cost.[22] In the 1990s, concerns arose about the potentially irreparable damage caused by intrauterine exposure to cocaine on the development of infants, which led to the popularization of the term “crack babies.”[23] Although no strong longitudinal studies supported this claim at the time, it was not without merit. The Maternal Lifestyle Study (NCT00059540) was a prospective longitudinal observational study that compared the outcomes of newborns exposed to cocaine in-utero to those without.[24] One of its studies revealed one month old newborns with cocaine exposure had “lower arousal, poorer quality of movements and self-regulation, higher excitability, more hypertonia, and more nonoptimal reflexes.”[25] Another study showed that at one month old, heavy cocaine exposure affected neural transmission from the ear to the brain.[26] Long-term follow up from the study showed that at seven years old, children with high intrauterine cocaine exposure were more likely to have externalizing behavior problems such as aggressive behavior, temper tantrums, and destructive acts.[27] While I have witnessed this behavior in the teenage patient during my pediatrics rotation, not all newborns with intrauterine drug exposure are inevitably bound to have psychiatric and behavioral issues later in life. NPR recorded a podcast in 2010 highlighting a mother who used substances during pregnancy and, with early intervention, had positive outcomes. After being arrested 50 times within five years, she went through STEP: Self-Taught Empowerment and Pride, a public program that allowed her to complete her GED and provided guidance and encouragement for a more meaningful life during her time in jail. Her daughter, who was exposed to cocaine before birth, had a normal childhood and ended up going to college.[28] From a public health standpoint, more needs to be done to prevent the complications of substance misuse during pregnancy. Some states consider substance misuse (and even prescribed use) during pregnancy child abuse. Officials have prosecuted countless women across 45 states for exposing their unborn children to drugs.[29] With opioid and polysubstance use on the rise, the efficacy of laws that result in punitive measures seems questionable.[30] So far, laws are not associated with a decrease in the misuse of drugs during pregnancy. Millions of dollars are being poured into managing neonatal abstinence syndrome, including prosecuting women and taking their children away. Rather than policing and criminalizing substance use, pregnant women should get the appropriate care they need and deserve. I. Misconception One: Mothers with Substance Use Disorder Can Get an Abortion If an unplanned pregnancy occurs, one course of action could be to terminate the pregnancy. On the surface, this solution seems like a quick fix. However, the reality is that obtaining an abortion can be challenging due to two significant barriers: accessibility and mandated reporting. Abortion laws vary by state, and in Tennessee, for instance, abortions are banned after six weeks of gestation, typically when fetal heart rhythms are detected. An exception to this is in cases where the mother's life is at risk.[31] Unfortunately, many women with substance use disorders are from lower socioeconomic backgrounds and cannot access pregnancy tests, which could indicate they are pregnant before the six-week cutoff. If a Tennessee woman with substance use disorder decides to seek an abortion after six weeks, she may need to travel to a neighboring state. However, this is not always a feasible option, as the surrounding states (WV, MO, AR, MI, AL, and GA) also have restrictive laws that either prohibit abortions entirely or ban them after six weeks. Moreover, she may be hesitant to visit an obstetrician for an abortion, as some states require physicians by law to report their patients' substance use during pregnancy. For example, Virginia considers substance use during pregnancy child abuse and mandates that healthcare providers report it. This would ultimately limit her to North Carolina if she wants to remain in a nearby state, but she must go before 20 weeks gestation.[32] For someone who may or may not have access to reliable transportation, traveling to another state might be impossible. Without resources or means, these restrictive laws have made it incredibly difficult to obtain the medical care they need. II. Misconception Two: Mothers with SUD are Not Fit to Care for Children If a woman cannot take care of herself, one might wonder how she can take care of another human being. Mothers with substance use disorders often face many adversities, including lack of economic opportunity, trauma from abuse, history of poverty, and mental illness.[33] Fortunately, studies suggest keeping mother and baby together has many benefits. Breastfeeding, for example, helps the baby develop a strong immune system while reducing the mother’s risk of cancer and high blood pressure.[34] Additionally, newborns with neonatal abstinence syndrome who are breastfed by mothers receiving methadone or buprenorphine require less pharmacological treatment, have lower withdrawal scores, and experience shorter hospital stays.[35] Opioid concentration in breastmilk is minimal and does not pose a risk to newborns.[36] Moreover, oxytocin, the hormone responsible for mother-baby bonding, is increased in breastfeeding mothers, reducing withdrawal symptoms and stress-induced reactivity and cravings while also increasing protective maternal instincts.[37] Removing an infant from their mother’s care immediately after birth would result in the loss of all these positive benefits for both the mother and her newborn. The newborns I observed during my pediatrics rotation probably could have benefited from breastfeeding rather than bottle feeding and being passed around from one nurse to the next. They probably would have cried less and suffered fewer withdrawal symptoms had they been given the opportunity to breastfeed. And even if the mothers were lethargic and unresponsive while going through withdrawal, it would still have been possible to breastfeed with proper support. Unfortunately, many believe mothers with substance use disorder cannot adequately care for their children. This pervasive societal bias sets them up for failure from the beginning and greatly inhibits their willingness to change and mend their relationship with their providers. It is a healthcare provider’s duty to provide non-judgmental care that prioritizes the patient’s well-being. They must treat these mothers with the same empathy and respect as any other patient, even if they are experiencing withdrawal. III. Safe Harbor and Medication-Assisted Treatment Addiction is like any other disease and society should regard treatment without stigma. There is no simple fix to this problem, given that it involves the political, legal, and healthcare systems. Punitive policies push pregnant women away from receiving healthcare and prevent them from receiving beneficial interventions. States need to enact laws that protect these women from being reported to authorities. Montana, for example, passed a law in 2019 that provides women with substance use disorders safe harbor from prosecution if they seek treatment for their condition.[38] Medication-assisted treatment with methadone or buprenorphine is the first line treatment option and should be available to all pregnant women regardless of their ability to pay for medical care.[39] To promote continuity of care, health officials could include financial incentives to motivate new mothers to go to follow-up appointments. For example, vouchers for groceries or enrollment in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) may offset financial burdens and allow a mother to focus on taking care of her child and her recovery. IV. Mandated Substance Abuse Programs Although the number of people sentenced to state prisons for drug related crimes has been declining, it is still alarming that there were 171,300 sentencings in 2019.[40] Only 11 percent of the 65 percent of our nation’s inmates with substance use disorder receive treatment, implying that the other 89 percent were left without much-needed support to overcome their addiction.[41] It is erroneous to assume that their substance use disorder would disappear after a period without substance use while behind bars. After withdrawal, those struggling with substance use disorder may still have cravings and the likelihood of relapsing remains high without proper medical intervention. Even if they are abstinent for some time during incarceration, the underlying problem persists, and the cycle inevitably continues upon release from custody. In line with the recommendations by Global Commission on Drug Policy and the lessons learned from the failed War on Drugs, one proposed change in our criminal justice system would be to require enrollment and participation in assisted alcohol cessation programs before legal punishment. Policy makers must place emphasis on the safety of the patient and baby rather than the cessation of substance use. This would incentivize people to actively seek medical care, restore the patient-physician relationship, and ensure that they take rehabilitation programs seriously. If the patient or baby is unsafe, a caregiver could intervene while the patient re-enrolls in the program. Those currently serving sentences in prisons and jails can treat their substance use disorder through medication assisted treatment, cognitive behavioral therapy, and programs like Self Taught Empowerment and Pride (STEP). Medication assisted treatment under the supervision of medical professionals can help inmates achieve and maintain sobriety in a healthy and safe way. Furthermore, cognitive behavioral therapy can help to identify triggers and teach healthier coping mechanisms to prepare for stressors outside of jail. Finally, multimodal empowerment programs can connect people to jobs, education, and support upon release. People often leave prisons and jail without a sense of purpose, which can lead to relapse and reincarceration. Structured programs have been shown to decrease drug use and criminal behavior by helping reintegrate productive individuals into society.[42] V. Medical Education: Narcotic Treatment Programs and Suboxone Clinics Another proactive approach could be to have medical residency programs register with the Drug Enforcement Administration (DEA) as Narcotic Treatment Programs and incorporate suboxone clinics into their education and rotations. Rather than family medicine, OB/GYN, or emergency medicine healthcare workers having to refer their patients to an addiction specialist, they could treat patients with methadone for maintenance or detoxification where they would deliver their baby. Not only would this educate and prepare the future generation of physicians to handle the opioid crisis, but it would allow pregnant women to develop strong patient-physician relationships. CONCLUSION Society needs to change from the mindset of tackling a problem after it occurs to taking a proactive approach by addressing upstream factors, thereby preventing those problems from occurring in the first place. Emphasizing public health measures and adequate medical care can prevent complications and developmental issues in newborns and pregnant women with substance use disorders. Decriminalizing drug use and encouraging good health habits during pregnancy is essential, as is access to prenatal care, especially for lower socioeconomic patients. Many of the current laws and regulations that policy makers initially created due to naïve political opinion and unfounded bias to serve the War on Drugs need to be changed to provide these opportunities. To progress as a society, physicians and interprofessional teams must work together to truly understand the needs of patients with substance use disorders and provide support from prenatal to postnatal care. There should be advocation for legislative change, not by providing an opinion but by highlighting the facts and conclusions of scientific studies grounded in scientific evidence, health, security, and human rights. There can be no significant change if society continues to view those with substance use disorders as underserving of care. Only when the perspective shifts to compassion can these mothers and children receive adequate care that rehabilitates and supports their future and empowers them to raise their children. - [1] NIDA. 2023, February 15. Pregnant People with Substance Use Disorders Need Treatment, Not Criminalization. https://nida.nih.gov/about-nida/noras-blog/2023/02/pregnant-people-substance-use-disorders-need-treatment-not-criminalization [2] Substance Use Disorder Hurts Moms and Babies. National Partnership for Women and Families. June 2021 [3] All stories have been fictionalized and anonymized. [4] A History of the Drug War. Drug Policy Alliance. https://drugpolicy.org/issues/brief-history-drug-war [5] The Harrison Narcotic Act (1914) https://www.druglibrary.org/Schaffer/library/studies/cu/cu8.html [6] The War on Drugs. The Global Commission on Drug Policy. Published June 2011. https://www.globalcommissionondrugs.org/reports/the-war-on-drugs [7] Werb D, Rowell G, Guyatt G, Kerr T, Montaner J, Wood E. Effect of drug law enforcement on drug market violence: A systematic review. Int J Drug Policy. 2011;22(2):87-94. doi:10.1016/j.drugpo.2011.02.002 [8] Global Commission on Drug Policy, 2011 [9] Women NA for P. Tennessee’s Fetal Assault Law: Understanding its impact on marginalized women - New York. Pregnancy Justice. Published December 14, 2020. https://www.pregnancyjusticeus.org/tennessees-fetal-assault-law-understanding-its-impact-on-marginalized-women/ [10] Roberts SCM, Nuru-Jeter A. Women’s perspectives on screening for alcohol and drug use in prenatal care. Womens Health Issues Off Publ Jacobs Inst Womens Health. 2010;20(3):193-200. doi:10.1016/j.whi.2010.02.003 [11] Klaman SL, Isaacs K, Leopold A, et al. Treating Women Who Are Pregnant and Parenting for Opioid Use Disorder and the Concurrent Care of Their Infants and Children: Literature Review to Support National Guidance. J Addict Med. 2017;11(3):178-190. doi:10.1097/ADM.0000000000000308 [12] Substance Abuse Reporting and Pregnancy: The Role of the Obstetrician–Gynecologist. https://www.acog.org/en/clinical/clinical-guidance/committee-opinion/articles/2011/01/substance-abuse-reporting-and-pregnancy-the-role-of-the-obstetrician-gynecologist [13] R. Ghertner, G Lincoln The Opioid Crisis and Economic Opportunity: Geographic and Economic Trends. ASPE. Office of Assistant Secretary for Planning and Evaluation. DHHS Revised September 11, 2018 https://aspe.hhs.gov/reports/economic-opportunity-opioid-crisis-geographic-economic-trends [14] Midon, M. Z., Gerzon, L. R., & de Almeida, C. S. (2021). Crack and motor development of babies living in an assistance shelter. ABCS Health Sciences, 46, e021215-e021215. And for example, see Crack Babies: Twenty Years Later : NPR https://www.npr.org/templates/story/story.php?storyId=126478643 [15] Williams JF, Smith VC, the Committee on Substance Abuse. Fetal Alcohol Spectrum Disorders. Pediatrics. 2015;136(5):e20153113. doi:10.1542/peds.2015-3113 [16] CDC Tobacco Free. Smoking During Pregnancy. Centers for Disease Control and Prevention. Published April 11, 2022. https://www.cdc.gov/tobacco/basic_information/health_effects/pregnancy/index.htm [17] Abuse NI on D. What are the risks of methamphetamine misuse during pregnancy? National Institute on Drug Abuse. https://nida.nih.gov/publications/research-reports/methamphetamine/what-are-risks-methamphetamine-misuse-during-pregnancy [18] CDC. Basics About Opioid Use During Pregnancy | CDC. Centers for Disease Control and Prevention. Published July 21, 2021. https://www.cdc.gov/pregnancy/opioids/basics.html [19] Honein MA, Boyle C, Redfield RR. Public Health Surveillance of Prenatal Opioid Exposure in Mothers and Infants. Pediatrics. 2019;143(3):e20183801. doi:10.1542/peds.2018-3801 [20] Winkelman TNA, Villapiano N, Kozhimannil KB, Davis MM, Patrick SW. Incidence and Costs of Neonatal Abstinence Syndrome Among Infants with Medicaid: 2004–2014. Pediatrics. 2018;141(4):e20173520. doi:10.1542/peds.2017-3520 [21] Strahan AE, Guy GP Jr, Bohm M, Frey M, Ko JY. Neonatal Abstinence Syndrome Incidence and Health Care Costs in the United States, 2016. JAMA Pediatr. 2020;174(2):200-202. doi:10.1001/jamapediatrics.2019.4791 [22] Ghose R, Forati AM, Mantsch JR. Impact of the COVID-19 Pandemic on Opioid Overdose Deaths: a Spatiotemporal Analysis. J Urban Health Bull N Y Acad Med. 2022;99(2):316-327. doi:10.1007/s11524-022-00610-0 [23] Mayes LC, Granger RH, Bornstein MH, Zuckerman B. The Problem of Prenatal Cocaine Exposure: A Rush to Judgment. JAMA. 1992;267(3):406-408. doi:10.1001/jama.1992.03480030084043 [24] NICHD Neonatal Research Network. The Maternal Lifestyle Study. clinicaltrials.gov; 2016. https://clinicaltrials.gov/ct2/show/study/NCT00059540 [25] Lester BM, Tronick EZ, LaGasse L, et al. The maternal lifestyle study: effects of substance exposure during pregnancy on neurodevelopmental outcome in 1-month-old infants. Pediatrics. 2002;110(6):1182-1192. doi:10.1542/peds.110.6.1182 [26] Lester BM, Lagasse L, Seifer R, et al. The Maternal Lifestyle Study (MLS): effects of prenatal cocaine and/or opiate exposure on auditory brain response at one month. J Pediatr. 2003;142(3):279-285. doi:10.1067/mpd.2003.112 [27] Bada HS, Bann CM, Bauer CR, et al. Preadolescent behavior problems after prenatal cocaine exposure: Relationship between teacher and caretaker ratings (Maternal Lifestyle Study). Neurotoxicol Teratol. 2011;33(1):78-87. doi:10.1016/j.ntt.2010.06.005 [28] N, P, R. Crack Babies: Twenty Years Later. NPR. Published May 3, 2010. https://www.npr.org/templates/story/story.php?storyId=126478643 [29] Miranda L, Dixon V, September CRP on, 30, 2015. How States Handle Drug Use During Pregnancy http://projects.propublica.org/graphics/maternity-drug-policies-by-state [30] NCDAS: Substance Abuse and Addiction Statistics [2023]. NCDAS. https://drugabusestatistics.org/ [31] (Tenn. Code Ann. § 39-15-216). [32] Institute G. Interactive Map: US Abortion Policies and Access After Roe. https://states.guttmacher.org/policies/ [33] Whitesell M, Bachand A, Peel J, Brown M. Familial, Social, and Individual Factors Contributing to Risk for Adolescent Substance Use. J Addict. 2013;2013:579310. doi:10.1155/2013/579310 [34] CDC. Five Great Benefits of Breastfeeding. Centers for Disease Control and Prevention. Published July 27, 2021. https://www.cdc.gov/nccdphp/dnpao/features/breastfeeding-benefits/index.html [35] Welle-Strand GK, Skurtveit S, Jansson LM, Bakstad B, Bjarkø L, Ravndal E. 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On the morning of Thursday, 4 May 2006, the United States House Permanent Select Committee on Intelligence held an open hearing entitled “Terrorist Use of the Internet.” The Intelligence committee meeting was scheduled to take place in Room 1302 of the Longworth Office Building, a Depression-era structure with a neoclassical façade. Because of a dysfunctional elevator, some of the congressional representatives were late to the meeting. During the testimony about the newest political applications for cutting-edge digital technology, the microphones periodically malfunctioned, and witnesses complained of “technical problems” several times. By the end of the day it seemed that what was to be remembered about the hearing was the shocking revelation that terrorists were using videogames to recruit young jihadists. The Associated Press wrote a short, restrained article about the hearing that only mentioned “computer games and recruitment videos” in passing. Eager to have their version of the news item picked up, Reuters made videogames the focus of their coverage with a headline that announced, “Islamists Using US Videogames in Youth Appeal.” Like a game of telephone, as the Reuters videogame story was quickly re-run by several Internet news services, each iteration of the title seemed less true to the exact language of the original. One Internet news service changed the headline to “Islamic militants recruit using U.S. video games.” Fox News re-titled the story again to emphasise that this alert about technological manipulation was coming from recognised specialists in the anti-terrorism surveillance field: “Experts: Islamic Militants Customizing Violent Video Games.” As the story circulated, the body of the article remained largely unchanged, in which the Reuters reporter described the digital materials from Islamic extremists that were shown at the congressional hearing. During the segment that apparently most captured the attention of the wire service reporters, eerie music played as an English-speaking narrator condemned the “infidel” and declared that he had “put a jihad” on them, as aerial shots moved over 3D computer-generated images of flaming oil facilities and mosques covered with geometric designs. Suddenly, this menacing voice-over was interrupted by an explosion, as a virtual rocket was launched into a simulated military helicopter. The Reuters reporter shared this dystopian vision from cyberspace with Western audiences by quoting directly from the chilling commentary and describing a dissonant montage of images and remixed sound. “I was just a boy when the infidels came to my village in Blackhawk helicopters,” a narrator’s voice said as the screen flashed between images of street-level gunfights, explosions and helicopter assaults. Then came a recording of President George W. Bush’s September 16, 2001, statement: “This crusade, this war on terrorism, is going to take a while.” It was edited to repeat the word “crusade,” which Muslims often define as an attack on Islam by Christianity. According to the news reports, the key piece of evidence before Congress seemed to be a film by “SonicJihad” of recorded videogame play, which – according to the experts – was widely distributed online. Much of the clip takes place from the point of view of a first-person shooter, seen as if through the eyes of an armed insurgent, but the viewer also periodically sees third-person action in which the player appears as a running figure wearing a red-and-white checked keffiyeh, who dashes toward the screen with a rocket launcher balanced on his shoulder. Significantly, another of the player’s hand-held weapons is a detonator that triggers remote blasts. As jaunty music plays, helicopters, tanks, and armoured vehicles burst into smoke and flame. Finally, at the triumphant ending of the video, a green and white flag bearing a crescent is hoisted aloft into the sky to signify victory by Islamic forces. To explain the existence of this digital alternative history in which jihadists could be conquerors, the Reuters story described the deviousness of the country’s terrorist opponents, who were now apparently modifying popular videogames through their wizardry and inserting anti-American, pro-insurgency content into U.S.-made consumer technology. One of the latest video games modified by militants is the popular “Battlefield 2” from leading video game publisher, Electronic Arts Inc of Redwood City, California. Jeff Brown, a spokesman for Electronic Arts, said enthusiasts often write software modifications, known as “mods,” to video games. “Millions of people create mods on games around the world,” he said. “We have absolutely no control over them. It’s like drawing a mustache on a picture.” Although the Electronic Arts executive dismissed the activities of modders as a “mustache on a picture” that could only be considered little more than childish vandalism of their off-the-shelf corporate product, others saw a more serious form of criminality at work. Testifying experts and the legislators listening on the committee used the video to call for greater Internet surveillance efforts and electronic counter-measures. Within twenty-four hours of the sensationalistic news breaking, however, a group of Battlefield 2 fans was crowing about the idiocy of reporters. The game play footage wasn’t from a high-tech modification of the software by Islamic extremists; it had been posted on a Planet Battlefield forum the previous December of 2005 by a game fan who had cut together regular game play with a Bush remix and a parody snippet of the soundtrack from the 2004 hit comedy film Team America. The voice describing the Black Hawk helicopters was the voice of Trey Parker of South Park cartoon fame, and – much to Parker’s amusement – even the mention of “goats screaming” did not clue spectators in to the fact of a comic source. Ironically, the moment in the movie from which the sound clip is excerpted is one about intelligence gathering. As an agent of Team America, a fictional elite U.S. commando squad, the hero of the film’s all-puppet cast, Gary Johnston, is impersonating a jihadist radical inside a hostile Egyptian tavern that is modelled on the cantina scene from Star Wars. Additional laughs come from the fact that agent Johnston is accepted by the menacing terrorist cell as “Hakmed,” despite the fact that he utters a series of improbable clichés made up of incoherent stereotypes about life in the Middle East while dressed up in a disguise made up of shoe polish and a turban from a bathroom towel. The man behind the “SonicJihad” pseudonym turned out to be a twenty-five-year-old hospital administrator named Samir, and what reporters and representatives saw was nothing more exotic than game play from an add-on expansion pack of Battlefield 2, which – like other versions of the game – allows first-person shooter play from the position of the opponent as a standard feature. While SonicJihad initially joined his fellow gamers in ridiculing the mainstream media, he also expressed astonishment and outrage about a larger politics of reception. In one interview he argued that the media illiteracy of Reuters potentially enabled a whole series of category errors, in which harmless gamers could be demonised as terrorists. It wasn’t intended for the purpose what it was portrayed to be by the media. So no I don’t regret making a funny video . . . why should I? The only thing I regret is thinking that news from Reuters was objective and always right. The least they could do is some online research before publishing this. If they label me al-Qaeda just for making this silly video, that makes you think, what is this al-Qaeda? And is everything al-Qaeda? Although Sonic Jihad dismissed his own work as “silly” or “funny,” he expected considerably more from a credible news agency like Reuters: “objective” reporting, “online research,” and fact-checking before “publishing.” Within the week, almost all of the salient details in the Reuters story were revealed to be incorrect. SonicJihad’s film was not made by terrorists or for terrorists: it was not created by “Islamic militants” for “Muslim youths.” The videogame it depicted had not been modified by a “tech-savvy militant” with advanced programming skills. Of course, what is most extraordinary about this story isn’t just that Reuters merely got its facts wrong; it is that a self-identified “parody” video was shown to the august House Intelligence Committee by a team of well-paid “experts” from the Science Applications International Corporation (SAIC), a major contractor with the federal government, as key evidence of terrorist recruitment techniques and abuse of digital networks. Moreover, this story of media illiteracy unfolded in the context of a fundamental Constitutional debate about domestic surveillance via communications technology and the further regulation of digital content by lawmakers. Furthermore, the transcripts of the actual hearing showed that much more than simple gullibility or technological ignorance was in play. Based on their exchanges in the public record, elected representatives and government experts appear to be keenly aware that the digital discourses of an emerging information culture might be challenging their authority and that of the longstanding institutions of knowledge and power with which they are affiliated. These hearings can be seen as representative of a larger historical moment in which emphatic declarations about prohibiting specific practices in digital culture have come to occupy a prominent place at the podium, news desk, or official Web portal. This environment of cultural reaction can be used to explain why policy makers’ reaction to terrorists’ use of networked communication and digital media actually tells us more about our own American ideologies about technology and rhetoric in a contemporary information environment. When the experts come forward at the Sonic Jihad hearing to “walk us through the media and some of the products,” they present digital artefacts of an information economy that mirrors many of the features of our own consumption of objects of electronic discourse, which seem dangerously easy to copy and distribute and thus also create confusion about their intended meanings, audiences, and purposes. From this one hearing we can see how the reception of many new digital genres plays out in the public sphere of legislative discourse. Web pages, videogames, and Weblogs are mentioned specifically in the transcript. The main architecture of the witnesses’ presentation to the committee is organised according to the rhetorical conventions of a PowerPoint presentation. Moreover, the arguments made by expert witnesses about the relationship of orality to literacy or of public to private communications in new media are highly relevant to how we might understand other important digital genres, such as electronic mail or text messaging. The hearing also invites consideration of privacy, intellectual property, and digital “rights,” because moral values about freedom and ownership are alluded to by many of the elected representatives present, albeit often through the looking glass of user behaviours imagined as radically Other. For example, terrorists are described as “modders” and “hackers” who subvert those who properly create, own, legitimate, and regulate intellectual property. To explain embarrassing leaks of infinitely replicable digital files, witness Ron Roughead says, “We’re not even sure that they don’t even hack into the kinds of spaces that hold photographs in order to get pictures that our forces have taken.” Another witness, Undersecretary of Defense for Policy and International Affairs, Peter Rodman claims that “any video game that comes out, as soon as the code is released, they will modify it and change the game for their needs.” Thus, the implication of these witnesses’ testimony is that the release of code into the public domain can contribute to political subversion, much as covert intrusion into computer networks by stealthy hackers can. However, the witnesses from the Pentagon and from the government contractor SAIC often present a contradictory image of the supposed terrorists in the hearing transcripts. Sometimes the enemy is depicted as an organisation of technological masterminds, capable of manipulating the computer code of unwitting Americans and snatching their rightful intellectual property away; sometimes those from the opposing forces are depicted as pre-modern and even sub-literate political innocents. In contrast, the congressional representatives seem to focus on similarities when comparing the work of “terrorists” to the everyday digital practices of their constituents and even of themselves. According to the transcripts of this open hearing, legislators on both sides of the aisle express anxiety about domestic patterns of Internet reception. Even the legislators’ own Web pages are potentially disruptive electronic artefacts, particularly when the demands of digital labour interfere with their duties as lawmakers. Although the subject of the hearing is ostensibly terrorist Websites, Representative Anna Eshoo (D-California) bemoans the difficulty of maintaining her own official congressional site. As she observes, “So we are – as members, I think we’re very sensitive about what’s on our Website, and if I retained what I had on my Website three years ago, I’d be out of business. So we know that they have to be renewed. They go up, they go down, they’re rebuilt, they’re – you know, the message is targeted to the future.” In their questions, lawmakers identify Weblogs (blogs) as a particular area of concern as a destabilising alternative to authoritative print sources of information from established institutions. Representative Alcee Hastings (D-Florida) compares the polluting power of insurgent bloggers to that of influential online muckrakers from the American political Right. Hastings complains of “garbage on our regular mainstream news that comes from blog sites.” Representative Heather Wilson (R-New Mexico) attempts to project a media-savvy persona by bringing up the “phenomenon of blogging” in conjunction with her questions about jihadist Websites in which she notes how Internet traffic can be magnified by cooperative ventures among groups of ideologically like-minded content-providers: “These Websites, and particularly the most active ones, are they cross-linked? And do they have kind of hot links to your other favorite sites on them?” At one point Representative Wilson asks witness Rodman if he knows “of your 100 hottest sites where the Webmasters are educated? What nationality they are? Where they’re getting their money from?” In her questions, Wilson implicitly acknowledges that Web work reflects influences from pedagogical communities, economic networks of the exchange of capital, and even potentially the specific ideologies of nation-states. It is perhaps indicative of the government contractors’ anachronistic worldview that the witness is unable to answer Wilson’s question. He explains that his agency focuses on the physical location of the server or ISP rather than the social backgrounds of the individuals who might be manufacturing objectionable digital texts. The premise behind the contractors’ working method – surveilling the technical apparatus not the social network – may be related to other beliefs expressed by government witnesses, such as the supposition that jihadist Websites are collectively produced and spontaneously emerge from the indigenous, traditional, tribal culture, instead of assuming that Iraqi insurgents have analogous beliefs, practices, and technological awareness to those in first-world countries. The residual subtexts in the witnesses’ conjectures about competing cultures of orality and literacy may tell us something about a reactionary rhetoric around videogames and digital culture more generally. According to the experts before Congress, the Middle Eastern audience for these videogames and Websites is limited by its membership in a pre-literate society that is only capable of abortive cultural production without access to knowledge that is archived in printed codices. Sometimes the witnesses before Congress seem to be unintentionally channelling the ideas of the late literacy theorist Walter Ong about the “secondary orality” associated with talky electronic media such as television, radio, audio recording, or telephone communication. Later followers of Ong extend this concept of secondary orality to hypertext, hypermedia, e-mail, and blogs, because they similarly share features of both speech and written discourse. Although Ong’s disciples celebrate this vibrant reconnection to a mythic, communal past of what Kathleen Welch calls “electric rhetoric,” the defence industry consultants express their profound state of alarm at the potentially dangerous and subversive character of this hybrid form of communication. The concept of an “oral tradition” is first introduced by the expert witnesses in the context of modern marketing and product distribution: “The Internet is used for a variety of things – command and control,” one witness states. “One of the things that’s missed frequently is how and – how effective the adversary is at using the Internet to distribute product. They’re using that distribution network as a modern form of oral tradition, if you will.” Thus, although the Internet can be deployed for hierarchical “command and control” activities, it also functions as a highly efficient peer-to-peer distributed network for disseminating the commodity of information. Throughout the hearings, the witnesses imply that unregulated lateral communication among social actors who are not authorised to speak for nation-states or to produce legitimated expert discourses is potentially destabilising to political order. Witness Eric Michael describes the “oral tradition” and the conventions of communal life in the Middle East to emphasise the primacy of speech in the collective discursive practices of this alien population: “I’d like to point your attention to the media types and the fact that the oral tradition is listed as most important. The other media listed support that. And the significance of the oral tradition is more than just – it’s the medium by which, once it comes off the Internet, it is transferred.” The experts go on to claim that this “oral tradition” can contaminate other media because it functions as “rumor,” the traditional bane of the stately discourse of military leaders since the classical era. The oral tradition now also has an aspect of rumor. A[n] event takes place. There is an explosion in a city. Rumor is that the United States Air Force dropped a bomb and is doing indiscriminate killing. This ends up being discussed on the street. It ends up showing up in a Friday sermon in a mosque or in another religious institution. It then gets recycled into written materials. Media picks up the story and broadcasts it, at which point it’s now a fact. In this particular case that we were telling you about, it showed up on a network television, and their propaganda continues to go back to this false initial report on network television and continue to reiterate that it’s a fact, even though the United States government has proven that it was not a fact, even though the network has since recanted the broadcast. In this example, many-to-many discussion on the “street” is formalised into a one-to many “sermon” and then further stylised using technology in a one-to-many broadcast on “network television” in which “propaganda” that is “false” can no longer be disputed. This “oral tradition” is like digital media, because elements of discourse can be infinitely copied or “recycled,” and it is designed to “reiterate” content. In this hearing, the word “rhetoric” is associated with destructive counter-cultural forces by the witnesses who reiterate cultural truisms dating back to Plato and the Gorgias. For example, witness Eric Michael initially presents “rhetoric” as the use of culturally specific and hence untranslatable figures of speech, but he quickly moves to an outright castigation of the entire communicative mode. “Rhetoric,” he tells us, is designed to “distort the truth,” because it is a “selective” assembly or a “distortion.” Rhetoric is also at odds with reason, because it appeals to “emotion” and a romanticised Weltanschauung oriented around discourses of “struggle.” The film by SonicJihad is chosen as the final clip by the witnesses before Congress, because it allegedly combines many different types of emotional appeal, and thus it conveniently ties together all of the themes that the witnesses present to the legislators about unreliable oral or rhetorical sources in the Middle East: And there you see how all these products are linked together. And you can see where the games are set to psychologically condition you to go kill coalition forces. You can see how they use humor. You can see how the entire campaign is carefully crafted to first evoke an emotion and then to evoke a response and to direct that response in the direction that they want. Jihadist digital products, especially videogames, are effective means of manipulation, the witnesses argue, because they employ multiple channels of persuasion and carefully sequenced and integrated subliminal messages. To understand the larger cultural conversation of the hearing, it is important to keep in mind that the related argument that “games” can “psychologically condition” players to be predisposed to violence is one that was important in other congressional hearings of the period, as well one that played a role in bills and resolutions that were passed by the full body of the legislative branch. In the witness’s testimony an appeal to anti-game sympathies at home is combined with a critique of a closed anti-democratic system abroad in which the circuits of rhetorical production and their composite metonymic chains are described as those that command specific, unvarying, robotic responses. This sharp criticism of the artful use of a presentation style that is “crafted” is ironic, given that the witnesses’ “compilation” of jihadist digital material is staged in the form of a carefully structured PowerPoint presentation, one that is paced to a well-rehearsed rhythm of “slide, please” or “next slide” in the transcript. The transcript also reveals that the members of the House Intelligence Committee were not the original audience for the witnesses’ PowerPoint presentation. Rather, when it was first created by SAIC, this “expert” presentation was designed for training purposes for the troops on the ground, who would be facing the challenges of deployment in hostile terrain. According to the witnesses, having the slide show showcased before Congress was something of an afterthought. Nonetheless, Congressman Tiahrt (R-KN) is so impressed with the rhetorical mastery of the consultants that he tries to appropriate it. As Tiarht puts it, “I’d like to get a copy of that slide sometime.” From the hearing we also learn that the terrorists’ Websites are threatening precisely because they manifest a polymorphously perverse geometry of expansion. For example, one SAIC witness before the House Committee compares the replication and elaboration of digital material online to a “spiderweb.” Like Representative Eshoo’s site, he also notes that the terrorists’ sites go “up” and “down,” but the consultant is left to speculate about whether or not there is any “central coordination” to serve as an organising principle and to explain the persistence and consistency of messages despite the apparent lack of a single authorial ethos to offer a stable, humanised, point of reference. In the hearing, the oft-cited solution to the problem created by the hybridity and iterability of digital rhetoric appears to be “public diplomacy.” Both consultants and lawmakers seem to agree that the damaging messages of the insurgents must be countered with U.S. sanctioned information, and thus the phrase “public diplomacy” appears in the hearing seven times. However, witness Roughhead complains that the protean “oral tradition” and what Henry Jenkins has called the “transmedia” character of digital culture, which often crosses several platforms of traditional print, projection, or broadcast media, stymies their best rhetorical efforts: “I think the point that we’ve tried to make in the briefing is that wherever there’s Internet availability at all, they can then download these – these programs and put them onto compact discs, DVDs, or post them into posters, and provide them to a greater range of people in the oral tradition that they’ve grown up in. And so they only need a few Internet sites in order to distribute and disseminate the message.” Of course, to maintain their share of the government market, the Science Applications International Corporation also employs practices of publicity and promotion through the Internet and digital media. They use HTML Web pages for these purposes, as well as PowerPoint presentations and online video. The rhetoric of the Website of SAIC emphasises their motto “From Science to Solutions.” After a short Flash film about how SAIC scientists and engineers solve “complex technical problems,” the visitor is taken to the home page of the firm that re-emphasises their central message about expertise. The maps, uniforms, and specialised tools and equipment that are depicted in these opening Web pages reinforce an ethos of professional specialisation that is able to respond to multiple threats posed by the “global war on terror.” By 26 June 2006, the incident finally was being described as a “Pentagon Snafu” by ABC News. From the opening of reporter Jake Tapper’s investigative Webcast, established government institutions were put on the spot: “So, how much does the Pentagon know about videogames? Well, when it came to a recent appearance before Congress, apparently not enough.” Indeed, the very language about “experts” that was highlighted in the earlier coverage is repeated by Tapper in mockery, with the significant exception of “independent expert” Ian Bogost of the Georgia Institute of Technology. If the Pentagon and SAIC deride the legitimacy of rhetoric as a cultural practice, Bogost occupies himself with its defence. In his recent book Persuasive Games: The Expressive Power of Videogames, Bogost draws upon the authority of the “2,500 year history of rhetoric” to argue that videogames represent a significant development in that cultural narrative. Given that Bogost and his Watercooler Games Weblog co-editor Gonzalo Frasca were actively involved in the detective work that exposed the depth of professional incompetence involved in the government’s line-up of witnesses, it is appropriate that Bogost is given the final words in the ABC exposé. As Bogost says, “We should be deeply bothered by this. We should really be questioning the kind of advice that Congress is getting.” Bogost may be right that Congress received terrible counsel on that day, but a close reading of the transcript reveals that elected officials were much more than passive listeners: in fact they were lively participants in a cultural conversation about regulating digital media. After looking at the actual language of these exchanges, it seems that the persuasiveness of the misinformation from the Pentagon and SAIC had as much to do with lawmakers’ preconceived anxieties about practices of computer-mediated communication close to home as it did with the contradictory stereotypes that were presented to them about Internet practices abroad. In other words, lawmakers found themselves looking into a fun house mirror that distorted what should have been familiar artefacts of American popular culture because it was precisely what they wanted to see. References ABC News. “Terrorist Videogame?” Nightline Online. 21 June 2006. 22 June 2006 http://abcnews.go.com/Video/playerIndex?id=2105341>. Bogost, Ian. Persuasive Games: Videogames and Procedural Rhetoric. Cambridge, MA: MIT Press, 2007. Game Politics. “Was Congress Misled by ‘Terrorist’ Game Video? We Talk to Gamer Who Created the Footage.” 11 May 2006. http://gamepolitics.livejournal.com/285129.html#cutid1>. Jenkins, Henry. Convergence Culture: Where Old and New Media Collide. New York: New York UP, 2006. julieb. “David Morgan Is a Horrible Writer and Should Be Fired.” Online posting. 5 May 2006. Dvorak Uncensored Cage Match Forums. http://cagematch.dvorak.org/index.php/topic,130.0.html>. Mahmood. “Terrorists Don’t Recruit with Battlefield 2.” GGL Global Gaming. 16 May 2006 http://www.ggl.com/news.php?NewsId=3090>. Morgan, David. “Islamists Using U.S. Video Games in Youth Appeal.” Reuters online news service. 4 May 2006 http://today.reuters.com/news/ArticleNews.aspx?type=topNews &storyID=2006-05-04T215543Z_01_N04305973_RTRUKOC_0_US-SECURITY- VIDEOGAMES.xml&pageNumber=0&imageid=&cap=&sz=13&WTModLoc= NewsArt-C1-ArticlePage2>. Ong, Walter J. Orality and Literacy: The Technologizing of the Word. London/New York: Methuen, 1982. Parker, Trey. Online posting. 7 May 2006. 9 May 2006 http://www.treyparker.com>. Plato. “Gorgias.” Plato: Collected Dialogues. Princeton: Princeton UP, 1961. Shrader, Katherine. “Pentagon Surfing Thousands of Jihad Sites.” Associated Press 4 May 2006. SonicJihad. “SonicJihad: A Day in the Life of a Resistance Fighter.” Online posting. 26 Dec. 2005. Planet Battlefield Forums. 9 May 2006 http://www.forumplanet.com/planetbattlefield/topic.asp?fid=13670&tid=1806909&p=1>. Tapper, Jake, and Audery Taylor. “Terrorist Video Game or Pentagon Snafu?” ABC News Nightline 21 June 2006. 30 June 2006 http://abcnews.go.com/Nightline/Technology/story?id=2105128&page=1>. U.S. Congressional Record. Panel I of the Hearing of the House Select Intelligence Committee, Subject: “Terrorist Use of the Internet for Communications.” Federal News Service. 4 May 2006. Welch, Kathleen E. Electric Rhetoric: Classical Rhetoric, Oralism, and the New Literacy. Cambridge, MA: MIT Press, 1999. Citation reference for this article MLA Style Losh, Elizabeth. "Artificial Intelligence: Media Illiteracy and the SonicJihad Debacle in Congress." M/C Journal 10.5 (2007). echo date('d M. Y'); ?> <http://journal.media-culture.org.au/0710/08-losh.php>. APA Style Losh, E. (Oct. 2007) "Artificial Intelligence: Media Illiteracy and the SonicJihad Debacle in Congress," M/C Journal, 10(5). Retrieved echo date('d M. Y'); ?> from <http://journal.media-culture.org.au/0710/08-losh.php>.

Introduction I think the Privacy Act is a huge edifice to protect the minority of things that could go wrong. I’ve got a good example for you, I’m just trying to think … yeah the worst one I’ve ever seen was the Balga Youth Program where we took these students on a reward excursion all the way to Fremantle and suddenly this very alienated kid started to jump under a bus, a moving bus so the kid had to be restrained. The cops from Fremantle arrived because all the very good people in Fremantle were alarmed at these grown-ups manhandling a kid and what had happened is that DCD [Department of Community Development] had dropped him into the program but hadn’t told us that this kid had suicide tendencies. No, it’s just chronically bad. And there were caseworkers involved and … there is some information that we have to have that doesn’t get handed down. Rather than a blanket rule that everything’s confidential coming from them to us, and that was a real live situation, and you imagine how we’re trying to handle it, we had taxis going from Balga to Fremantle to get staff involved and we only had to know what to watch out for and we probably could have … well what you would have done is not gone on the excursion I suppose (School Principal, quoted in Balnaves and Luca 49). These comments are from a school principal in Perth, Western Australia in a school that is concerned with “at-risk” students, and in a context where the Commonwealth Privacy Act 1988 has imposed limitations on their work. Under this Act it is illegal to pass health, personal or sensitive information concerning an individual on to other people. In the story cited above the Department of Community Development personnel were apparently protecting the student’s “negative right”, that is, “freedom from” interference by others. On the other hand, the principal’s assertion that such information should be shared is potentially a “positive right” because it could cause something to be done in that person’s or society’s interests. Balnaves and Luca noted that positive and negative rights have complex philosophical underpinnings, and they inform much of how we operate in everyday life and of the dilemmas that arise (49). For example, a ban on euthanasia or the “assisted suicide” of a terminally ill person can be a “positive right” because it is considered to be in the best interests of society in general. However, physicians who tacitly approve a patient’s right to end their lives with a lethal dose by legally prescribed dose of medication could be perceived as protecting the patient’s “negative right” as a “freedom from” interference by others. While acknowledging the merits of collaboration between people who are working to improve the wellbeing of students “at-risk”, this paper examines some of the barriers to collaboration. Based on both primary and secondary sources, and particularly on oral testimonies, the paper highlights the tension between privacy as a negative right and collaborative helping as a positive right. It also points to other difficulties and dilemmas within and between the institutions engaged in this joint undertaking. The authors acknowledge Michel Foucault’s contention that discourse is power. The discourse on privacy and the sharing of information in modern societies suggests that privacy is a negative right that gives freedom from bureaucratic interference and protects the individual. However, arguably, collaboration between agencies that are working to support individuals “at-risk” requires a measured relaxation of the requirements of this negative right. Children and young people “at-risk” are a case in point. Towards Collaboration From a series of interviews conducted in 2004, the school authorities at Balga Senior High School and Midvale Primary School, people working for the Western Australian departments of Community Development, Justice, and Education and Training in Western Australia, and academics at the Edith Cowan and Curtin universities, who are working to improve the wellbeing of students “at-risk” as part of an Australian Research Council (ARC) project called Smart Communities, have identified students “at-risk” as individuals who have behavioural problems and little motivation, who are alienated and possibly violent or angry, who under-perform in the classroom and have begun to truant. They noted also that students “at-risk” often suffer from poor health, lack of food and medication, are victims of unwanted pregnancies, and are engaged in antisocial and illegal behaviour such as stealing cars and substance abuse. These students are also often subject to domestic violence (parents on drugs or alcohol), family separation, and homelessness. Some are depressed or suicidal. Sometimes cultural factors contribute to students being regarded as “at-risk”. For example, a social worker in the Smart Communities project stated: Cultural factors sometimes come into that as well … like with some Muslim families … they can flog their daughter or their son, usually the daughter … so cultural factors can create a risk. Research elsewhere has revealed that those children between the ages of 11-17 who have been subjected to bullying at school or physical or sexual abuse at home and who have threatened and/or harmed another person or suicidal are “high-risk” youths (Farmer 4). In an attempt to bring about a positive change in these alienated or “at-risk” adolescents, Balga Senior High School has developed several programs such as the Youth Parents Program, Swan Nyunger Sports Education program, Intensive English Centre, and lower secondary mainstream program. The Midvale Primary School has provided services such as counsellors, Aboriginal child protection workers, and Aboriginal police liaison officers for these “at-risk” students. On the other hand, the Department of Community Development (DCD) has provided services to parents and caregivers for children up to 18 years. Academics from Edith Cowan and Curtin universities are engaged in gathering the life stories of these “at-risk” students. One aspect of this research entails the students writing their life stories in a secured web portal that the universities have developed. The researchers believe that by engaging the students in these self-exploration activities, they (the students) would develop a more hopeful outlook on life. Though all agencies and educational institutions involved in this collaborative project are working for the well-being of the children “at-risk”, the Privacy Act forbids the authorities from sharing information about them. A school psychologist expressed concern over the Privacy Act: When the Juvenile Justice Department want to reintroduce a student into a school, we can’t find out anything about this student so we can’t do any preplanning. They want to give the student a fresh start, so there’s always that tension … eventually everyone overcomes [this] because you realise that the student has to come to the school and has to be engaged. Of course, the manner and consequences of a student’s engagement in school cannot be predicted. In the scenario described above students may have been given a fair chance to reform themselves, which is their positive right but if they turn out to be at “high risk” it would appear that the Juvenile Department protected the negative right of the students by supporting “freedom from” interference by others. Likewise, a school health nurse in the project considered confidentiality or the Privacy Act an important factor in the security of the student “at-risk”: I was trying to think about this kid who’s one of the children who has been sexually abused, who’s a client of DCD, and I guess if police got involved there and wanted to know details and DCD didn’t want to give that information out then I’d guess I’d say to the police “Well no, you’ll have to talk to the parents about getting further information.” I guess that way, recognising these students are minor and that they are very vulnerable, their information … where it’s going, where is it leading? Who wants to know? Where will it be stored? What will be the outcomes in the future for this kid? As a 14 year old, if they’re reckless and get into things, you know, do they get a black record against them by the time they’re 19? What will that information be used for if it’s disclosed? So I guess I become an advocate for the student in that way? Thus the nurse considers a sexually abused child should not be identified. It is a positive right in the interest of the person. Once again, though, if the student turns out to be at “high risk” or suicidal, then it would appear that the nurse was protecting the youth’s negative right—“freedom from” interference by others. Since collaboration is a positive right and aims at the students’ welfare, the workable solution to prevent the students from suicide would be to develop inter-agency trust and to share vital information about “high-risk” students. Dilemmas of Collaboration Some recent cases of the deaths of young non-Caucasian girls in Western countries, either because of the implications of the Privacy Act or due to a lack of efficient and effective communication and coordination amongst agencies, have raised debates on effective child protection. For example, the British Laming report (2003) found that Victoria Climbié, a young African girl, was sent by her parents to her aunt in Britain in order to obtain a good education and was murdered by her aunt and aunt’s boyfriend. However, the risk that she could be harmed was widely known. The girl’s problems were known to 6 local authorities, 3 housing authorities, 4 social services, 2 child protection teams, and the police, the local church, and the hospital, but not to the education authorities. According to the Laming Report, her death could have been prevented if there had been inter-agency sharing of information and appropriate evaluation (Balnaves and Luca 49). The agencies had supported the negative rights of the young girl’s “freedom from” interference by others, but at the cost of her life. Perhaps Victoria’s racial background may have contributed to the concealment of information and added to her disadvantaged position. Similarly, in Western Australia, the Gordon Inquiry into the death of Susan Taylor, a 15 year old girl Aboriginal girl at the Swan Nyungah Community, found that in her short life this girl had encountered sexual violation, violence, and the ravages of alcohol and substance abuse. The Gordon Inquiry reported: Although up to thirteen different agencies were involved in providing services to Susan Taylor and her family, the D[epartment] of C[ommunity] D[evelopment] stated they were unaware of “all the services being provided by each agency” and there was a lack of clarity as to a “lead coordinating agency” (Gordon et al. quoted in Scott 45). In this case too, multiple factors—domestic, racial, and the Privacy Act—may have led to Susan Taylor’s tragic end. In the United Kingdom, Harry Ferguson noted that when a child is reported to be “at-risk” from domestic incidents, they can suffer further harm because of their family’s concealment (204). Ferguson’s study showed that in 11 per cent of the 319 case sample, children were known to be re-harmed within a year of initial referral. Sometimes, the parents apply a veil of secrecy around themselves and their children by resisting or avoiding services. In such cases the collaborative efforts of the agencies and education may be thwarted. Lack of cultural education among teachers, youth workers, and agencies could also put the “at-risk” cultural minorities into a high risk category. For example, an “at-risk” Muslim student may not be willing to share personal experiences with the school or agencies because of religious sensitivities. This happened in the UK when Khadji Rouf was abused by her father, a Bangladeshi. Rouf’s mother, a white woman, and her female cousin from Bangladesh, both supported Rouf when she finally disclosed that she had been sexually abused for over eight years. After group therapy, Rouf stated that she was able to accept her identity and to call herself proudly “mixed race”, whereas she rejected the Asian part of herself because it represented her father. Other Asian girls and young women in this study reported that they could not disclose their abuse to white teachers or social workers because of the feeling that they would be “letting down their race or their Muslim culture” (Rouf 113). The marginalisation of many Muslim Australians both in the job market and in society is long standing. For example, in 1996 and again in 2001 the Muslim unemployment rate was three times higher than the national total (Australian Bureau of Statistics). But since the 9/11 tragedy and Bali bombings visible Muslims, such as women wearing hijabs (headscarves), have sometimes been verbally and physically abused and called ‘terrorists’ by some members of the wider community (Dreher 13). The Howard government’s new anti-terrorism legislation and the surveillance hotline ‘Be alert not alarmed’ has further marginalised some Muslims. Some politicians have also linked Muslim asylum seekers with terrorists (Kabir 303), which inevitably has led Muslim “at-risk” refugee students to withdraw from school support such as counselling. Under these circumstances, Muslim “at-risk” students and their parents may prefer to maintain a low profile rather than engage with agencies. In this case, arguably, federal government politics have exacerbated the barriers to collaboration. It appears that unfamiliarity with Muslim culture is not confined to mainstream Australians. For example, an Aboriginal liaison police officer engaged in the Smart Communities project in Western Australia had this to say about Muslim youths “at-risk”: Different laws and stuff from different countries and they’re coming in and sort of thinking that they can bring their own laws and religions and stuff … and when I say religions there’s laws within their religions as well that they don’t seem to understand that with Australia and our laws. Such generalised misperceptions of Muslim youths “at-risk” would further alienate them, thus causing a major hindrance to collaboration. The “at-risk” factors associated with Aboriginal youths have historical connections. Research findings have revealed that indigenous youths aged between 10-16 years constitute a vast majority in all Australian States’ juvenile detention centres. This over-representation is widely recognised as associated with the nature of European colonisation, and is inter-related with poverty, marginalisation and racial discrimination (Watson et al. 404). Like the Muslims, their unemployment rate was three times higher than the national total in 2001 (ABS). However, in 1998 it was estimated that suicide rates among Indigenous peoples were at least 40 per cent higher than national average (National Advisory Council for Youth Suicide Prevention, quoted in Elliot-Farrelly 2). Although the wider community’s unemployment rate is much lower than the Aboriginals and the Muslims, the “at-risk” factors of mainstream Australian youths are often associated with dysfunctional families, high conflict, low-cohesive families, high levels of harsh parental discipline, high levels of victimisation by peers, and high behavioural inhibition (Watson et al. 404). The Macquarie Fields riots in 2005 revealed the existence of “White” underclass and “at-risk” people in Sydney. Macquarie Fields’ unemployment rate was more than twice the national average. Children growing up in this suburb are at greater risk of being involved in crime (The Age). Thus small pockets of mainstream underclass youngsters also require collaborative attention. In Western Australia people working on the Smart Communities project identified that lack of resources can be a hindrance to collaboration for all sectors. As one social worker commented: “government agencies are hierarchical systems and lack resources”. They went on to say that in their department they can not give “at-risk” youngsters financial assistance in times of crisis: We had a petty cash box which has got about 40 bucks in it and sometimes in an emergency we might give a customer a couple of dollars but that’s all we can do, we can’t give them any larger amount. We have bus/metro rail passes, that’s the only thing that we’ve actually got. A youth worker in Smart Communities commented that a lot of uncertainty is involved with young people “at-risk”. They said that there are only a few paid workers in their field who are supported and assisted by “a pool of volunteers”. Because the latter give their time voluntarily they are under no obligation to be constant in their attendance, so the number of available helpers can easily fluctuate. Another youth worker identified a particularly important barrier to collaboration: because of workers’ relatively low remuneration and high levels of work stress, the turnover rates are high. The consequence of this is as follows: The other barrier from my point is that you’re talking to somebody about a student “at-risk”, and within 14 months or 18 months a new person comes in [to that position] then you’ve got to start again. This way you miss a lot of information [which could be beneficial for the youth]. Conclusion The Privacy Act creates a dilemma in that it can be either beneficial or counter-productive for a student’s security. To be blunt, a youth who has suicided might have had their privacy protected, but not their life. Lack of funding can also be a constraint on collaboration by undermining stability and autonomy in the workforce, and blocking inter-agency initiatives. Lack of awareness about cultural differences can also affect unity of action. The deepening inequality between the “haves” and “have-nots” in the Australian society, and the Howard government’s harshness on national security issues, can also pose barriers to collaboration on youth issues. Despite these exigencies and dilemmas, it would seem that collaboration is “the only game” when it comes to helping students “at-risk”. To enhance this collaboration, there needs to be a sensible modification of legal restrictions to information sharing, an increase in government funding and support for inter-agency cooperation and informal information sharing, and an increased awareness about the cultural needs of minority groups and knowledge of the mainstream underclass. Acknowledgments The research is part of a major Australian Research Council (ARC) funded project, Smart Communities. The authors very gratefully acknowledge the contribution of the interviewees, and thank *Donald E. Scott for conducting the interviews. References Australian Bureau of Statistics. 1996 and 2001. 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"Students “at Risk”: Dilemmas of Collaboration." M/C Journal 9.2 (2006). echo date('d M. Y'); ?> <http://journal.media-culture.org.au/0605/04-kabirbalnaves.php>. APA Style Kabir, N., and M. Balnaves. (May 2006) "Students “at Risk”: Dilemmas of Collaboration," M/C Journal, 9(2). Retrieved echo date('d M. Y'); ?> from <http://journal.media-culture.org.au/0605/04-kabirbalnaves.php>.