Academic literature on the topic 'United States > Officials and employees > Leave regulations'

Exports of technology and items containing technical information are regulated by the United States government. United States export control regulations exist to help protect national security, economic, and political interests. United States defense industry companies manufacture products and develop technologies and information that the United States has a particular interest in protecting. Therefore, defense industry companies must comply with United States export control regulations when exporting items and information to their international partners and customers. An “export” not only includes shipments of hardware or other tangible assets to foreign end-users but also includes the sharing of certain types of information with foreign recipients in the form of phone conversations, emails, meetings, conferences, presentations, and so on. Many employees of defense industry companies travel internationally with company issued laptops and cellphones containing company information that could be viewed by foreign persons. All of these activities are considered exports and may require prior authorization from the United States government under export control regulations. Failure to follow export regulations could result in a violation requiring a report to the United States government that may result in civil penalties or criminal charges. Additionally, intentional as well as unintentional releases of information to certain foreign persons could be detrimental to a defense industry company’s business and reputation and may even result in security concerns for the United States. Although the government has an interest in regulating defense industry companies’ technology and information, critics argue that strong export control regulations may result in invasions of privacy, violations of free speech, and a displacement of the United States as a leader in a world of technological advancement. However, despite current regulations, defense industry information is still at risk of cyberattacks and inadvertent data releases, creating potential threats to national security and the security of company technology and information. In an effort to secure company and sensitive information while exporting, defense industry companies utilize encryption and other cybersecurity measures. Advancing technologies in cybersecurity can help the government and defense industry companies by bolstering the security of their information. These same advancements can also aid attackers in breaking through cybersecurity defenses. Some advances in technology are even preventing law enforcement from gathering necessary information to conduct investigations when cyber-attacks occur, making it difficult to identify criminal actors and seek justice.The United States government faces challenges in creating and up- dating regulations to keep up with consistently advancing technology. Likewise, defense industry companies must adhere to government regulations by creating robust compliance programs, but they should also implement security and compliance measures above and beyond what the government requires to ensure more effective security for their technology and information. This Article discusses the effect of advancing cyber technology; United States export regulations; reporting requirements related to the export of encrypted items; and encryption technology in the defense industry. First, the Article defines encryption and encrypted items. Second, the Article explains United States regulations of ex- ports and specifically, regulations related to encryption and encrypted items. Third, the Article explains the need for defense industry companies to export and to use encrypted items. Fourth, the Article analyzes criticisms of export regulations and the differing views on United States controls. Fifth, the Article will discuss the complexities of com- plying with export regulations and defense industry compliance pro- grams. Sixth, the Article examines the outlook for encryption technology, the future of regulations related to cybersecurity, and the outlook for defense industry security measures and compliance with regulations. The United States government is beginning to recognize the need for more advanced security measures to protect domestically produced technology and information, especially information that puts national security at risk. Specifically, the technology and information produced by United States defense industry companies should be protected from getting into the hands of our foreign adversaries at all costs. In response to the growing need for security measures, the United States government has implemented new programs, commissions, agencies, and projects to create more robust security systems and regulations. The United States should employ the most talented and experienced cybersecurity professionals to innovate and produce security systems that protect our nation’s most sensitive information. The government should then provide these systems to its defense industry companies at minimal cost and should require companies to use the best technology in its security measures. With or without the government’s assistance, defense industry companies within the United States must also implement their own measures of protection. Current policies offer little protection of sensitive and export controlled information including encrypted items and in- formation. In addition, the government should also provide the defense industry companies better guidance and access to resources in order to assist them in protecting the important information and encrypted items.207 For example, any new systems or software purchased by the United States should be made available to defense industry companies as the standard. If the government truly wishes to protect its most important technology and information, it should provide the new systems at minimal cost to the defense industry. Advancements in security programs should be shared with defense industry companies as soon as they are available and ready for use. Nevertheless, the government may not want to provide defense industry companies with the best security technology because in the event that the government needs to conduct an investigation, a company utilizing strong cyber- security and encryption software is much more difficult to investigate. Alternatively, the United States could update current regulations to require that defense industry companies must utilize specific security measures or face a penalty for failing to do so. Such regulation could require defense companies to implement more robust security pro- grams with updated security software. This is a less effective solution as the advancement in cyberattack technology increases so rapidly, and reformed regulations will likely be outdated as soon as they are implemented. It makes more sense to require that defense companies must implement the most updated software and programs determined by government security experts and cyber-security experts. Also, by allowing defense companies to decide which security companies it will work with, the defense companies obtain the option to shop for the best and most expensive program, or the company could choose the cheapest option, resulting in less efficient security. Cybersecurity regulations that are too specific run the risk of being outdated quickly, whereas broad requirements leave the option for companies to implement the lowest of security measures. Even if the government declines these suggested measures, defense industry companies should make the protection of their sensitive in- formation and encrypted items top priority. This method would re- quire complete buy-in from the senior management within the company and a thorough flow-down of cultural beliefs among its employees. A change in norms must be implemented, and defense industry personnel should be inundated with reminders on the importance of information security. Companies should provide employees with easy access to guidance, training, and assistance in handling, sharing, protecting, and exporting sensitive and export controlled information. Changing company culture takes time, and failure to change personnel beliefs will result in a lack of understanding and potential violations of export control regulations. In the worst cases, data spills and cyberattacks could result in the loss of sensitive or even classified in- formation that could jeopardize national security. Huge unauthorized data releases of sensitive information will negatively affect a company’s reputation thus affecting its ability to generate revenue. The risks in using and exporting encryption technology and sensitive information should be a major concern for defense industry companies. This concern should motivate the government to invest significant resources into compliance programs. Resources such as dedicated and qualified personnel can create policy and procedure to ensure compliance with United States government regulations, and the procedures will provide guidance and training to all employees. In addition, companies should employ IT security, data security, and counterintelligence personnel to work with the compliance team in innovating preventive measures and in addressing any potential data releases and export violations. Immediate actions and counter measures should be prioritized not just among the compliance and security teams but should be a known, expected response from all employees. In other words, cybersecurity norms should be instilled company-wide and thoroughly policed from within the company. How a company chooses to implement such measures remains discretionary, but a better resourced compliance department dedicated to implementing effective policies and responding quickly to potential issues will prevent export control violations and data releases of important information. Defense industry companies transfer export controlled information that may subject the United States to security risks. The United States responds to this risk by implementing regulations to control the high- risk exports. Defense industry companies must comply with these regulations. Therefore, defense industry companies should approach exports and cybersecurity from the standpoint that technology is always advancing—failure to simultaneously advance security and compliance measures will leave the country and the company vulnerable to attack.

The subject of the study is the legislative and law enforcement experience of the United States in the field of using special types of trust management of property of civil servants and officials as a tool to overcome conflicts of interest in the public service. The relevance of this study is confirmed by the fact that the United States, one of the few states that uses this tool, as well as the Russian Federation. However, in our country, the legal regulation of this institution is still not perfect enough, therefore, it is important enough to study the experience of those states where there is such a practice. The work was prepared as part of the state assignment to the Financial University under the Government of the Russian Federation for 2022. The scientific novelty of the research is determined by the fact that currently there are practically no works containing an analysis of the institute in question. In the course of the study, the following conclusions were made.The most developed, from the point of view of the legal regulation of the institution of trust management of the property of civil servants, is the legal regulation in the USA, where, in addition to the legislative consolidation of the very possibility of placing their assets in a trust (as an alternative to sale), there are detailed administrative regulations for the actions of employees, including, among other things, developed forms forms of documents for each stage of the procedure. For Russian legislation, a detailed regulation of the actions of civil servants in the situation with the transfer of property to trust management also seems very reasonable, since the current reference to the norms of civil legislation obviously does not satisfy the necessary regulatory need, which leads to significant difficulties in law enforcement.

Aim/Purpose: The purpose of this paper is to examine the phenomena of vicarious bullying, or an abetting bully, when a bully’s subordinate is used to inflict abuse on the target. This study examines who is most affected by this multi-faceted organizational abuse in American higher education. Background: Workplace bullying has received international attention. Recent studies in the United States have focused on workplace bullying in higher education. However, workplace bullying emerges from an elaborate social structure. This research article brings the unique perspective of vicarious bullying for analysis. Methodology: A data collection from 729 American higher education professionals was used to answer the following three research questions which were addressed in this study: RQ1: What is the overall prevalence of vicarious bullying in American higher education? RQ2: What is the likelihood of experiencing vicarious bullying in American higher education based on gender? RQ3: What is the likelihood of experiencing vicarious bullying in American higher education based on a woman’s race? A chi-square analysis was used to examine which demographic groups are more susceptible to vicarious bullying. Contribution: This article expands the literature on workplace bullying in American higher education by considering how unethical leadership can contribute to and inspire abetting and vicarious bullies who are enabled to maintain the toxic work culture. Findings: This article expands the literature on workplace bullying in American higher education by considering how unethical leadership can contribute to and inspire abetting and vicarious bullies who are enabled to maintain the toxic work culture. Recommendations for Practitioners: Vicarious bullying occurs when the organization fails to curtail managerial abuse. The result is higher turnover for women employees. Working with chief diversity officers and EEO officials can develop policies that stifle this behavior. Recommendation for Researchers: While workplace bullying has gained international attention, the organizational behavior of vicarious bullying is a unique organizational perspective that warrants further study. Impact on Society: Data confirm that women are more likely to leave their organizations to avoid workplace bullying. Women’s departures weaken an organization when they take their insight and knowledge with them. Future Research: Future research can consider the relationship between ethical leadership at the department level and executive level of higher education, and how that might have an impact on the prevalence of workplace bullying.

During the past two decades, immunisation has saved millions of lives and prevented countless illnesses and disabilities in South Africa. Vaccination is the most important thing we can do to protect ourselves and our children against ill health. Vaccinations prevent up to three million deaths worldwide every year. However, the World Health Organization (WHO) has listed vaccine hesitancy as one of the biggest threats to global health. Vaccine hesitancy entails people with access to vaccines delaying or refusing vaccination. In addition to vaccine hesitancy, many people are of the view that it infringes on their fundamental human right to bodily integrity. However, this article presents findings that suggest that this right can be limited because everyone has a fundamental right to be protected from the spread of the disease. Tensions have increased as more vaccine mandates are implemented. Businesses continue to review and revise their Covid-19 vaccination policies as new mutations emerge and employers may be asking what they can do if workers refuse to get the jab. Some employers have dismissed employees or put them on unpaid leave. Others have required unvaccinated employees to submit to weekly testing and take other safety precautions. In terms of the Code of Practice: Managing Exposure to SARS-COV-2 in the Workplace, 2022, the identifiable hazard relating to Covid-19 that workers face is the transmission of virus by an infectious person to others in the workplace. The Regulations for Hazardous Biological Agents, 2022 lists SARS-COV-2 as a hazardous biological agent that places legal responsibilities on employers to mitigate the associated risks. Each situation requires special measures to be implemented by employers in order to prevent the transmission of the virus. Universities in South Africa are also faced with this conundrum regarding the mandating of vaccines. This article examines and discusses mandating vaccines in South Africa, especially at universities, with guidance received from international instruments such as the European Union and countries such as United States. Various legislative and policy frameworks are also analysed.

Although I'm a rich white guy, I'm also a feminist anti-racism activist who fights for the rights of the poor and oppressed. (Carl Kenner)Systemic bias is a scourge to the pillar of neutrality. (Cerejota)Count me in. Let's leave the bias to the mainstream media. (Orcar967)Because this is so important. (CuttingEdge)These are a handful of comments posted by online editors who have banded together in a virtual coalition to combat Western bias on the world’s largest digital encyclopedia, Wikipedia. This collective action by Wikipedians both acknowledges the inherent inequalities of a user-controlled information project like Wikpedia and highlights the potential for progressive change within that same project. These community members are taking the responsibility of social change into their own hands (or more aptly, their own keyboards).In recent years much research has emerged on Wikipedia from varying fields, ranging from computer science, to business and information systems, to the social sciences. While critical at times of Wikipedia’s growth, governance, and influence, most of this work observes with optimism that barriers to improvement are not firmly structural, but rather they are socially constructed, leaving open the possibility of important and lasting change for the better.WikiProject: Countering Systemic Bias (WP:CSB) considers one such collective effort. Close to 350 editors have signed on to the project, which began in 2004 and itself emerged from a similar project named CROSSBOW, or the “Committee Regarding Overcoming Serious Systemic Bias on Wikipedia.” As a WikiProject, the term used for a loose group of editors who collaborate around a particular topic, these editors work within the Wikipedia site and collectively create a social network that is unified around one central aim—representing the un- and underrepresented—and yet they are bound by no particular unified set of interests. The first stage of a multi-method study, this paper looks at a snapshot of WP:CSB’s activity from both content analysis and social network perspectives to discover “who” geographically this coalition of the unrepresented is inserting into the digital annals of Wikipedia.Wikipedia and WikipediansDeveloped in 2001 by Internet entrepreneur Jimmy Wales and academic Larry Sanger, Wikipedia is an online collaborative encyclopedia hosting articles in nearly 250 languages (Cohen). The English-language Wikipedia contains over 3.2 million articles, each of which is created, edited, and updated solely by users (Wikipedia “Welcome”). At the time of this study, Alexa, a website tracking organisation, ranked Wikipedia as the 6th most accessed site on the Internet. Unlike the five sites ahead of it though—Google, Facebook, Yahoo, YouTube (owned by Google), and live.com (owned by Microsoft)—all of which are multibillion-dollar businesses that deal more with information aggregation than information production, Wikipedia is a non-profit that operates on less than $500,000 a year and staffs only a dozen paid employees (Lih). Wikipedia is financed and supported by the WikiMedia Foundation, a charitable umbrella organisation with an annual budget of $4.6 million, mainly funded by donations (Middleton).Wikipedia editors and contributors have the option of creating a user profile and participating via a username, or they may participate anonymously, with only an IP address representing their actions. Despite the option for total anonymity, many Wikipedians have chosen to visibly engage in this online community (Ayers, Matthews, and Yates; Bruns; Lih), and researchers across disciplines are studying the motivations of these new online collectives (Kane, Majchrzak, Johnson, and Chenisern; Oreg and Nov). The motivations of open source software contributors, such as UNIX programmers and programming groups, have been shown to be complex and tied to both extrinsic and intrinsic rewards, including online reputation, self-satisfaction and enjoyment, and obligation to a greater common good (Hertel, Niedner, and Herrmann; Osterloh and Rota). Investigation into why Wikipedians edit has indicated multiple motivations as well, with community engagement, task enjoyment, and information sharing among the most significant (Schroer and Hertel). Additionally, Wikipedians seem to be taking up the cause of generativity (a concern for the ongoing health and openness of the Internet’s infrastructures) that Jonathan Zittrain notably called for in The Future of the Internet and How to Stop It. Governance and ControlAlthough the technical infrastructure of Wikipedia is built to support and perhaps encourage an equal distribution of power on the site, Wikipedia is not a land of “anything goes.” The popular press has covered recent efforts by the site to reduce vandalism through a layer of editorial review (Cohen), a tightening of control cited as a possible reason for the recent dip in the number of active editors (Edwards). A number of regulations are already in place that prevent the open editing of certain articles and pages, such as the site’s disclaimers and pages that have suffered large amounts of vandalism. Editing wars can also cause temporary restrictions to editing, and Ayers, Matthews, and Yates point out that these wars can happen anywhere, even to Burt Reynold’s page.Academic studies have begun to explore the governance and control that has developed in the Wikipedia community, generally highlighting how order is maintained not through particular actors, but through established procedures and norms. Konieczny tested whether Wikipedia’s evolution can be defined by Michels’ Iron Law of Oligopoly, which predicts that the everyday operations of any organisation cannot be run by a mass of members, and ultimately control falls into the hands of the few. Through exploring a particular WikiProject on information validation, he concludes:There are few indicators of an oligarchy having power on Wikipedia, and few trends of a change in this situation. The high level of empowerment of individual Wikipedia editors with regard to policy making, the ease of communication, and the high dedication to ideals of contributors succeed in making Wikipedia an atypical organization, quite resilient to the Iron Law. (189)Butler, Joyce, and Pike support this assertion, though they emphasise that instead of oligarchy, control becomes encapsulated in a wide variety of structures, policies, and procedures that guide involvement with the site. A virtual “bureaucracy” emerges, but one that should not be viewed with the negative connotation often associated with the term.Other work considers control on Wikipedia through the framework of commons governance, where “peer production depends on individual action that is self-selected and decentralized rather than hierarchically assigned. Individuals make their own choices with regard to resources managed as a commons” (Viegas, Wattenberg and McKeon). The need for quality standards and quality control largely dictate this commons governance, though interviewing Wikipedians with various levels of responsibility revealed that policies and procedures are only as good as those who maintain them. Forte, Larco, and Bruckman argue “the Wikipedia community has remained healthy in large part due to the continued presence of ‘old-timers’ who carry a set of social norms and organizational ideals with them into every WikiProject, committee, and local process in which they take part” (71). Thus governance on Wikipedia is a strong representation of a democratic ideal, where actors and policies are closely tied in their evolution. Transparency, Content, and BiasThe issue of transparency has proved to be a double-edged sword for Wikipedia and Wikipedians. The goal of a collective body of knowledge created by all—the “expert” and the “amateur”—can only be upheld if equal access to page creation and development is allotted to everyone, including those who prefer anonymity. And yet this very option for anonymity, or even worse, false identities, has been a sore subject for some in the Wikipedia community as well as a source of concern for some scholars (Santana and Wood). The case of a 24-year old college dropout who represented himself as a multiple Ph.D.-holding theology scholar and edited over 16,000 articles brought these issues into the public spotlight in 2007 (Doran; Elsworth). Wikipedia itself has set up standards for content that include expectations of a neutral point of view, verifiability of information, and the publishing of no original research, but Santana and Wood argue that self-policing of these policies is not adequate:The principle of managerial discretion requires that every actor act from a sense of duty to exercise moral autonomy and choice in responsible ways. When Wikipedia’s editors and administrators remain anonymous, this criterion is simply not met. It is assumed that everyone is behaving responsibly within the Wikipedia system, but there are no monitoring or control mechanisms to make sure that this is so, and there is ample evidence that it is not so. (141) At the theoretical level, some downplay these concerns of transparency and autonomy as logistical issues in lieu of the potential for information systems to support rational discourse and emancipatory forms of communication (Hansen, Berente, and Lyytinen), but others worry that the questionable “realities” created on Wikipedia will become truths once circulated to all areas of the Web (Langlois and Elmer). With the number of articles on the English-language version of Wikipedia reaching well into the millions, the task of mapping and assessing content has become a tremendous endeavour, one mostly taken on by information systems experts. Kittur, Chi, and Suh have used Wikipedia’s existing hierarchical categorisation structure to map change in the site’s content over the past few years. Their work revealed that in early 2008 “Culture and the arts” was the most dominant category of content on Wikipedia, representing nearly 30% of total content. People (15%) and geographical locations (14%) represent the next largest categories, while the natural and physical sciences showed the greatest increase in volume between 2006 and 2008 (+213%D, with “Culture and the arts” close behind at +210%D). This data may indicate that contributing to Wikipedia, and thus spreading knowledge, is growing amongst the academic community while maintaining its importance to the greater popular culture-minded community. Further work by Kittur and Kraut has explored the collaborative process of content creation, finding that too many editors on a particular page can reduce the quality of content, even when a project is well coordinated.Bias in Wikipedia content is a generally acknowledged and somewhat conflicted subject (Giles; Johnson; McHenry). The Wikipedia community has created numerous articles and pages within the site to define and discuss the problem. Citing a survey conducted by the University of Würzburg, Germany, the “Wikipedia:Systemic bias” page describes the average Wikipedian as:MaleTechnically inclinedFormally educatedAn English speakerWhiteAged 15-49From a majority Christian countryFrom a developed nationFrom the Northern HemisphereLikely a white-collar worker or studentBias in content is thought to be perpetuated by this demographic of contributor, and the “founder effect,” a concept from genetics, linking the original contributors to this same demographic has been used to explain the origins of certain biases. Wikipedia’s “About” page discusses the issue as well, in the context of the open platform’s strengths and weaknesses:in practice editing will be performed by a certain demographic (younger rather than older, male rather than female, rich enough to afford a computer rather than poor, etc.) and may, therefore, show some bias. Some topics may not be covered well, while others may be covered in great depth. No educated arguments against this inherent bias have been advanced.Royal and Kapila’s study of Wikipedia content tested some of these assertions, finding identifiable bias in both their purposive and random sampling. They conclude that bias favoring larger countries is positively correlated with the size of the country’s Internet population, and corporations with larger revenues work in much the same way, garnering more coverage on the site. The researchers remind us that Wikipedia is “more a socially produced document than a value-free information source” (Royal & Kapila).WikiProject: Countering Systemic BiasAs a coalition of current Wikipedia editors, the WikiProject: Countering Systemic Bias (WP:CSB) attempts to counter trends in content production and points of view deemed harmful to the democratic ideals of a valueless, open online encyclopedia. WP:CBS’s mission is not one of policing the site, but rather deepening it:Generally, this project concentrates upon remedying omissions (entire topics, or particular sub-topics in extant articles) rather than on either (1) protesting inappropriate inclusions, or (2) trying to remedy issues of how material is presented. Thus, the first question is "What haven't we covered yet?", rather than "how should we change the existing coverage?" (Wikipedia, “Countering”)The project lays out a number of content areas lacking adequate representation, geographically highlighting the dearth in coverage of Africa, Latin America, Asia, and parts of Eastern Europe. WP:CSB also includes a “members” page that editors can sign to show their support, along with space to voice their opinions on the problem of bias on Wikipedia (the quotations at the beginning of this paper are taken from this “members” page). At the time of this study, 329 editors had self-selected and self-identified as members of WP:CSB, and this group constitutes the population sample for the current study. To explore the extent to which WP:CSB addressed these self-identified areas for improvement, each editor’s last 50 edits were coded for their primary geographical country of interest, as well as the conceptual category of the page itself (“P” for person/people, “L” for location, “I” for idea/concept, “T” for object/thing, or “NA” for indeterminate). For example, edits to the Wikipedia page for a single person like Tony Abbott (Australian federal opposition leader) were coded “Australia, P”, while an edit for a group of people like the Manchester United football team would be coded “England, P”. Coding was based on information obtained from the header paragraphs of each article’s Wikipedia page. After coding was completed, corresponding information on each country’s associated continent was added to the dataset, based on the United Nations Statistics Division listing.A total of 15,616 edits were coded for the study. Nearly 32% (n = 4962) of these edits were on articles for persons or people (see Table 1 for complete coding results). From within this sub-sample of edits, a majority of the people (68.67%) represented are associated with North America and Europe (Figure A). If we break these statistics down further, nearly half of WP:CSB’s edits concerning people were associated with the United States (36.11%) and England (10.16%), with India (3.65%) and Australia (3.35%) following at a distance. These figures make sense for the English-language Wikipedia; over 95% of the population in the three Westernised countries speak English, and while India is still often regarded as a developing nation, its colonial British roots and the emergence of a market economy with large, technology-driven cities are logical explanations for its representation here (and some estimates make India the largest English-speaking nation by population on the globe today).Table A Coding Results Total Edits 15616 (I) Ideas 2881 18.45% (L) Location 2240 14.34% NA 333 2.13% (T) Thing 5200 33.30% (P) People 4962 31.78% People by Continent Africa 315 6.35% Asia 827 16.67% Australia 175 3.53% Europe 1411 28.44% NA 110 2.22% North America 1996 40.23% South America 128 2.58% The areas of the globe of main concern to WP:CSB proved to be much less represented by the coalition itself. Asia, far and away the most populous continent with more than 60% of the globe’s people (GeoHive), was represented in only 16.67% of edits. Africa (6.35%) and South America (2.58%) were equally underrepresented compared to both their real-world populations (15% and 9% of the globe’s population respectively) and the aforementioned dominance of the advanced Westernised areas. However, while these percentages may seem low, in aggregate they do meet the quota set on the WP:CSB Project Page calling for one out of every twenty edits to be “a subject that is systematically biased against the pages of your natural interests.” By this standard, the coalition is indeed making headway in adding content that strategically counterbalances the natural biases of Wikipedia’s average editor.Figure ASocial network analysis allows us to visualise multifaceted data in order to identify relationships between actors and content (Vego-Redondo; Watts). Similar to Davis’s well-known sociological study of Southern American socialites in the 1930s (Scott), our Wikipedia coalition can be conceptualised as individual actors united by common interests, and a network of relations can be constructed with software such as UCINET. A mapping algorithm that considers both the relationship between all sets of actors and each actor to the overall collective structure produces an image of our network. This initial network is bimodal, as both our Wikipedia editors and their edits (again, coded for country of interest) are displayed as nodes (Figure B). Edge-lines between nodes represents a relationship, and here that relationship is the act of editing a Wikipedia article. We see from our network that the “U.S.” and “England” hold central positions in the network, with a mass of editors crowding around them. A perimeter of nations is then held in place by their ties to editors through the U.S. and England, with a second layer of editors and poorly represented nations (Gabon, Laos, Uzbekistan, etc.) around the boundaries of the network.Figure BWe are reminded from this visualisation both of the centrality of the two Western powers even among WP:CSB editoss, and of the peripheral nature of most other nations in the world. But we also learn which editors in the project are contributing most to underrepresented areas, and which are less “tied” to the Western core. Here we see “Wizzy” and “Warofdreams” among the second layer of editors who act as a bridge between the core and the periphery; these are editors with interests in both the Western and marginalised nations. Located along the outer edge, “Gallador” and “Gerrit” have no direct ties to the U.S. or England, concentrating all of their edits on less represented areas of the globe. Identifying editors at these key positions in the network will help with future research, informing interview questions that will investigate their interests further, but more significantly, probing motives for participation and action within the coalition.Additionally, we can break the network down further to discover editors who appear to have similar interests in underrepresented areas. Figure C strips down the network to only editors and edits dealing with Africa and South America, the least represented continents. From this we can easily find three types of editors again: those who have singular interests in particular nations (the outermost layer of editors), those who have interests in a particular region (the second layer moving inward), and those who have interests in both of these underrepresented regions (the center layer in the figure). This last group of editors may prove to be the most crucial to understand, as they are carrying the full load of WP:CSB’s mission.Figure CThe End of Geography, or the Reclamation?In The Internet Galaxy, Manuel Castells writes that “the Internet Age has been hailed as the end of geography,” a bold suggestion, but one that has gained traction over the last 15 years as the excitement for the possibilities offered by information communication technologies has often overshadowed structural barriers to participation like the Digital Divide (207). Castells goes on to amend the “end of geography” thesis by showing how global information flows and regional Internet access rates, while creating a new “map” of the world in many ways, is still closely tied to power structures in the analog world. The Internet Age: “redefines distance but does not cancel geography” (207). The work of WikiProject: Countering Systemic Bias emphasises the importance of place and representation in the information environment that continues to be constructed in the online world. This study looked at only a small portion of this coalition’s efforts (~16,000 edits)—a snapshot of their labor frozen in time—which itself is only a minute portion of the information being dispatched through Wikipedia on a daily basis (~125,000 edits). Further analysis of WP:CSB’s work over time, as well as qualitative research into the identities, interests and motivations of this collective, is needed to understand more fully how information bias is understood and challenged in the Internet galaxy. The data here indicates this is a fight worth fighting for at least a growing few.ReferencesAlexa. “Top Sites.” Alexa.com, n.d. 10 Mar. 2010 ‹http://www.alexa.com/topsites>. Ayers, Phoebe, Charles Matthews, and Ben Yates. How Wikipedia Works: And How You Can Be a Part of It. San Francisco, CA: No Starch, 2008.Bruns, Axel. Blogs, Wikipedia, Second Life, and Beyond: From Production to Produsage. New York: Peter Lang, 2008.Butler, Brian, Elisabeth Joyce, and Jacqueline Pike. Don’t Look Now, But We’ve Created a Bureaucracy: The Nature and Roles of Policies and Rules in Wikipedia. Paper presented at 2008 CHI Annual Conference, Florence.Castells, Manuel. The Internet Galaxy: Reflections on the Internet, Business, and Society. Oxford: Oxford UP, 2001.Cohen, Noam. “Wikipedia.” New York Times, n.d. 12 Mar. 2010 ‹http://www.nytimes.com/info/wikipedia/>. Doran, James. “Wikipedia Chief Promises Change after ‘Expert’ Exposed as Fraud.” The Times, 6 Mar. 2007 ‹http://technology.timesonline.co.uk/tol/news/tech_and_web/article1480012.ece>. Edwards, Lin. “Report Claims Wikipedia Losing Editors in Droves.” Physorg.com, 30 Nov 2009. 12 Feb. 2010 ‹http://www.physorg.com/news178787309.html>. Elsworth, Catherine. “Fake Wikipedia Prof Altered 20,000 Entries.” London Telegraph, 6 Mar. 2007 ‹http://www.telegraph.co.uk/news/1544737/Fake-Wikipedia-prof-altered-20000-entries.html>. Forte, Andrea, Vanessa Larco, and Amy Bruckman. “Decentralization in Wikipedia Governance.” Journal of Management Information Systems 26 (2009): 49-72.Giles, Jim. “Internet Encyclopedias Go Head to Head.” Nature 438 (2005): 900-901.Hansen, Sean, Nicholas Berente, and Kalle Lyytinen. “Wikipedia, Critical Social Theory, and the Possibility of Rational Discourse.” The Information Society 25 (2009): 38-59.Hertel, Guido, Sven Niedner, and Stefanie Herrmann. “Motivation of Software Developers in Open Source Projects: An Internet-Based Survey of Contributors to the Linex Kernel.” Research Policy 32 (2003): 1159-1177.Johnson, Bobbie. “Rightwing Website Challenges ‘Liberal Bias’ of Wikipedia.” The Guardian, 1 Mar. 2007. 8 Mar. 2010 ‹http://www.guardian.co.uk/technology/2007/mar/01/wikipedia.news>. Kane, Gerald C., Ann Majchrzak, Jeremaih Johnson, and Lily Chenisern. A Longitudinal Model of Perspective Making and Perspective Taking within Fluid Online Collectives. Paper presented at the 2009 International Conference on Information Systems, Phoenix, AZ, 2009.Kittur, Aniket, Ed H. Chi, and Bongwon Suh. What’s in Wikipedia? Mapping Topics and Conflict Using Socially Annotated Category Structure. Paper presented at the 2009 CHI Annual Conference, Boston, MA.———, and Robert E. Kraut. Harnessing the Wisdom of Crowds in Wikipedia: Quality through Collaboration. Paper presented at the 2008 Association for Computing Machinery’s Computer Supported Cooperative Work Annual Conference, San Diego, CA.Konieczny, Piotr. “Governance, Organization, and Democracy on the Internet: The Iron Law and the Evolution of Wikipedia.” Sociological Forum 24 (2009): 162-191.———. “Wikipedia: Community or Social Movement?” Interface: A Journal for and about Social Movements 1 (2009): 212-232.Langlois, Ganaele, and Greg Elmer. “Wikipedia Leeches? The Promotion of Traffic through a Collaborative Web Format.” New Media & Society 11 (2009): 773-794.Lih, Andrew. The Wikipedia Revolution. New York, NY: Hyperion, 2009.McHenry, Robert. “The Real Bias in Wikipedia: A Response to David Shariatmadari.” OpenDemocracy.com 2006. 8 Mar. 2010 ‹http://www.opendemocracy.net/media-edemocracy/wikipedia_bias_3621.jsp>. Middleton, Chris. “The World of Wikinomics.” Computer Weekly, 20 Jan. 2009: 22-26.Oreg, Shaul, and Oded Nov. “Exploring Motivations for Contributing to Open Source Initiatives: The Roles of Contribution, Context and Personal Values.” Computers in Human Behavior 24 (2008): 2055-2073.Osterloh, Margit and Sandra Rota. “Trust and Community in Open Source Software Production.” Analyse & Kritik 26 (2004): 279-301.Royal, Cindy, and Deepina Kapila. “What’s on Wikipedia, and What’s Not…?: Assessing Completeness of Information.” Social Science Computer Review 27 (2008): 138-148.Santana, Adele, and Donna J. Wood. “Transparency and Social Responsibility Issues for Wikipedia.” Ethics of Information Technology 11 (2009): 133-144.Schroer, Joachim, and Guido Hertel. “Voluntary Engagement in an Open Web-Based Encyclopedia: Wikipedians and Why They Do It.” Media Psychology 12 (2009): 96-120.Scott, John. Social Network Analysis. London: Sage, 1991.Vego-Redondo, Fernando. Complex Social Networks. Cambridge: Cambridge UP, 2007.Viegas, Fernanda B., Martin Wattenberg, and Matthew M. McKeon. “The Hidden Order of Wikipedia.” Online Communities and Social Computing (2007): 445-454.Watts, Duncan. Six Degrees: The Science of a Connected Age. New York, NY: W. W. Norton & Company, 2003Wikipedia. “About.” n.d. 8 Mar. 2010 ‹http://en.wikipedia.org/wiki/Wikipedia:About>. ———. “Welcome to Wikipedia.” n.d. 8 Mar. 2010 ‹http://en.wikipedia.org/wiki/Main_Page>.———. “Wikiproject:Countering Systemic Bias.” n.d. 12 Feb. 2010 ‹http://en.wikipedia.org/wiki/Wikipedia:WikiProject_Countering_systemic_bias#Members>. Zittrain, Jonathan. The Future of the Internet and How to Stop It. New Haven, CT: Yale UP, 2008.

Photo ID 131102170 © Geckophotos | Dreamstime.com INTRODUCTION Medical tourism should contribute to developing a more robust healthcare system that acts in the best interests of patients and ensures equal access to healthcare. This paper examines medical tourism in Colombia and argues that developing a system that aligns with bioethical principles is necessary. People traveling for care should have access to the Ministry of Health rather than only the Ministry of Industry and Tourism, emphasizing their purpose as patients seeking medical procedures or treatments rather than tourists engaging in leisure activities. Additionally, in the interest of justice, Colombian patients should benefit from the revenue derived from medical tourism. It is crucial to recognize that both patients traveling for care and people in the destination country can derive benefits from medical tourism. The Colombian government can protect the rights and well-being of patients seeking care and ensure that any benefits are distributed fairly among Colombian citizens. I. Background Medical tourism refers to people traveling to foreign countries to obtain health care.[1] Many individuals from high-income countries seek health care in less developed countries to take advantage of the lower costs. Destination countries are increasingly showing interest in becoming medical tourism hubs due to the significant financial potential of this multi-billion dollar industry. The global medical tourism market is projected to reach $207.9 billion by 2027.[2] This growth not only generates income but also creates employment opportunities and business prospects for local residents in sectors such as tourism, pharmaceuticals, and infrastructure. By establishing themselves as medical tourism destinations, countries can stimulate economic development and enhance their healthcare structure. Colombia is among the fastest-growing medical tourism destinations in the world. It has become a popular destination for medical tourists due to its advanced healthcare infrastructure, biotechnology, and highly skilled physicians who cater to international patients at affordable prices.[3] The healthcare entities in Colombia offer a wide range of medical procedures, including cardiovascular, bariatric, orthopedics, cosmetic surgery, dental care, and fertility treatments. [4] The Colombian government has actively promoted medical tourism to position the country as a destination for world-class medical services.[5] Through strategic economic policies, effective regulation, and digital marketing, medical tourism has emerged as a significant contributor to Colombia’s income. The Colombian Ministry of Industry and Tourism, which regulates medical tourism in Colombia, forecasts at least 2.8 million health tourists and a revenue of at least $6.3 billion by 2032.[6] Colombia intends to have medical tourism play a significant role in its economy. However, ethical issues exist. The Colombia Ministry of Industry and Tourism is more involved in medical tourism than the Ministry of Health is. Additionally, the government has not been held accountable for the shortcomings in the medical tourism industry. There should be an organization advocating for the rights and well-being of medical tourists. Furthermore, using public funds to attract international patients may divert funds from local communities. Last, the negative impacts of medical tourism on Colombian patients deserve attention. This paper aims to explore these ethical issues from two perspectives: that of medical tourists and that of Colombian citizens. I argue that the benefits of medical tourism outweigh the harms but that those traveling for health care deserve protection. II. Patients: Are They International Patients or Tourists? When medical tourists seek hospitals and physicians in a destination country, facilitators may direct them to non-licensed practitioners and questionable facilities. These facilitators, who receive commissions, may not act in the patient’s best interest. Rather, like travel agents, they base their referrals on the referral fees that hospitals or physicians pay.[7] International patients risk getting lower-quality health care from unregulated hospitals or providers. This can interfere with informed consent and increase the risk of infections. There may be an absence of medical malpractice coverage from physicians. Unregulated or unlicensed medical care may even lead to patient fatalities. Therefore, it is crucial for international patients to carefully evaluate the risks associated with “booking” their healthcare options. To mitigate these risks, it is important for international patients to thoroughly assess the accreditation status of the hospital or clinic they plan to visit. The Joint Commission International (JCI) accreditation can provide patients with an external quality assessment and assist them in making an informed decision.[8] International patients should proactively seek out certified and reputable healthcare providers and institutions to ensure both their safety and a high quality of care. Colombia has five hospitals and clinics with JCI accreditation.[9] Colombia is the third most-used destination for plastic surgery in the world; the first is Brazil, and the second is Turkey. In Colombia, one out of every three plastic surgery patients is an international patient.[10] The Colombian Association for Plastic Surgery advises all patients to check the hospital's accreditation. Patients should check the website of the local Secretary of Health in each city and see if the physician conducting the plastic surgery is listed.[11] Institutions and doctors must fully comply with requirements, including describing the procedure and obtaining informed consent from patients. It is very common to read in the media plastic surgeries conducted in what is known in Latin America as “clinicas de garage” (garage clinics) with negative results and deaths.[12] Official data covers plastic surgeries conducted at accredited institutions with registered doctors. There is a lack of data on garage clinics. There are a few things the government can do to make medical tourism safer. First, the Ministry of Health’s website should maintain a list of healthcare providers with JCI accreditation. In each city, the local Secretary of Health is responsible for providing patients with information about the quality of care of the hospitals in its region. Second, the government should take responsibility for providing accurate and comprehensive information to international patients, enabling them to make fully informed decisions regarding their medical procedures. In the context of informed consent, patients may have trouble understanding due to language barriers, terminology, and the complexity of the risks involved in medical procedures. Lastly, Congress should enact a legal framework that determines the responsibility of all parties involved in medical tourism.[13] In the unfortunate event that a medical tourist requires intensive care, it becomes imperative to determine who will bear the responsibility for their well-being and any potential financial implications. Medical tourists are not protected from errors and failures of medical procedures because the Colombia Constitution specifies that the healthcare system exclusively caters to its citizens, while coverage for foreigners is limited to emergencies only. The US State Department recommends that those traveling to Colombia have international health insurance.[14] International patients can sue doctors in Colombia for medical malpractice, referred to as medical liability.[15] The government should take responsibility for certifying medical institutions and issuing medical visas with specific requirements and regulations specific to medical tourism.[16] A new medical visa system is in place. Changing the terminology may help the government see those traveling for care as medical patients rather than medical tourists. That may lead to a different mindset and spur the government to protect them and ensure high-quality care. It may also help those traveling avoid tourism industry facilitators and find reputable surgeons and hospitals. III. Are Colombian Patients and the Local Healthcare System Benefiting from Medical Tourism? The main reason for the growth of medical tourism from developed countries to developing countries like Colombia is the excessive cost of treatment in wealthier nations.[17] Other reasons include the long queues for certain types of medical services in the home country, the availability of better technologies abroad, inadequate (or absence of) health insurance, and the unavailability[18] (or prohibition) of certain medical services in the home country.[19] The Colombian Constitution recognizes health as a fundamental right for all citizens.[20] Pursuant to the Constitution’s health mandate, Colombia designed a mandatory universal social health insurance system in 1993. It aims to achieve a fair distribution of resources, opportunities, and services while holding the government accountable.[21] Before 1993, less than 25 percent of the population had coverage; now, between 94 and 99 percent have it, regardless of income level or employment.[22] However, universal care does not entitle Colombian citizens to many of the modern surgical centers, technology, and doctors that tourists access. Local wealthy Colombian citizens tend to purchase private insurance that allows them many more healthcare options.[23] The OECD reports that only 41 percent of Colombian citizens were satisfied with the availability of the quality of care, while the OECD average is 67 percent. According to the OECD, the out-of-pocket health expenditure in Colombia is 14 percent, which is lower than the OECD average of 18 percent. Despite its recognized right to health care, the current system is not providing the quality of care that the people would prefer. Those traveling to Colombia for care are not covered by universal social health insurance and must pay for their health care[24] out of pocket or through their private insurers using international coverage.[25] Like local supplemental private insurance, medical tourists and their insurance plans tend to pay more for their care than the rate that the universal system would pay the providers for care provided to the general Colombian population. This situation often leads to higher revenue from medical tourists than local patients unless the local patients have supplemental private insurance. The mismatched payment schemes leave the local population with unequal access to healthcare resources[26] since healthcare providers prefer to cater to patients paying more than the government-subsidized insurance pays. Medical tourism “threatens to result in a dual market structure”[27] characterized by a higher-quality, expensive segment that serves wealthy nationals and foreigners alongside a lower-quality segment that caters to the poor, most of whom are covered by universal healthcare coverage.[28] Medical tourists should pay taxes or a special premium to improve the local healthcare system. While the medical tourism industry arguably generates tax revenue,[29] some additional money should flow from the medical tourists to the healthcare outlets that the local people use. Then, the country can benefit even more from promoting medical tourism while ensuring that the government and the healthcare system follow the principles of justice, beneficence, and public welfare.[30] In Colombia, Fundación Cardioinfantil, a private non-profit hospital known as “La Cardio,” is a good example of a regional leader committed to providing clinical excellence to both national and international patients.[31] About 20 years ago, La Cardio, well known for its cardiovascular health care, aimed to become the top hospital in the region (Latin America and the Caribbean) to obtain financial resources for improving its facilities. It became the first hospital in Colombia to achieve the JCI accreditation, attracting patients from countries with inadequate cardiovascular healthcare systems.[32] Foreign governments covered their citizens’ medical expenses, allowing La Cardio to fund system improvement. Currently ranked as the fifth-best clinic in Latin America and having won the Gold Award for Corporate Social Responsibility, La Cardio has received recognition for its dedication to serving economically disadvantaged Colombian patients.[33] This example demonstrates how introducing a high-paying market has not led to neglecting local patients, as resources from medical tourists are used to enhance the healthcare system for the local population. CONCLUSION The Colombian government needs to recognize that international patients are seeking medical services, not tourism or vacation experiences. Therefore, a new policy should categorize international patients separately from the tourism sector and treat them purely as patients. The introduction of medical visas may help this. Once establishing international patients are patients and not tourists, the Colombian government could impose taxes on them and allocate the funds generated to reinvest in the healthcare needs of its citizens, ensuring justice and promoting awareness of the ethical rights of international patients. At the same time, home country governments directing patients to a destination country should conduct thorough due diligence of the ethical principles applied to international patients as well as the accreditation of the destination country’s hospitals. Colombia may be aware of the implications of the difference in terms but unwilling to modify the language due to the associated costs, liabilities, and risks involved. - [1] Gaines, J., Lee, C. V. (2019). Medical tourism. Travel Medicine, 371–375. https://doi.org/10.1016/b978-0-323-54696-6.00039-2 https://www.sciencedirect.com/science/article/pii/B9780323546966000392 [2] Forecasted Evolution of Medical Travels, 2023-2027: A Segmental View. ReportLinker. (2023, December). https://www.reportlinker.com/p06473784/Medical-Tourism-Market-Size-Share-Trends-and-Analysis-by-Region-Service-Provider-and-Segment-Forecast.html [3] Forecasted Evolution of Medical Travels, 2023-2027: A Segmental View. ReportLinker. (2023, December). [4] Arias-Aragonés, F.J.A., Payares, A.M.C., & Jiménez, O.J. (2020). Characterization of the healthcare tourism in the city of Bogotá and the District of Cartagena. Clío América, 14 (28), 486-492. https://doi.org/10.21676/23897848.3941 [5] Arias-Aragonés, et al. (2020). [6] Arias- Aragones, et al. (2020). https://www.colombiaproductiva.com/ptp-sectores/historico/turismo-salud (citing the Colombian Production Transformation Program (PTP)) [7] Glenn Cohen, Patients with Passports Medical Tourism, Law, and Ethics. New York Oxford University Press, 2015, p. 25 [8] Glenn, Cohen. (2015), p. 23-24. [9] A Global Leader for Health Care Quality and Patient Safety. Joint Commission International. https://www.jointcommissioninternational.org/ (The five Colombian hospitals and clinics with JCI accreditation are two hospitals in the capital city Bogota (la Cardio and Fundación Hospital Universitario Santa Fé de Bogotá), one hospital in Cali (Clinica Inbanaco), one hospital in Medellín (Hospital Pablo Tobón), and one clinic in Florida Blanca (Fundación Cardiovascular de Colombia). Nearby countries such as Venezuela and Trinidad Tobago do not have any accredited hospitals or clinics. Ecuador and Panamá have one each, Perú has eleven, and Brazil has seventy-one.) [10] International Society of Aesthetic Plastic Surgery ISAPS (2023), ISAPS International Survey on Aesthetic/Cosmetic Procedures performed in 2022, p. 52. https://www.isaps.org/discover/about-isaps/global-statistics/reports-and-press-releases/global-survey-2022-full-report-and-press-releases/ (most frequently cited countries of foreign patients in Colombia are the US, Spain, and Panama.) [11] Why choose a member of the SCCP. (2023). Colombia Plastic Surgery Association (SCCP). https://cirugiaplastica.org.co/porque-elegir-un-miembro-de-la-sccp/ See also: To Find a Surgeon. (2023). Colombia Plastic Surgery Association (SCCP). https://cirugiaplastica.org.co (This website is helpful for checking the list of members of the SCCP.) [12] Cosmetic Surgeries Performed in Garage Offices can Become a Public Health Problem. Concejo de Bogotá D.C. (2022). https://concejodebogota.gov.co/cirugias-esteticas-practicadas-en-consultorios-de-garaje-se-pueden/cbogota/2015-07-17/100100.php (There are many cases of deaths resulting from illegal plastic surgeries. The local government in Bogota is aware of the deaths, as reported in the Bogota Counsel (2015)). See also Travel.State.Gov, US Department of State, Bureau of Consular Affairs. (August 17, 2023). https://travel.state.gov/content/travel/en/international-travel/International-Travel-Country-Information-Pages/Colombia.html (There is a warning that says: “Although Colombia has many elective/cosmetic surgery facilities that are on par with those found in the United States, the quality of care varies widely. If you plan to undergo surgery in Colombia, carefully research the doctor and recovery facility you plan to use. Make sure that emergency medical facilities are available, and that professionals are accredited and qualified. Share all health information (e.g., medical conditions, medications, allergies) with your doctor before surgery.") [13] Arias-Aragonés, F.J.A., Payares, A.M.C., & Jiménez, O.J. (2020), p. 490. (report “the absence of regulation and a legal framework that determines the responsibilities of each link in the production chain” as a difficulty that affects competitivity to become a leader in medical tourism in the Latin American region.) See also: Trujillo, M. A. (2023, November 24). Colombia’s New Bill on Regulating Cosmetic Surgeries. BNN Breaking. https://bnn.network/breaking-news/health/colombia-to-regulate-cosmetic-surgeries-a-step-towards-patient-safety/ (On November 22, 2023, as a response to rising cases of death and injuries associated with plastic surgeries, a bill was introduced in the Colombian House of Representatives to regulate the practice of cosmetic surgeries and protect the integrity of patients) [14] U.S. Department of State, Travel.State.Gov, Colombia. (August 17, 2023). Traveler’s Checklist, https://travel.state.gov/content/travel/en/international-travel/International-Travel-Country-Information-Pages/Colombia.html [15] U.S. Department of State, Travel.State.Gov, Colombia. (August 17, 2023). Traveler’s Checklist. See also: Medical Tourism and Elective Surgery. The Department of State informs that “U.S. citizens have suffered serious complications or died during or after having cosmetic surgery or other elective surgery“ and “the legal options in cases of malpractice are very limited in Colombia,” https://travel.state.gov/content/travel/en/international-travel/International-Travel-Country-Information-Pages/Colombia.html See also: The law firm Alvarez Gonzalez Tolosa Attorneys. (August 8, 2023). Medical Malpractice in Colombia, includes medical malpractice as one of the areas of expertise of the firm. https://www.agtattorneys.com/blog/medical-malpractice-in-colombia/ [16] Colombia recently enacted a new visa regulation (Resolution 5477 from July 22, 2022, issued by the Ministry of Foreign Affairs) effective as of October 22, 2022. No data currently exists about a "medical treatment" visa because it is a new legislation. Even though the regulation refers to the visitor as a patient and includes requirements such as (1) a letter from the medical institution explaining the treatment and approximate duration, (2) a letter explaining costs and who will pay for the treatment, (3) insurance policy, and (4) the general requirements for tourists, the regulation specifically explains that this kind of visa is considered as a TOURISM visa (art 37). [17] Glenn, Cohen. 2015 [18] Frequently Asked Questions. Bioxcellerator. https://www.bioxcellerator.com/faqs (For example, Bioxellerator stem cell therapies conducted in Medellin, Colombia, are not FDA-approved.) [19] Vovk, Viktoriia, Lyudmila Beztelesna, and Olha Pliashko. (2021). "Identification of Factors for the Development of Medical Tourism in the World" International Journal of Environmental Research and Public Health 18, no. 21: 11205. https://doi.org/10.3390/ijerph182111205 [20] Colombian Constitution. (1991). art. 49 [21] Ministry of Health and Protection. Columbia Ministry of Health. (2023). https://www.minsalud.gov.co/English/Paginas/Ministry.aspx [22] “Does Colombia’s Health System Need an Overhaul?” (March 2, 2023). The Dialogue, Latin America Advisor. https://www.thedialogue.org/analysis/does-colombias-health-system-need-an-overhaul/ [23] Health at a Glance 2021 Colombia Country Note. OECD. (2023). https://search.oecd.org/colombia/health-at-a-glance-Colombia-EN.pdf [24] Travel.State.Gov, US Department of State, Bureau of Consular Affairs. https://travel.state.gov/content/travel/en/international-travel/International-Travel-Country-Information-Pages/Colombia.html [25] Glenn, Cohen. (2015). p. 2-9. [26] Banco de la República. (2023). Regional Health Inequalities in Colombia. https://www.banrep.gov.co/en/regional-health-inequalities-colombia (The Central Bank of Colombia (“Banco de la República”) in reports that despite having relatively high health coverage compared with other countries, empirical results show persistent inequalities in the healthcare system. The aim is to reduce and eventually eliminate such inequalities.) [27] Glenn, Cohen (2015), p. 158-160, citing Rupa Chanda, an Indian business professor, Trade in Health Services, 80 Bull. World Health Org. 158, 160 (2002). [28] Banco de la República. (2023). Regional Health Inequalities in Columbia. https://investiga.banrep.gov.co/es/be-1233. (Under Colombian law, it is mandatory for all employees and employers to pay 4 percent and 8 percent of the applicable salary, respectively, to the universal healthcare system (EPS) to obtain coverage for the employee and family members. This is known as the contributive system, and the funding is known as parafiscal. The unemployed obtain coverage through the government-subsidized system known as SISBEN (System of Identification of Beneficiaries of Social programs), funded with taxpayers’ money, known as fiscal funding. According to the Central Bank of Colombia (Banco de la República), “in recent years, the healthcare sector has faced financial and administrative problems that have increased the need for fiscal resources for its financing and that could affect its sustainability. Regarding the composition of the outflow, it is worth noting the cost of ensuring the contributory and subsidized regime, which on average explains 80 percent of the total system expenses during the period 2011-2022.” “Additionally, pressures derived from the Covid-19 pandemic, Venezuelan migration” and expenses derived from the increase in the subsidized system due to the high rate of unemployment and informal employment are negatively impacting financing of the healthcare system in Colombia. Additional fiscal resources are needed because the health care Colombians receive costs more than what beneficiaries pay.) [29] Statista. (2023). Revenue of the medical tourism sector in Colombia from 2019 to 2024 https://www.statista.com/statistics/1156551/colombia-revenue-medical-tourism/ [30] Glenn, Cohen. (2015), p.218 (The beneficence principle is the general moral obligation to act for the benefit of others, and some of those acts are obligatory, as is the government’s obligation concerning healthcare.) [31] Hospital Cardioinfantil Bogotá, Colombia. https://cardioinfantil.org [32] Hospital Cardioinfantil https://cardioinfantil.org (Trinidad and Tobago, Aruba, Curacao, and Panamá were the first countries with international agreements with La Cardio.) [33] Hospital Cardioinfantil Bogotá, Colombia. https://www.lacardio.org/historia/

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. Breastfeeding reduces the need for withdrawal treatment in opioid-exposed infants. Acta Paediatr. 2013;102(11):1060-1066. doi:10.1111/apa.12378 [36] Ilett KF, Hackett LP, Gower S, Doherty DA, Hamilton D, Bartu AE. Estimated dose exposure of the neonate to buprenorphine and its metabolite norbuprenorphine via breastmilk during maternal buprenorphine substitution treatment. Breastfeed Med Off J Acad Breastfeed Med. 2012;7:269-274. doi:10.1089/bfm.2011.0096 [37] Pedersen CA, Smedley KL, Leserman J, et al. Intranasal Oxytocin Blocks Alcohol Withdrawal in Human Subjects. Alcohol Clin Exp Res. 2013;37(3):484-489. doi:10.1111/j.1530-0277.2012.01958.x [38] Montana SB0289. https://leg.mt.gov/bills/2019/billhtml/SB0289.htm [39] Mullins N, Galvin SL, Ramage M, Gannon M, Lorenz K, Sager B, Coulson CC. Buprenorphine and Naloxone Versus Buprenorphine for Opioid Use Disorder in Pregnancy: A Cohort Study. J Addict Med. 2020 May/Jun;14(3):185-192. doi: 10.1097/ADM.0000000000000562. PMID: 31567599. [40] Drug Related Crime Statistics [2023]: Offenses Involving Drug Use. NCDAS. https://drugabusestatistics.org/drug-related-crime-statistics/ [41] Association APH. Online only: Report finds most U.S. inmates suffer from substance abuse or addiction. Nations Health. 2010;40(3):E11-E11. [42] Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition) | NIDA Archives. Published January 17, 2018. http://archives.nida.nih.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition

This chapter explores the interconnections of Chinese exclusion and maritime law, including the ways in which immigration officials used exclusion laws to regulate Asian sailors, and the ways in which these sailors resisted their regulation. Immigration officials were concerned that maritime statutes did not effectively address Asian sailors; specifically shore leave allowed them the opportunity to evade exclusion and enter the United States without authorization. In contrast to their relatively restrained implementation of exclusion laws against arriving immigrants, Ellis Island officials pushed for the strict regulation of Asian sailors under existing laws. Initially developed to regulate Chinese sailors, federal immigration officials extended new regulations to all Asian sailors. Chinese and other Asian sailors did not passively accept the restrictions placed on them. They challenged their unequal treatment through unions, through legal strategies, through verbal and violent conflicts, and by jumping ship.