Gotowa bibliografia na temat „Ridgefield (N.J.). Free Public Library”

We, the participants in the Joint Meeting of the Asia Pacific Association of Medical Journal Editors (APAME) and the Western Pacific Region Index Medicus (WPRIM) held in Singapore from November 4 to 5, 2009: CONSIDERING That quality scientific and technical health information is essential for health policy makers, healthcare providers and health researchers to develop, improve, and implement efficient and effective healthcare systems and services; That inequitable access to quality health information could result in poor health planning and healthcare delivery which adversely affect the health conditions of the public; That surmounting this inequity requires public - private partnerships to facilitate equitable access to both production and consumption of health information for all; That the Western Pacific Region Index Medicus (WPRIM), the Global Health Library (GHL), and the Asia Pacific Association of Medical Journal Editors (APAME) are important collaborative initiatives which are vital instruments to ensure the global accessibility and dissemination of quality health information in the Western Pacific Region; CONFIRM Our commitment to free and universal dissemination and access to quality health information through the WPRIM and the GHL; Our commitment to pursue the goals and objectives of APAME by further building networks, convening conferences, and organizing events to educate and empower editors, peer reviewers and authors in generating quality scientific and technical publications; CALL ON Member States of the Western Pacific Region, in collaboration with stakeholders from the private sector, to formulate and implement policies that endorse free and equitable access to quality health information; Stakeholders from the public and private sectors, national and international organizations, to support WPRIM and the GHL in order to ensure the free and global accessibility of health research done in the Western Pacific Region; Governments, the private sector and other editors’ associations to support APAME in implementing various activities, guidelines and practices that would improve the quality of scientific writing and publications n the Asia Pacific Region; COMMIT Ourselves to persevere in the pursuit of the WPRIM and GHL initiatives through APAME, by encouraging peer-to-peer relationships that will allow editors, editorial staff and librarians to maintain balance, work out ideas and provide mutual support; Our organization, APAME, to building further networks, convening conferences, and organizing events to educate and empower editors, peer reviewers and authors to achieve and maintain internationally acceptable, but regionally realistic, scholarly standards. November 6, 2009, Singapore www.wpro.who.int/apame apame@wpro.who.int (This declaration was launched at the International Forum on Academic Medical Publishing held in conjunction with the Singapore Medical Journal Golden Jubilee Conference on November 6, 2009. It is simultaneously published in the Singapore Med J 2009; 50(11):1043 and several other regional journals.)

A Review of: Quesenberry, A. C., Oelschlegel, S., Earl, M., Leonard, K., & Vaughn, C. J. (2016). The impact of library resources and services on the scholarly activity of medical faculty and residents. Medical Reference Services Quarterly, 35(3), 259-265. http://dx.doi.org/10.1080/02763869.2016.1189778 Abstract Objective – To assess the impact of academic medical library services and resources on information-seeking behaviours during the academic efforts of medical faculty and residents. Design – Value study derived from a 23-item survey. Setting – Public medical residency program and training hospital in Tennessee, USA. Subjects – 433 faculty and residents currently employed by or completing residency in an academic medical centre. Methods – Respondents completed a 23-question survey about their use of library resources and services in preparation for publishing, presenting, and teaching. The library services in the survey included literature searches completed by librarians and document delivery for preparation of publications, presentations, and lecture material. The survey also included questions about how resources were being accessed in preparation for scholarship. The survey sought information on whether respondents published articles or chapters or presented papers or posters in the previous three years. If respondents answered in the affirmative to one of the aforementioned methods of scholarship, they were provided with further questions about how they access library resources and whether they sought mediated literature search and document delivery services in preparation for their recent presentations and publications. The survey also included questions concerning what types of scholarly activity prompt faculty and residents to use online library resources. Main Results – The study was provided to 433 subjects, including 220 faculty and 213 residents, contacted through an email distribution list. The response rate to the survey was 15% (N=65). Residents comprised 35% of the respondents, and faculty at each of the three levels of tenure comprised 60%. The remaining 5% of respondents included PhD and non-clinical faculty within the graduate school. Over 50% of respondents reported use of library services in preparation for publishing and presenting. These library services were literature searches, document delivery, and accessing online resources. Faculty and residents reported use of PubMed first (71%) and most often, with 56% of respondents reporting weekly use, followed by Google or Google Scholar, with 20% of respondents reporting its use first and 23% of respondents reporting weekly use. However, regarding responses to the question concerning how journal articles are accessed, “using a search engine” was chosen most often, at almost 65%, followed by (in order) clicking library links in a database, contacting the library directly, searching the list of library e-journals, clicking publisher links in a database, using personal subscriptions, searching the library catalog, and using bookmarks saved in a web browser. Based on survey responses, faculty reported higher use of library services and resources than residents; however, residents reported higher use of library services and resources when preparing posters and papers for conferences and professional meetings. In addition, several comments spoke to the importance of the library for scholarly activity, many indicating the critical role of library assistance or resources in their academic accomplishments. Conclusion – This study provides evidence in support of library resources and services for medical faculty and residents, which contributes to discussions of the contributions of medical libraries. As hospital libraries close and academic medical libraries see reductions in budgets, this study contributes to the value of a library’s presence, as well as the role of the health sciences librarian in medical research and scholarly communication. This academic medical library was reported to be first and most often used, in comparison with other resources or none, in preparation for publication and presenting. The results of this and similar studies can contribute to the generalizability of its findings relating to the value of medical libraries. In addition, PubMed, UpToDate, and Google were the resources used most often by respondents, along with search engines and library links in databases. These findings can be incorporated into future outreach, marketing, and instructional curriculum for this library’s users. The survey results also provide additional support for the library’s role in the academic research lifecycle, and free-text comments about the critical role of library services furthered those findings. The authors state that further research is necessary for improving awareness of library resources and services in the role of scholarship at institutions.

Naturalist intelligence of early childhood has a very big role in today's modern age as the basis for children to have environmental-loving behaviour. The purpose of this study was to determine the effect of Loose Parts learning media on the naturalist intelligence. This study uses a quasi-experimental method with data collection techniques through multiple intelligence tests of children's intelligence instruments. The subjects of this study were 17 children aged 5-6 years. The results showed that there was a significant effect of giving Loose Parts media to the naturalist intelligence of early childhood after seeing a difference between pre-test and post-test. The use of natural-based Loose Parts media can be a means for teachers to increase children's naturalist intelligence in kindergarten and be a development of conventional media made from manufacturers in the learning cycle so far. For further research, it is recommended to look at the influence of other factors on naturalist intelligence in early childhood. Keywords: Early Childhood, Loose Parts, Naturalist Intelligence References: Aljabreen, H. (2020). Montessori, Waldorf, and Reggio Emilia: A Comparative Analysis of Alternative Models of Early Childhood Education. International Journal of Early Childhood, 52(3), 337–353. https://doi.org/10.1007/s13158-020-00277-1 Anjari, T. Y., & Purwanta, E. (2019). Effectiveness of the Application of Discovery Learning to the Naturalist Intelligence of Children About the Natural Environment in Children Aged 5-6 Years. International Conference on Special and Inclusive Education (ICSIE 2018), 296, 356–359. https://doi.org/10.2991/icsie-18.2019.65 Armstrong, T. (2002). You’re Smarter Than You Think: A Kid’s Guide to Multiple Intelligences. Free Spirit Publishing Inc., 217 Fifth Ave., North, Suite 200, Minneapolis, MN 55401-1299. Asih, S., & Susanto, A. (2017). Peningkatan Kecerdasan Naturalis Pada Anak Usia 5-6 Tahun Melalui Model Pembelajaran Di Sentra Bahan Alam. Yaa Bunayya: Jurnal Pendidikan Anak Usia Dini, 1(1). https://doi.org/10.24853/yby.1.1.33-38 Ata-Akturk, A., & Sevimli-Celik, S. (2020). Creativity in early childhood teacher education: Beliefs and practices. International Journal of Early Years Education, 1–20. https://doi.org/10.1080/09669760.2020.1754174 Azizah, E. N. (2021). Peningkatan Kecerdasan Naturalis Melalui Kolase Bahan Alam Pada Anak Kelompok A TK Kemala Bhayangkari 54 Ngawi. Journal of Childhood Education, 5(1). https://doi.org/10.30736/jce.v5i1.491 Damayanti, A., Akbar, M., & Yufiarti, Y. (2019). The Interaction Effect of Learning Methods and Naturalist Intelligence Toward Children’s Art Creativity. Proceedings of the First International Conference on Technology and Educational Science. https://doi.org/10.4108/eai.21-11-2018.2282278 Diana, H., Diana, S., & Wulan, A. R. (2019). Hubungan antara kecerdasan naturalis dengan sikap lingkungan. Konferensi Internasional Tentang Biologi Dan Sains Terapan (ICOBAS). Ebrahimi, T. (2017). Effect of Technology on Education in Middle East: Traditional Education Versus Digital Education. In Digital Transformation in Journalism and News Media (pp. 519–531). Springer International Publishing. https://doi.org/10.1007/978-3-319-27786-8_38 Faridy, F., & Rohendi, A. (2021). The Role of Parents in Engaging Early Childhood to Implement 3R (Reduce, Reuse, Recycle). Proceedings of the International Conference on Engineering, Technology and Social Science (ICONETOS 2020), 529(Iconetos 2020), 483–486. https://doi.org/10.2991/assehr.k.210421.070 Fatonah, S., & Prasetyo, Z. K. (2018). Science Learning Model To Improve Naturalist Intelligence For Early Childhood. Sunan Kalijaga International Journal on Islamic Educational Research, 1(1), 34–50. https://doi.org/10.14421/skijier.2017.2017.11-03 Flannigan, C., & Dietze, B. (2018). Children, Outdoor Play, and Loose Parts. Journal of Childhood Studies, 53–60. https://doi.org/10.18357/jcs.v42i4.18103 Furi, A. Z., Harmawati, Denok, M., & B.A. (2019). Meningkatkan Kemampuan Kognitif melalui Penerapan Metode Eksperimen Menggunakan Media Loose Parts pada Anak Kelompok B. Emphaty Cons: Journal of Guidance and Counseling, 1(2), 7–19. Gardner, H. (1994). Frames Of Mind. New York, NY, Basic Books. Gibson, J. L., Cornell, M., & Gill, T. (2017). A Systematic Review of Research into the Impact of Loose Parts Play on Children’s Cognitive, Social and Emotional Development. School Mental Health, 9(4), 295–309. https://doi.org/10.1007/s12310-017-9220-9 Gold, Z. S., & Elicker, J. (2020). Engineering Peer Play: A New Perspective on Science, Technology, Engineering, and Mathematics (STEM) Early Childhood Education (pp. 61–75). https://doi.org/10.1007/978-3-030-42331-5_5 Gull, C., Bogunovich, J., Goldstein, S. L., & Rosengarten, T. (2019). Definitions of Loose Parts in Early Childhood Outdoor Classrooms: A Scoping Review Carla Gull Jessica Bogunovich Suzanne Levenson Goldstein Tricia Rosengarten. International Journal of Early Childhood Environmental Education Copyright, 6(3), 37–52. Hafizotun, L. (2017). Pemberdayaan Sentra Bahan Alam Untuk Mengembangkan Kecerdasan Naturalis Anak Usia Dini Di Taman Kanak-Kanak Islam Terpadu Nurul Ilmi Kota Jambi. Jurnal Al-Ashlah, 1(Vol 1, No 2 (2017)). Hapidin, Gunarti, W., Pujianti, Y., & Siti Syarah, E. (2020). STEAM to R-SLAMET Modification: An Integrative Thematic Play Based Learning with R-SLAMETS Content in Early Child-hood Education. JPUD - Jurnal Pendidikan Usia Dini, 14(2), 262–274. https://doi.org/10.21009/JPUD.142.05 Hartika, D., Diana, S., & Wulan, A. R. (2019). Relationship between naturalist intelligence with environmental attitude. 060017. https://doi.org/10.1063/1.5115717 Herwati, Y. (2019). Pengaruh Permainan Ludo Bergambar Terhadap Kecerdasan Naturalis Anak di Taman Kanak-kanak Tunas Bangsa Bukittinggi. Jurnal Obsesi : Jurnal Pendidikan Anak Usia Dini, 4(1), 428. https://doi.org/10.31004/obsesi.v4i1.358 Houser, N. E., Cawley, J., Kolen, A., Rainham, D., Rehman, L., Turner, J., Kirk, S., & Stone, M. (2019). A Loose Parts Randomized Controlled Trial to Promote Active Outdoor Play in Preschool-aged Children: Physical Literacy in the Early Years (PLEY) Project. Methods and Protocols, 2(2), 27. https://doi.org/10.3390/mps2020027 Houser, N. E., Roach, L., Stone, M. R., Turner, J., & Kirk, S. F. L. (2016). Let the Children Play: Scoping Review on the Implementation and Use of Loose Parts for Promoting Physical Activity Participation. AIMS Public Health, 3(4), 781–799. https://doi.org/10.3934/publichealth.2016.4.781 Imamah, Z., & Muqowim, M. (2020). Pengembangan kreativitas dan berpikir kritis pada anak usia dini melalui motode pembelajaran berbasis STEAM and loose part. Yinyang: Jurnal Studi Islam Gender Dan Anak, 263–278. https://doi.org/10.24090/yinyang.v15i2.3917 Jamaris, M. (2018). Pengembangan Instrumen Baku Kecerdasan Jamak Anak Usia Dini. PARAMETER: Jurnal Pendidikan Universitas Negeri Jakarta, 25(2), 123–137. https://doi.org/10.21009/parameter.252.08 Juniarti, Y. (2015). Peningkatan Kecerdasan Naturalis Melalui Metode Kunjungan Lapangan (Field Trip). JPUD - Jurnal Pendidikan Usia Dini, 9(2). https://doi.org/10.21009/JPUD.092.05 Karwowski, M., Kaufman, J. C., Lebuda, I., Szumski, G., & Firkowska-Mankiewicz, A. (2017). Intelligence in childhood and creative achievements in middle-age: The necessary condition approach. Intelligence, 64, 36–44. https://doi.org/10.1016/j.intell.2017.07.001 Keniger, L., Gaston, K., Irvine, K., & Fuller, R. (2013). What are the Benefits of Interacting with Nature? International Journal of Environmental Research and Public Health, 10(3), 913–935. https://doi.org/10.3390/ijerph10030913 Kirkham, J. A., & Kidd, E. (2017). The Effect of Steiner, Montessori, and National Curriculum Education Upon Children’s Pretence and Creativity. The Journal of Creative Behavior, 51(1), 20–34. https://doi.org/10.1002/jocb.83 Kristiawan, M. (2016). Telaah Revolusi Mental Dan Pendidikan Karakter Dalam Pembentukkan Sumber Daya Manusia Indonesia Yang Pandai Dan Berakhlak Mulia. Ta’dib, 18(1), 13. https://doi.org/10.31958/jt.v18i1.274 Latifah, C. N., & Prasetyo, I. (2019). Effectiveness of Educational Game for the Intelligence of Early Childhood Naturalist. Advances in Social Science, Education and Humanities Research, 296(Icsie 2018), 310–314. https://doi.org/10.2991/icsie-18.2019.56 Liani, S., & Barsihanor. (2020). Strategies for Developing Naturalist Intelligence at Nature Schools. Journal of K6 Education and Management, 3(3), 401–410. https://doi.org/10.11594/jk6em.03.03.12 Marsden, E., & Torgerson, C. J. (2012). Article in Oxford Review of Education ·. May 2016. https://doi.org/10.2307/41702779 Maulisa, R., Israwati, & Amri, A. (2016). Meningkatkan Kecerdasan Naturalis Anak Melalui Media Bahan Alam Di Paud It Aneuk Shaleh Ceria Desa Neuheun Kebupaten Aceh Besar. Jurnal Ilmiah Mahasiswa Pendidikan Anak Usia Dini, 1(1), 99–107. Ningrum, Z. B., Soesilo, T. E. B., & Herdiansyah, H. (2018). Naturalistic Intelligence and Environmental Awareness among Graduate Students. E3S Web of Conferences, 68, 02004. https://doi.org/10.1051/e3sconf/20186802004 Nipriansyah, N., Rambat Nur Sasongko, Muhammad Kristiawan, E. S., & Hasanah, P. F. A. (2021). Increase Creativity And Imagination Children Through Learning Science, Technologic, Engineering, Art And Mathematic With Loose Parts Media. Al-Athfaal: Jurnal Ilmiah Pendidikan Anak Usia Dini, 4(1). https://doi.org/10.24042/ajipaud.v4i1.8598 Nurfadilah. (2020). Kemampuan Motorik Halus Melalui Kegiatan Kolase Dengan Bahan Loose Part Pada Anak Usia 4-6 Tahun di Bangkinang Kota. Journal on Teacher Education, 2(1). https://doi.org/10.31004/jote.v2i1.1193 Nurhafizah, N. (2018). Development of Naturalist Intelligence of Children in Kindergarten. International Conference of Early Childhood Education (ICECE 2017), 169, 17–20. https://doi.org/10.2991/icece-17.2018.5 Nurjanah, N. E. (2020). Pembelajaran STEM Berbasis Loose Parts Untuk Meningkatkan Kreativitas Anak Usia Dini. Jurnal Ilmiah Kajian Ilmu Anak Dan Media Informasi PUD, 1(1), 19–31. Olsen, H., & Smith, B. (2017). Sandboxes, loose parts, and playground equipment: A descriptive exploration of outdoor play environments. Early Child Development and Care, 187(5–6), 1055–1068. https://doi.org/10.1080/03004430.2017.1282928 Prameswari, T., & Anik Lestariningrum. (2020). Strategi Pembelajaran Berbasis STEAM Dengan Bermain Loose Parts Untuk Pencapaian Keterampilan 4c Pada Anak Usia 4-5 Tahun. Efektor, 7(1), 24–34. https://doi.org/10.29407/e.v7i2.14387 Rahmatunnisa, S., & Halimah, S. (2018). Upaya Meningkatkan Kecerdasan Naturalis Anak Usia 4 – 5 Tahun Melalui Bermain Pasir. Jurnal Pendidikan Anak Usia Dini, 2(1), 67–82. Ramdani, Z. (2017). Increased naturalist intelligence through the use of realia media. Jurnal Golden Age Hamzanwadi University, 1(1), 16–32. Rizkia, N., Hayati, F., & Amelia, L. (2020). Analisis Penggunaan Media Pasir Kinetik Dalam Menstimulasi Kecerdasan Naturalis Pada Anak Kelompok B1 Tk Pertiwi Lhoknga. Jurnal Ilmiah Mahasiswa Pendidikan, 1(1), 1–12. Rocmah, L. I. (2016). Peningkatan Kecerdasan Naturalis Melalui Bermain Messy Play terhadap Anak Usia 5-6 Tahun. PEDAGOGIA: Jurnal Pendidikan, 5(1), 47. https://doi.org/10.21070/pedagogia.v5i1.88 Rueda, L., Benitez, J., & Braojos, J. (2017). From traditional education technologies to student satisfaction in Management education: A theory of the role of social media applications. Information & Management, 54(8), 1059–1071. https://doi.org/10.1016/j.im.2017.06.002 Sari, N. E., & Suryana, D. (2019). 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When children only see their friends in little squares via Google Meet or Zoom, can teachers really address concepts like the importance of teamwork or how to manage conflict? This is a learning phenomenon during the COVID-19 pandemic and the era after it. This study aims to see the role of parents as children's learning companions in terms of mentors and motivators when online education takes place. This research using photovoice within phenomenological methodology and have been doing with thematic analysis and collecting data through interviews and observations. The participants were eight parents and one female teacher as a homeroom teacher. The research findings show that although there are many obstacles in online learning for children, learning during the COVID-19 pandemic can still run by involving the role of parents and teachers as pillars of education for preschool-age children. For further research, it is hoped that the findings will be a way in solving learning problems for children. Keywords: early childhood education, parents’ role, online learning References: Adedoyin, O. B., & Soykan, E. (2020). Covid-19 pandemic and online learning: The challenges and opportunities. In Interactive Learning Environments. https://doi.org/10.1080/10494820.2020.1813180 Aras, S. (2016). Free play in early childhood education: A phenomenological study. Early Child Development and Care, 186(7). https://doi.org/10.1080/03004430.2015.1083558 Arkorful, V. (2021). The role of e-learning, advantages and disadvantages of its adoption in higher The role of e-learning, the advantages and disadvantages of its adoption in Higher Education . International Journal of Education and Research, 2(December 2014). Atiles, J. T., Almodóvar, M., Chavarría Vargas, A., Dias, M. J. A., & Zúñiga León, I. M. (2021). International responses to COVID-19: Challenges faced by early childhood professionals. European Early Childhood Education Research Journal, 29(1). https://doi.org/10.1080/1350293X.2021.1872674 Barnett, W. S., Grafwallner, R., & Weisenfeld, G. G. (2021). Corona pandemic in the United States shapes new normal for young children and their families. In European Early Childhood Education Research Journal (Vol. 29, Issue 1). https://doi.org/10.1080/1350293X.2021.1872670 Basham, J. D., Blackorby, J., & Marino, M. T. (2020). Opportunity in Crisis: The Role of Universal Design for Learning in Educational Redesign. In Learning Disabilities: A Contemporary Journal (Vol. 18, Issue 1). Beatriks Novianti Bunga, R. 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Educational research: Planning, conducting, and evaluating quantitative and qualitative research (Fifth edition). Pearson. Dodd, H. F., Fitzgibbon, L., Watson, B. E., & Nesbit, R. J. (2021). Children’s play and independent mobility in 2020: Results from the british children’s play survey. International Journal of Environmental Research and Public Health, 18(8). https://doi.org/10.3390/ijerph18084334 Duran, A. (2019). A Photovoice Phenomenological Study Exploring Campus Belonging for Queer Students of Color. Journal of Student Affairs Research and Practice, 56(2). https://doi.org/10.1080/19496591.2018.1490308 Ebbeck, M., Yim, H. Y. B., Chan, Y., & Goh, M. (2016). Singaporean Parents’ Views of Their Young Children’s Access and Use of Technological Devices. Early Childhood Education Journal. https://doi.org/10.1007/s10643-015-0695-4 Ekyana, Luluk, Fauziddin Muhammad & Arifiyanti Nurul. (2021). 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Galczyk (2021) Preschool Parents’ Views of Distance Learning during COVID-19, Early Education and Development, 32:7, 923-939, DOI: 10.1080/10409289.2021.1930936 Muhdi, Nurkolis, & Yuliejantiningsih, Y. (2020). The Implementation of Online Learning in Early Childhood Education During the Covid-19 Pandemic. JPUD - Jurnal Pendidikan Usia Dini, 14(2). https://doi.org/10.21009/jpud.142.04 Ortlipp, M. (2015). Keeping and Using Reflective Journals in the Qualitative Research Process. The Qualitative Report. https://doi.org/10.46743/2160-3715/2008.1579 Paat, Y. F. (2013). Working with Immigrant Children and Their Families: An Application of Bronfenbrenner’s Ecological Systems Theory. Journal of Human Behavior in the Social Environment, 23(8). https://doi.org/10.1080/10911359.2013.800007 Plowman, L., Stephen, C., & McPake, J. (2010). Supporting young children’s learning with technology at home and in preschool. 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Journal of Early Childhood Research, 19(3). https://doi.org/10.1177/1476718X20971321 Sri Indah Pujiastuti, Sofia Hartati & Jun Wang (2022) Socioemotional Competencies of Indonesian Preschoolers: Comparisons between the Pre-Pandemic and Pandemic Periods and among DKI Jakarta, DI Yogyakarta and West Java Provinces, Early Education and Development, DOI: 10.1080/10409289.2021.2024061 Stone, K., Burgess, C., Daniel, B., Smith, J., & Stephen, C. (2017). Nurture corners in preschool settings: Involving and nurturing children and parents. Emotional and Behavioural Difficulties, 22(4). https://doi.org/10.1080/13632752.2017.1309791 Suzanne M. Egan & Chloé Beatty (2021) To school through the screens: the use of screen devices to support young children's education and learning during the COVID-19 pandemic, Irish Educational Studies, 40:2, 275-283, DOI: 10.1080/03323315.2021.1932551 Thomson, S. (2007). Do’s and don’ts: Children’s experiences of the primary school playground. Environmental Education Research, 13(4). https://doi.org/10.1080/13504620701581588 Vallejo-Ruiz, M., & Torres-Soto, A. (2020). Teachers’ conceptions on the quality of the teaching and learning process in early childhood education. Revista Electronica Educare, 24(3). https://doi.org/10.15359/REE.24-3.13 Widodo, H. P. (2014). Methodological considerations in interview data transcription. International Journal of Innovation in English Language, 3(1). Wijaya, Candra., Dalimunthe, Rasyid Anwar., & Muslim. Parents’ Perspective on The Online Learning Using Zoom Application in Early Childhood Education. JPUD: Jurnal Pendidikan Usia Dini, Volume 15 Number 2. DOI: https://doi.org/10.21009/JPUD.152.06 Winship, M., Standish, H., Trawick-Smith, J., & Perry, C. (2021). Reflections on practice: Providing authentic experiences with families in early childhood teacher education. In Journal of Early Childhood Teacher Education (Vol. 42, Issue 3). https://doi.org/10.1080/10901027.2020.1736695

Use of technologies in domestic spaces in a market economy suggests a certain notion of consumption. But is this the same as consumption or use of technologies in public spaces such as urban streets, internet cafes and libraries? As Baudrillard has argued, consumption can be seen as a form of desire for social meaning and interaction [1988]. How then do we describe the types of social interaction made possible by virtualising technologies, and the tensions between these interactions and the physical spaces in which they take place? Studies of the social and behavioural impacts of new technologies often focus on the home as a site where these technologies (for example, radio and television) are consumed, appropriated, fetishised or made into artefacts by their owners. For example Silverstone and Haddon [1996] speak of the domestication of new technologies as a process involving four stages, making a claim for the role of users/consumers and consumption in the production, design and innovation of technologies - a role which has until recently very rarely been acknowledged. Such a process is dependent on the processes of a capitalist market system in general, which sets roles for people not just in the workplace but in the home as well. Historically this system informed the distinction between public and private spaces. Embedded in this dichotomy are notions of gender, class and race. While Silverstone and Haddon are showing the artificiality of the distinction, their assumption that consumption is a largely domestic activity reinforces the public/private divide. This however begs the question of how technologies are consumed and indeed, whether this is even the right word to use when describing such uses in public spaces. It is ironic that our consumption of technologies has become so public and yet so disconnected from traditional notions of social interaction. The mobile phone, numbers of which surpassed fixed lines for the first time last year in Australia [ACA 2002] is a much-hyped case in point. In our new mobile condition we minimise social encounters with strangers on the street and avoid face-to-face contact. Instead we invest in mediated faceless conversations with known counterparts through text messaging and mobile telephony. After all, as Baudrillard says, most of these machines are used for delusion, for eluding communication (leave a message) for absolving us of the face-to-face relation and the social responsibility. [1995] This may in part explain the sense of anxiety often expressed by commentators (and users) in respect of these new technologies. Perhaps the falling back on a form of technological determinism is in actual fact the expression of a profound pessimism, similar to that voiced by a journalist in a London newspaper in 1897: We shall soon be nothing but transparent heaps of jelly to each other. [Marvin 1988, 68] The use of technologies in public spaces in our own time use has not until recently been noted, even in official statistics, due perhaps to an overwhelming preoccupation with domestic access. It must also be acknowledged that Australian government policy with respect to the Internet during the last decade has assumed that the functions of the free market will deliver access to the home, the assumption being that, like the fixed line telephone, the domestic Internet will eventually become ubiquitous. And, indeed, home computer ownership has risen over time; household connections to the Internet have also risen sharply, and a large number of Australians also access the Internet from work [ABS 2001]. Public libraries, tertiary institutions and friend or neighbour's house as sites of access make up a mere remainder in these statistics. And yet, the inclusion of these three categories makes for a far more complete picture when discussing effective use. What do people use technologies in public spaces for? Are these uses different to domestic uses? If not, what does this suggest about public use, in terms of present policy and provision? We can notionally divide the complex set of places known as public space into four categories: civic spaces (including libraries), commercial spaces (including malls, shops and arcades), public spaces (such as the street and the park) and semi-privat(is)e(d) spaces. The shopping mall, for example, is a semi-privatised space, which mediates both the type of users and their activities through surveillance and obtrusive design (images of the street). The library, as a civic space, represents a place in which the use of new technologies (for example the Internet, if not the mobile phone) can be both appropriate (i.e. relevant) and equitable. But what of Internet access in other public spaces? The existence of a growing body of literature relating to mobile phone use in public spaces, for example, suggests that the relationship between new technologies and space is fluid [see Lee 1999; also DoCoMo Reports 2000] At a more basic, societal level, interactions between people on the street have historically been mediated by considerations of gender, occupation and disability [see for example, Rendell's male rambler]. In the same way as the provision of public access is often miscast as being solely for those without access at home, so too the street has been characterised as a site whose occupiers are transient, homeless or otherwise unengaged (for example, unemployed). So, what happens when the street meets the commercial imperative, as in the case of an Internet cafe? Most Internet cafes in Australia operate on a commercial basis. A further distinction can be made between pay-per-session and free public access Internet cafes. Within the pay-per-session category we may locate not only Internet cafes but also kiosks (the vending machine approach to access) and wireless Internet users; while within the free category we could include libraries, community centres and tertiary institutions. Each of these spaces induce certain kinds of activities, encourage and discourage certain forms of behaviour. When we add use of the Internet, which in itself functions as a semi-private space, this cocktail of design, use, consumption and communication becomes very potent indeed. Crang describes the intersection of two different kinds of spaces: the architectural (where forms are entered and moved through) and the cinematic (where pictures move in front of an unmoving person) (2000, 5). We would argue that Internet cafes, especially those where customers are visible to passers-by on the street, embody this essentially urban, interactive, consumption-driven shopping mall kind of a space, whose 'liberties of action' (to borrow Sawhney's phrase) are contained not within the present but a (perhaps misnamed) hyperreality. This approach has been taken by several multimedia Internet cafes in Australia, notably the Ngapartji centre in Adelaide, where "Equity of access is underlined by the vision of the walk-in, hands-on, street-front showcase of high-end multimedia Timezone for grown-ups. [Green 1996] This is an overwhelmingly urban notion of space. Public space in non-urban areas, by comparison, is located within a predominantly civic framework (the ANZAC memorial, the Town Hall). It's therefore apparent that an examination of public space in terms of strict public/private demarcations must also take into account the inter-relationship between urbanisation and consumption. Crang's image-event (2000, 12) may have many manifestations, not all of which will fit into simple dichotomies such as public/private, commercial/charitable, streetside/inside. What then can we say about users of technologies in public spaces, engaged in a notionally private act in a public space, mediated by a cash transaction? In what ways is this complex interaction made possible by (or embedded within) the design of the Internet cafe itself? Does the kind of public space induce particular forms of behaviour or usage? How do people interact with each other in these public spaces, whilst also engaging with another community, whose sole physical presence is a screen? One could argue, as Connery [1997] does, that the cafe metaphor is appropriate not so much to the space itself, but to the interactions between people on mailing and discussion lists, whose interplay occurs, perhaps ironically, in a virtual space. Internet cafes occupy a vague, barely-researched space somewhere in between the home and the office. They are an example of the intersection between new communications technologies and sites where leisure activities take place. They are at once intensely public but also intensely private. Lee's (1999) study of an Internet cafe and its users is timely, as it refutes the notion that public access encourages totally different users and use, a point of view summed up in a (no longer accessible) 1999 BT OpenWorld market analysis of Internet cafes: The clientele will largely consist of people who appreciate the usefulness of the Internet, but have no other access to it. These circumstances will not continue indefinitely, as PC ownership is increasing daily. In other words, you'd better get in quick, before universal domestic access kills your business! Lee's study runs counter to this view, suggesting that the progression from public access to domestic access is not linear, and that people frequent Internet cafes for a variety of reasons, and may indeed have access elsewhere. Lee's conclusion that peoples' use of Internet cafes is directly connected to their home and work life suggests the need for a re-examination of the kinds of public access being made available, and the public policy assumptions behind this access. Public use does not necessarily equate with a lack of access elsewhere. In fact, mobile Internet users may use public access as an adjunct to their daily activities; travelling users may log on to workstations en route to another destination; public library users may be accessing training, Internet facilities and bibliographic databases at the same time. It is a matter of concern that recent government policies have shown little recognition of these subtleties in both users and their activities. References Australian Bureau of Statistics, 8147.0 Use of the Internet by Householders, Australia (Final Issue: November 2000) and 8146.0 Household Use of Information Technology. Australian Communications Authority (2002) Media Release: Mobile Numbers Up by 25%, 13 February [http://www.aca.gov.au/media/2002/02-06.htm (viewed 6 March 2002)]Baudrillard, J.(1995) The virtual illusion for the Automatic writing of the World in Theory, Culture and Society, 12: 97-107. Baudrillard, J.(1998) The Consumer Society, Myths and Structures, Sage, London Connery, B. (1997) IMHO: Authority and Egalitarian Rhetoric in the Virtual Coffeehouse, in Porter, D. (ed.) Internet Culture, Routledge. Crang, M. (2000) Public Space, Urban Space and Electronic Space: Would the Real City Please Stand Up? in Urban Studies February, 37.2: 301. DoCoMo Reports (2000) No. 9 (The use of cell phones/PHS phones in everyday life) and No. 10 (Current trends in mobile phone usage among adolescents) NTT DoCoMo (Japan), Public Relations Department [http://www.nttdocomo.com] Green, L. (1996) Interactive Multimedia, the Cooperative Multimedia Centre Story in Media International Australia, 81: 11-20. Lee, S. (1999) Private Uses in Public Space: a study of an Internet cafe, in New Media and Society, 1.3: 331-350. Marvin, C. (1988) When Old Technologies Were New: Thinking about Electronic Communications in the late 19th century, Oxford University Press. Rendell, J. (1998) Displaying Sexuality: Gendered Identities and the early nineteenth century street, in Fyfe, N. (ed.), Images of the Street: Planning, Identity and Control in Public Space, Routledge. Silverstone & Haddon (1996) Design and the Domestication of Information and Communication Technologies: Technical Change and Everyday Life in Mansell and Silverstone (eds.) Communication By Design: the Politics of Information and Communication Technologies. Oxford University Press. 44-74. Links http://www.nttdocomo.com http://www.ngapartji.com.au http://www.aca.gov.au/media/2002/02-06.htm Citation reference for this article MLA Style Prater, David and Miller, Sarah. "We shall soon be nothing but transparent heaps of jelly to each other" M/C: A Journal of Media and Culture 5.2 (2002). [your date of access] < http://www.media-culture.org.au/0205/transparent.php>. Chicago Style Prater, David and Miller, Sarah, "We shall soon be nothing but transparent heaps of jelly to each other" M/C: A Journal of Media and Culture 5, no. 2 (2002), < http://www.media-culture.org.au/0205/transparent.php> ([your date of access]). APA Style Prater, David and Miller, Sarah. (2002) We shall soon be nothing but transparent heaps of jelly to each other. M/C: A Journal of Media and Culture 5(2). < http://www.media-culture.org.au/0205/transparent.php> ([your date of access]).

ObjectiveAutomated syndromic surveillance using mobile devices is an emerging public health focus that has a high potential for enhanced disease tracking and prevention in areas with poor infrastructure. Pacific Northwest National Laboratory sought to develop an Android mobile application for syndromic biosurveillance that would i) use the phone camera to take images of human faces to detect individuals that are sick through a machine learning (ML) model and ii) collect image data to increase training data available for ML models. The initial prototype use case is for screening and tracking the health of soldiers for use by the Department of Defense’s Disease Threat Reduction Agency.IntroductionInfectious diseases present with multifarious factors requiring several efforts to detect, prevent, and break the chain of transmission. Recently, machine learning has shown to be promising for automated surveillance leading to rapid and early interventions, and extraction of phenotypic features of human faces [3, 5]. In addition, mobile devices have become a promising tool to provide on-the-ground surveillance, especially in remote areas and geolocation mapping [4].Pacific Northwest National Laboratory (PNNL) combines machine learning with mobile technology to provide a groundbreaking prototype of disease surveillance without the need for internet, just a camera. In this android application, VisionDx, a machine learning algorithm analyses human face images and within milliseconds notifies the user with confidence level whether or not the person is sick. VisionDx comes with two modes, photo and video, and additional features of history, map, and statistics. This application is the first of its kind and provides a new way to think about the future of syndromic surveillance.MethodsData. Human healthy (n = 1096) and non-healthy (n = 1269) facial images met the criteria for training the Machine Learning model after preprocessing them. The healthy images were obtained from the Chicago face database [6] and California Institute of Technology [2]. There are no known collections of disease facial images. Using open source image collection/curation services, images were identified by a variety of keywords, including specific infectious diseases. The criteria for image inclusion was 1. a frontal face was identified using OpenCV library [1], and 2. the image contained signs of disease through visual inspection (e.g., abnormal color, texture, swelling).Model. To identify a sick face from a healthy one, we used transfer machine learning and experimented with various pretrained Convolutional Neural Networks (CNN) from Google for mobile and embedded vision applications. Using MobileNet, we trained the final model with our data and deployed it to our prototype mobile app. Google Mobile Vision API and TensorFlow mobile were used to detect human faces and run predictions in the mobile app.Mobile Application. The Android app was built using Android Studio to provide an easily navigable interface that connects every action between tabbed features. The app features (i.e., Map, Camera, History, and Statistics) are in tab view format. The custom-made camera is the main feature of the app, and it contains face detection capability. A real-time health status detection function gives a level of confidence based the algorithm results found on detected faces in the camera image.ResultsPNNL's prototype Android application, VisionDx, was built with user-friendly tab views and functions to take camera images of human faces and classify them as sick or healthy through an inbuilt ML model. The major functions of the app are the camera, map, history, and statistics pages. The camera tab has a custom-made camera with face detection algorithm and classification model of sick or healthy. The camera has image or video mode and results of the algorithm are updated in milliseconds. The Statistics view provides a simple pie chart on sick/healthy images based on user selected time and location. The Map shows pins representing all labeled images stored, and the History displays all the labeled images. Clicking on an image in either view shows the image with metadata, i.e., model confidence levels, geolocation, and datetime.The CNN model prediction accuracy has ~98% validation accuracy and ~96% test accuracy. High model performance shows the possibility that deep learning could be a powerful tool to detect sickness. However, given the limited dataset, this high accuracy also means the model is most likely overfit to the data. The training set is limited: a. the number of training images is small compared to the variability in facial expressions and skin coloring, and b. the sick images only contained overt clinical signs. If trained on a larger, diverse set of data, this prototype app could prove extremely useful in surveillance efforts of individual to large groups of people in remote areas, e.g., to identify individuals in need of medical attention or get an overview of population health. In effort to improve the model, VisionDx was developed as a data collection tool to build a more comprehensive dataset. Within the tool, users can override the model prediction, i.e., false positive or false negative, with a simple toggle button. Lastly, the app was built to protect privacy so that other phone aps can't access the images unless shared by a user.ConclusionsDeveloped at PNNL for the Defense Threat Reduction Agency, VisionDx is a novel, camera-based mobile application for real-time biosurveillance and early warning in the field without internet dependency. The prototype mobile app takes pictures of faces and analyzes them using a state-of-the-art machine learning model to give two confidence levels of likelihood of being sick and healthy. With further development of a labeled dataset, such as by using the app as a data collection too, the results of the algorithm will quickly improve leading to a ground-breaking approach to public health surveillance.References1. Bradski G. (n.d.) The OpenCV Library. Retrieved Sept 30, 2018 at http://www.drdobbs.com/open-source/the-opencv-library/1844043192. Computational Vision: Archive. (1999). Retrieved Sept 22, 2018 at http://www.vision.caltech.edu/html-files/archive.html3. Ferry Q, Steinberg J, Webber C, et al (2014). Diagnostically relevant facial gestalt information from ordinary photos. ELife, 3, e02020.4. Fornace KM, Surendra H, Abidin TR, et al (2018). Use of mobile technology-based participatory mapping approaches to geolocate health facility attendees for disease surveillance in low resource settings. International Journal of Health Geographics, 17(1), 21. https://doi.org/10.1186/s12942-018-0141-05. Lopez DM, de Mello FL, G Dias, CM, et al (2017). Evaluating the Surveillance System for Spotted Fever in Brazil Using Machine-Learning Techniques. Frontiers in Public Health, 5. https://doi.org/10.3389/fpubh.2017.003236. Ma DS, Correll J, Wittenbrink B. (2015) The Chicago face database: A free stimulus set of faces and norming data. Behavior Research Methods, 47(4), 1122–1135. https://doi.org/10.3758/s13428-014-0532-5

Introdução: O padrão ouro atual para detectar o RNA de SARS-CoV-2 é por reação em cadeia da polimerase em tempo real de transcrição reversa (RT-rtPCR) em swabs nasofaríngeos (NPS). Por esse motivo, a demanda pelos NPS aumentou e sua escassez se tornou uma realidade em muitos países. Com isso o uso da saliva se mostra uma alternativa promissora na triagem epidemiológica além de ser de fácil coleta e não invasiva. Objetivo: realizar uma revisão sistemática da literatura para avaliar o uso da saliva como um espécime alternativo para a detecção de SARS-CoV-2. Metodologia: A pesquisa sistemática foi realizada em sete bancos de dados (PubMed, Cochrane Library, Lilacs, Scielo, Web of Science, Scopus e Google Scholar) usando a variação dos termos de pesquisa (COVID-19 OR SARS-CoV-2 OR 2019-nCoV) AND "Saliva" no ano de 2020, recuperando 5480 publicações. Resultados: Após a leitura dos títulos e resumos, 411 textos foram conduzidos para leitura integral e 30 publicações foram consideradas para avaliação qualitativa do artigo. Conclusão: A saliva se apresenta um método alternativo eficaz para a detecção de SARS-CoV-2 e diagnóstico de COVID-19.Descritores: Infecções por Coronavírus; Betacoronavirus; Saliva; Diagnóstico.ReferênciasHuang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395:497-506.Wang L, Wang Y, Ye D, Liu Q. A review of the 2019 Novel Coronavirus (COVID-19) based on current evidence. J Antimicrob Agents 2020;105948.Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al. A Novel Coronavirus from Patients with Pneumonia in China, 2019. N Engl J Med 2020;382:727-733.Coronaviridae Study Group of the International Committee on Taxonomy of V. 2020. The species Severe acute respiratory syndrome-related coronavirus: classifying 2019-nCoV and naming it SARS-CoV-2. Nat Microbiol. 2020;5:536-544.Lauer SA, Grantz KH, Bi Q, Jones FK, Zheng Q, Meredith HR, et al. The incubation period of Coronavirus Disease 2019 (COVID-19) from publicly reported confirmed cases: estimation and application. Ann Intern Med. 2020;172:577-82.To KK, Tsang OT, Chik-Yan Yip C, Chan KH, Wu TC, Chan JMC, et al. Consistent detection of 2019 novel coronavirus in saliva. Clin Infect Dis. 2020;149:5734265.Xu R, Cui B, Duan X, Zhang P, Zhou X, Yuan Q. Saliva: potential diagnostic value and transmission of 2019-nCoV. Int J Oral Sci. 2020;12:11.Khurshid Z, Asiri FYI, Al Wadaani H. Human Saliva: Non-Invasive Fluid for Detecting Novel Coronavirus (2019-nCoV). Int J Environ Res Public Health. 2020;17.Khurshid Z, Zohaib S, Najeeb S, Zafar MS, Slowey PD, Almas K. Human Saliva Collection Devices for Proteomics: An Update. Int J Mol Sci. 2016;17.Principais itens para relatar Revisões sistemáticas e Meta-análises: A recomendação PRISMA. Epidemiol. E Serviços Saúde 2015;24:335–42.Abdul MSM, Fatima U, Khanna SS, Bhanot R, Sharma A, Srivastava AP. Oral Manifestations of Covid-19-Are they the introductory symptoms?. J Adv Dent Sci Res. 2020;8:5.Azzi L, Carcano G, Dalla Gasperina D, Sessa F, Maurino V, Baj A. Two cases of COVID-19 with positive salivary and negative pharyngeal or respiratory swabs at hospital discharge: A rising concern. Oral Dis. 2020;00:1-3.Azzi L, Carcano G, Gianfagna F, Grossi P, Dalla Gasperina D, Genoni A, et al. Saliva is a reliable tool to detect SARS-CoV-2. J Infect. 2020;81:45-50.Becker D, Sandoval E, Amin A, De Hoff P, Leonetti N, Lim YW, et al. Saliva is less sensitive than nasopharyngeal swabs for COVID-19 detection in the community setting. medRxiv. 2020;20092338.Braz-Silva PH, Pallos D, Giannecchini S, To KKW. SARS-CoV-2: What can saliva tell us?. Oral Dis. 2020;13365.Chan JFW, Yip CCY, To KKW, Tang THC, Wong SCY, Leung KH, et al. Improved molecular diagnosis of COVID-19 by the novel, highly sensitive and specific COVID-19-RdRp/Hel real-time reverse transcription-PCR assay validated in vitro and with clinical specimens. J Clin Microbiol. 2020;58:5.Chen L, Zhao J, Peng J, Li X, Deng X, Geng Z, et al. Detection of 2019-nCoV in saliva and characterization of oral symptoms in COVID-19 patients. Lancet. 2020;3556665.Cheng VC, Wong SC, Chen JH, Yip CC, Chuang VW, Tsang OT, et al. Escalating infection control response to the rapidly evolving epidemiology of the Coronavirus disease 2019 (COVID-19) due to SARS-CoV-2 in Hong Kong. Infect Control Hosp Epidemiol. 2020;41:493-498.Han P, Ivanovski S. Saliva—Friend and Foe in the COVID-19 Outbreak. Diagn. 2020;10:290.Iwasaki S, Fujisawa S, Nakakubo S, Kamada K, Yamashita Y, Fukumoto T, et al. Comparison of SARS-CoV-2 detection in nasopharyngeal swab and saliva. J Infect. 2020;20:30349.Krajewska J, Krajewski W, Zub K, Zatoński T. COVID-19 in otolaryngologist practice: a review of current knowledge. Eur Arch Otorhinolaryngol. 2020;1-13.Lalli MA, Chen X, Langmade SJ, Fronick CC, Sawyer CS, Burcea LC, et al. Rapid and extraction-free detection of SARS-CoV-2 from saliva with colorimetric LAMP. medRxiv. 2020;7273276.Li X, Geng M, Peng Y, Meng L, Lu S. Molecular immune pathogenesis and diagnosis of COVID-19. J Pharm Anal. 2020;10:101-108.Li H, Liu SM, Yu XH, Tang SL, Tang CK. Coronavirus disease 2019 (COVID-19): current status and future perspective. Int J Antimicrob Agents. 2020;105951.McCormick-Baw C, Morgan K, Gaffney D, Cazares Y, Jaworski K, Byrd A, et al. Saliva as an Alternate Specimen Source for Detection of SARS-CoV-2 in Symptomatic Patients Using Cepheid Xpert Xpress SARS-CoV-2. J Clin Microbiol. 2020;01109-20.Pasomsub E, Watcharananan SP, Boonyawat K, Janchompoo P, Wongtabtim G, Suksuwan W, et al. Saliva sample as a non-invasive specimen for the diagnosis of coronavirus disease-2019 (COVID-19): a cross-sectional study. Clin Microbiol Infect. 2020;20302780.Sabino-Silva R, Jardim ACG, Siqueira WL. Coronavirus COVID-19 impacts to dentistry and potential salivary diagnosis. Clinical oral investigations. 2020;1-3.Sapkota D, Thapa SB, Hasséus B, Jensen JL. Saliva testing for COVID-19?. BDJ. 2020;228:658-659.Sharma S, Kumar V, Chawla A, Logani A. Rapid detection of SARS-CoV-2 in saliva: Can an endodontist take the lead in point-of-care COVID-19 testing?. Int Endod J. 2020;13317.Tang YW, Schmitz JE, Persing DH, Stratton CW. Laboratory Diagnosis of COVID-19: Current Issues and Challenges. J Clin Microbiol. 2020;58(6).Tatikonda SS, Reshu P, Hanish A, Konkati S, Madham S. A Review of Salivary Diagnostics and Its Potential Implication in Detection of Covid-19. Cureus. 2020;12(4).To KKW, Tsang OTY, Leung WS, Tam AR, Wu TC, Lung DC, et al. Temporal profiles of viral load in posterior oropharyngeal saliva samples and serum antibody responses during infection by SARS-CoV-2: an observational cohort study. Lancet Infect Dis. 2020;20:565-574.Vinayachandran D, Saravanakarthikeyan B. Salivary diagnostics in COVID-19: Future research implications. J Dent Sci. 2020;7177105.Williams E, Bond K, Zhang B, Putland M, Williamson DA. Saliva as a non-invasive specimen for detection of SARS-CoV-2. J Clin Microbiol. 2020;00776-20.Wyllie AL, Fournier J, Casanovas-Massana A, Campbell M, Tokuyama M, Vijayakumar P, et al. Saliva is more sensitive for SARS-CoV-2 detection in COVID-19 patients than nasopharyngeal swabs. Medrxiv. 2020;20067835.Yoon JG, Yoon J, Song JY, Yoon SY, Lim CS, Seong H, et al. Clinical Significance of a High SARS-CoV-2 Viral Load in the Saliva. J Korean Med Sci. 2020;35(20).Zheng S, Yu F, Fan J, Zou Q, Xie G, Yang X, et al. Saliva as a Diagnostic Specimen for SARS-CoV-2 by a PCR-Based Assay: A Diagnostic Validity Study. Lancet. 2020;3543605.Zhong F, Liang Y, Xu J, Chu M, Tang G, Hu F, et al. Continuously High Detection Sensitivity of Saliva, Viral Shedding in Salivary Glands and High Viral Load in Patients with COVID-19. Lancet. 2020;3576869.

ObjectiveTo describe the impact of civil unrest on the mental health of a community in near real-time using syndromic surveillance.IntroductionAs part of a wide-spread community discussion on the presence of monuments to Confederate Civil War figures, the Charlottesville city council voted to remove a statue of General Robert E. Lee.1 Multiple rallies were then held to protest the statue’s removal. A Ku Klux Klan (KKK) rally on July 8, 2017 (MMWR Week 27) and a Unite the Right rally on August 12, 2017 (MMWR Week 32) held in Charlottesville both resulted in violence and media attention.2,3 The violence associated with the Unite the Right rally included fatalities connected to motor vehicle and helicopter crashes.Syndromic surveillance has been used to study the impact of terrorism on a community’s mental health4 while more traditional data sources have looked at the impact of racially-charged civil unrest.5 Syndromic surveillance, however, has not previously been used to document the effect of racially-charged violence on the health of a community.MethodsThe Virginia Department of Health (VDH) analyzed syndromic surveillance data from three emergency departments (EDs) in the Charlottesville area (defined to include Charlottesville city and Albemarle county), regardless of patient residence following the Unite the Right rally. Visits to these EDs between January 1 and September 2, 2017 were analyzed using the Enhanced Surveillance System for the Early Notification of Community-based Epidemics (ESSENCE) and Microsoft SQL 2012. Encounters were identified as acute anxiety-related visits based on an International Classification of Diseases, Tenth Revision (ICD-10) discharge diagnosis beginning with ’F41’. Analyses were conducted using the ESSENCE algorithm EWMA 1.2 and SAS 9.3.ResultsThe greatest number of visits with a primary diagnosis of anxiety in 2017 (N=20) was observed in MMWR week 34 (August 20-26). This represented a statistically significant increase over baseline with a p-value of 0.01.By race, a significant increase over baseline in visits with a primary diagnosis of anxiety was observed among blacks or African Americans. The largest volume of visits was observed in MMWR week 33 with a total of 8 identified visits or 1.8% of total ED visit volume. The increase in visits for anxiety observed in weeks 33-35 was 2.2 times greater among blacks or African Americans than it was among whites, p = 0.016, 95% CI [1.14, 4.16].ConclusionsPrevious work done in Virginia to identify ED visits related to anxiety included only chief complaint criteria in the syndrome definition. Due to a change in how one ED in the Charlottesville area reported data during the study period, this syndrome definition could not be applied. In order to remove any potential data artifacts, only those visits with an initial diagnosis of anxiety were included in the analysis. The resulting syndrome definition likely underestimated the occurrence of anxiety in the Charlottesville area, both because it lacked chief complaint information and because syndromic surveillance does not include data on visits to mental health providers outside of EDs. This analysis presents a trend over time rather than a true measure of the prevalence of anxiety.This analysis, while conservative in its inclusion criteria, still identified an increase in visits for anxiety, particularly among blacks or African Americans. In today’s political environment of race-related civil unrest, a way to measure the burden of mental illness occurring in the community can be invaluable for public health response. In Charlottesville, the identification of a community-wide need for mental health support prompted many local providers to offer their services to those in need pro-bono.6References1 Suarez, C. (2017, February 6). Charlottesville City Council votes to remove statue from Lee Park. The Daily Progress. Retrieved from http://bit.ly/2wYOHhv2 Spencer, H., & Stevens, M. (2017, July 8). 23 Arrested and Tear Gas Deployed After a K.K.K. Rally in Virginia. The New York Times. Retrieved from http://nyti.ms/2tCiBGU3 Hanna, J., Hartung, K., Sayers, D., & Almasy, S. (2017, August 13). Virginia governor to white nationalists: ‘Go home … shame on you’. CNN. Retrieved from http://cnn.it/2vvAGHt4 Vandentorren, S., Paty, A. C., Baffert, E., Chansard, P., Caserio-Schönemann, C. (2016, February). Syndromic surveillance during the Paris terrorist attacks. The Lancet (387(10021), 846-847. doi:10.1016/S0140-6736(16)00507-95 Yimgang, D. P., Wang, Y., Paik, G., Hager, E. R., & Black, M. M. Civil Unrest in the Context of Chronic Community Violence: Impact on Maternal Depressive Symptoms. American Journal of Public Health 107(9), 1455-1462. doi:10.2105/AJPH.2017.3038766 DeLuca, P. (2017, August 19). Downtown Charlottesville Library Offers Free Counseling. NBC29.com. Retrieved from http://bit.ly/2yIzHbl

Photo by Sharon McCutcheon on Unsplash ABSTRACT COVID-19 highlighted a disproportionate impact upon marginalized communities that needs to be addressed. Specifically, a focus on equity rather than equality would better address and prevent the disparities seen in COVID-19. A distributive justice framework can provide this great benefit but will succeed only if the medical community engages in outreach, anti-racism measures, and listens to communities in need. INTRODUCTION COVID-19 disproportionately impacted communities of color and lower socioeconomic status, sparking political discussion about existing inequities in the US.[1] Some states amended their guidelines for allocating resources, including vaccines, to provide care for marginalized communities experiencing these inequities, but there has been no clear consensus on which guidelines states should amend or how they should be ethically grounded. In part, this is because traditional justice theories do not acknowledge the deep-seated institutional and interpersonal discrimination embedded in our medical system. Therefore, a revamped distributive justice approach that accounts for these shortcomings is needed to guide healthcare decision-making now and into the post-COVID era. BACKGROUND Three terms – health disparity, health inequities, and health equity – help frame the issue. A health disparity is defined as any difference between populations in terms of disease incidence or adverse health events, such as morbidity or mortality. In contrast, health inequities are health disparities due to avoidable systematic structures rooted in racial, social, and economic injustice.[2] For example, current data demonstrate that Black, Latino, Indigenous Americans, and those living in poverty suffer higher morbidity and mortality rates from COVID-19.[3] Finally, health equity is the opportunity for anyone to attain his or her full health potential without interference from systematic structures and factors that generate health inequities, including race, socioeconomic status, gender, ethnicity, religion, sexual orientation, or geography.[4] ANALYSIS Health inequities for people of color with COVID-19 have led to critiques of states that do not account for race in their resource allocation guidelines.[5] For example, the Massachusetts Department of Public Health revised its COVID-19 guidelines regarding resource allocation to patients with the best chance of short-term survival.[6] Critics have argued that this change addresses neither preexisting structural inequities nor provider bias that may have led to comorbidities and increased vulnerability to COVID-19. By failing to address race specifically, they argue the policy will perpetuate poorer outcomes in already marginalized groups. As the inequities in COVID-19 outcomes continue to be uncovered and the data continue to prove that marginalized communities suffered disproportionately, we, as healthcare providers, must reconsider our role in addressing the injustices. Our actions must be ethically grounded in the concept of justice. l. Primary Theories of Justice The principle of justice in medical ethics relates to how we ought to treat people and allocate resources. Multiple theories have emerged to explain how justice should be implemented, with three of the most prominent being egalitarianism, utilitarianism, and distributive. This paper argues that distributive justice is the best framework for remedying past actions and enacting systemic changes that may persistently prevent injustices. An egalitarian approach to justice states all individuals are equal and, therefore, should have identical access to resources. In the allocation of resources, an egalitarian approach would support a strict distribution of equal value regardless of one’s attributes or characteristics. Putting this theory into practice would place a premium on guidelines based upon first-come, first-served basis or random selection.[7] However, the egalitarian approach taken in the UK continues to worsen health inequities due to institutional and structural discrimination.[8] A utilitarian approach to justice emphasizes maximizing overall benefits and achieving the greatest good for the greatest number of people. When resources are limited, the utilitarian principle historically guides decision-making. In contrast to the egalitarian focus on equal distribution, utilitarianism focuses on managing distributions to maximize numerical outcomes. During the COVID-19 pandemic, guidelines for allocating resources had utilitarian goals like saving the most lives, which may prioritize the youthful and those deemed productive in society, followed by the elderly and the very ill. It is important to reconsider using utilitarian approaches as the default in the post-COVID healthcare community. These approaches fail to address past inequity, sacrificing the marginalized in their emphasis on the greatest amount of good rather than the type of good. Finally, a distributive approach to justice mandates resources should be allocated in a manner that does not infringe individual liberties to those with the greatest need. Proposed by John Rawls in a Theory of Justice, this approach requires accounting for societal inequality, a factor absent from egalitarianism and utilitarianism.[9] Naomi Zack elaborates how distributive justice can be applied to healthcare, outlining why racism is a social determinant of health that must be acknowledged and addressed.[10] Until there are parallel health opportunities and better alignment of outcomes among different social and racial groups, the underlying systemic social and economic variables that are driving the disparities must be fixed. As a society and as healthcare providers, we should be striving to address the factors that perpetuate health inequities. While genetics and other variables influence health, the data show proportionately more exposure, more cases, and more deaths in the Black American and Hispanic populations. Preexisting conditions and general health disparities are signs of health inequity that increased vulnerability. Distributive justice as a theoretical and applied framework can be applied to preventable conditions that increase vulnerability and can justify systemic changes to prevent further bias in the medical community. During a pandemic, egalitarian and utilitarian approaches to justice are prioritized by policymakers and health systems. Yet, as COVID-19 has demonstrated, they further perpetuate the death and morbidity of populations that face discrimination. These outcomes are due to policies and guidelines that overall benefit white communities over communities of color. Historically, US policy that looks to distribute resources equally (focusing on equal access instead of outcomes), in a color-blind manner, has further perpetuated poor outcomes for marginalized communities.[11] ll. Historical and Ongoing Disparities Across socio-demographic groups, the medical system exacerbates historical and current inequities. Members of marginalized races,[12] women,[13] LGBTQ people,[14] and poor people[15] experience trauma caused by discrimination, marginalization, and failure to access high-quality public and private goods. Through the unequal treatment of marginalized communities, these historic traumas continue. In the US, people of color do not receive equal and fair medical treatment. A meta-analysis found that Hispanics and Black Americans were significantly undertreated for pain compared to their white counterparts over the last 20 years.[16] This is partly due to provider bias. Through interviewing medical trainees, a study by the National Academy of Science found that half of medical students and residents harbored racist beliefs such as “Black people’s nerve endings are less sensitive than white people’s” or “Black people’s skin is thicker than white people’s skin.”[17] More than 3,000 Indigenous American women were coerced, threatened, and deliberately misinformed to ensure cooperation in forced sterilization.[18] Hispanic people have less support in seeking medical care, in receiving culturally appropriate care, and they suffer from the medical community’s lack of resources to address language barriers.[19] In the US, patients of different sexes do not receive the same quality of healthcare. Despite having greater health needs, middle-aged and older women are more likely to have fewer hospital stays and fewer physician visits compared to men of similar demographics and health risk profiles.[20] In the field of critical care, women are less likely to be admitted to the ICU, less likely to receive interventions such as mechanical ventilation, and more likely to die compared to their male ICU counterparts.[21] In the US, patients of different socioeconomic statuses do not receive the same quality of healthcare. Low-income patients are more likely to have higher rates of infant mortality, chronic disease, and a shorter life span.[22] This is partly due to the insurance-based discrimination in the medical community.[23] One in three deaths of those experiencing homelessness could have been prevented by timely and effective medical care. An individual experiencing homelessness has a life expectancy that is decades shorter than that of the average American.[24] lll. Action Needed: Policy Reform While steps need to be taken to provide equitable care in the current pandemic, including the allocation of vaccines, they may not address the historical failures of health policy, hospital policy, and clinical care to eliminate bias and ensure equal treatment of patients. According to an applied distributive justice framework, inequities must be corrected. Rather than focusing primarily on fair resource allocation, medicine must be actively anti-racist, anti-sexist, anti-transphobic, and anti-discriminatory. Evidence has shown that the health inequities caused by COVID-19 are smaller in regions that have addressed racial wealth gaps through forms of reparations.[25] Distributive justice calls for making up for the past using tools of allocation as well as tools to remedy persistent problems. For example, Brigham and Women’s Hospital in Boston, MA, began “Healing ARC,” a pilot initiative that involves acknowledgement, redress, and closure on an institutional level.[26] Acknowledgement entails informing patients about disparities at the hospital, claiming responsibility, and incorporating community ideas for redress. Redress involves a preferential admission option for Black and Hispanic patients to specialty services, especially cardiovascular services, rather than general medicine. Closure requires that community and patient stakeholders work together to ensure that a new system is in place that will continue to prioritize equity. Of note, redress could take the form of cash transfers, discounted or free care, taxes on nonprofit hospitals that exclude patients of color,[27] or race-explicit protocol changes (such as those being instituted by Brigham and Women’s Hospital that admit patients historically denied access to certain forms of medical care). In New York, for instance, the New York State Bar Association drafted the COVID-19 resolutions to ensure that emergency regulations and guidelines do not discriminate against communities of color, and even mandate that diverse patient populations be included in clinical trials.[28] Also, physicians must listen to individuals from marginalized communities to identify needs and ensure that community members take part in decision-making. The solution is not to simply build new health centers in communities of color, as this may lead to tiers of care. Rather, local communities should have a chance to impact existing hospital policy and should also use their political participation to further their healthcare interests. Distributive justice does not seek to disenfranchise groups that hold power in the system. It aims to transform the system so that those in power do not continue to obtain unfair benefits at the expense of others. The framework accounts for unjust historical oppression and current injustices in our system to provide equitable outcomes to all who access the system. In this vein, we can begin to address the flagrant disparities between communities that have always – and continue to – exist in healthcare today.[29] CONCLUSION As equality focuses on access, it currently fails to do justice. Instead of outcomes, it is time to focus on equity. A focus on equity rather than equality would better address and prevent the disparities seen in COVID-19. A distributive justice framework can gain traction in clinical decision-making guidelines and system-level reallocation of resources but will succeed only if the medical community engages in outreach, anti-racism measures, and listens to communities in need. There should be an emphasis on implementing a distributive justice framework that treats all patients equitably, accounts for historical harm, and focuses on transparency in allocation and public health decision-making. [1] APM Research Lab Staff. 2020. “The Color of Coronavirus: COVID-19 Deaths by Race and Ethnicity in the U.S.” APM Research Lab. https://www.apmresearchlab.org/covid/deaths-by-race. [2] Bharmal, N., K. P. Derose, M. Felician, and M. M. Weden. 2015. “Understanding the Upstream Social Determinants of Health.” California: RAND Corporation 1-18. https://www.rand.org/pubs/working_papers/WR1096.html. [3] Yancy, C. W. 2020. “COVID-19 and African Americans.” JAMA. 323 (19): 1891-2. https://doi.org/10.1001/jama.2020.6548; Centers for Disease Control and Prevention. 2020. “COVID-19 in Racial and Ethnic Health Disparities.” Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/racial-ethnic-disparities/index.html. [4] Braveman, P., E. Arkin, T. Orleans, D. Proctor, and A. Plough. 2017. “What is Health Equity?” Robert Wood Johnson Foundation. https://www.rwjf.org/en/library/research/2017/05/what-is-health-equity-.html. [5] Bedinger, M. 2020 Apr 22. “After Uproar, Mass. Revises Guidelines on Who Gets an ICU Bed or Ventilator Amid COVID-19 Surge.” Wbur. https://www.wbur.org/commonhealth/2020/04/20/mass-guidelines-ventilator-covid-coronavirus; Wigglesworth, A. 2020 May 11. “Institutional Racism, Inequity Fuel High Minority Death Toll from Coronavirus, L.A. Officials Say.” Los Angeles Times. https://www.latimes.com/california/story/2020-05-11/institutional-racism-inequity-high-minority-death-toll-coronavirus. [6] Executive Office of Health and Human Services Department of Public Health. 2020 Oct 20. “Crises Standards of Care Planning and Guidance for the COVID-19 Pandemic.” Commonwealth of Massachusetts. https://www.mass.gov/doc/crisis-standards-of-care-planning-guidance-for-the-covid-19-pandemic. [7] Emanuel, E. J., G. Persad, R. Upshur, et al. 2020. “Fair Allocation of Scarce Medical Resources in the Time of Covid-19. New England Journal of Medicine 382: 2049-55. https://doi.org/10.1056/NEJMsb2005114. [8] Salway, S., G. Mir, D. Turner, G. T. Ellison, L. Carter, and K. Gerrish. 2016. “Obstacles to "Race Equality" in the English National Health Service: Insights from the Healthcare Commissioning Arena.” Social Science and Medicine 152: 102-110. https://doi.org/10.1016/j.socscimed.2016.01.031. [9] Rawls, J. A Theory of Justice (Revised Edition) (Cambridge, MA: Belknap Press of Harvard University Press, 1999). [10] Zack, N. Applicative Justice: A Pragmatic Empirical Approach to Racial Injustice (New York: The Rowman & Littlefield Publishing Group, 2016). [11] Charatz-Litt, C. 1992. “A Chronicle of Racism: The Effects of the White Medical Community on Black Health.” Journal of the National Medical Association 84 (8): 717-25. http://hdl.handle.net/10822/857182. [12] Washington, H. A. Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present (New York: Doubleday, 2006). [13] d'Oliveira, A. F., S. G. Diniz, and L. B. Schraiber. 2002. “Violence Against Women in Health-care Institutions: An Emerging Problem.” Lancet. 359 (9318): 1681-5. https://doi.org/10.1016/S0140-6736(02)08592-6. [14] Hafeez, H., M. Zeshan, M. A. Tahir, N. Jahan, and S. Naveed. 2017. “Health Care Disparities Among Lesbian, Gay, Bisexual, and Transgender Youth: A Literature Review. Cureus 9 (4): e1184. https://doi.org/10.7759/cureus.1184; Drescher, J., A. Schwartz, F. Casoy, et al. 2016. “The Growing Regulation of Conversion Therapy.” Journal of Medical Regulation 102 (2): 7-12. https://doi.org/10.30770/2572-1852-102.2.7; Stroumsa, D. 2014. “The State of Transgender Health Care: Policy, Law, and Medical Frameworks.” American Journal of Public Health. 104 (3): e31-8. https://doi.org/10.2105/AJPH.2013.301789. [15] Stepanikova, I., and G. R. Oates. 2017. “Perceived Discrimination and Privilege in Health Care: The Role of Socioeconomic Status and Race.” American Journal of Preventative Medicine. 52 (1s1): S86-s94. https://doi.org/10.1016/j.amepre.2016.09.024; Swartz, K. “Health Care for the Poor: For Whom, What Care, and Whose Responsibility?” In Cancian, M., and S. Danziger (Eds.). Changing Poverty, Changing Policies (New York: Russell Sage Foundation Press, 2009), 69-74. [16] Meghani, S. H., E. Byun, and R. M. Gallagher. 2012. “Time to Take Stock: A Meta-analysis and Systematic Review of Analgesic Treatment Disparities for Pain in the United States.” Pain Medicine 13 (2): 150-74. https://doi.org/10.1111/j.1526-4637.2011.01310.x; Williams, D. R., and T. D. Rucker. 2000. “Understanding and Addressing Racial Disparities in Health Care.” Health Care Financing Review 21 (4): 75-90. https://scholar.harvard.edu/davidrwilliams/dwilliam/publications/understanding-and-addressing-racial-disparities-health. [17] Hoffman, K. M., S. Trawalter, J. R. Axt, and M. N. Oliver. 2016. “Racial Bias in Pain assessment and treatment recommendations, and false beliefs about biological Differences Between Blacks and Whites.” PNAS 113 (16): 4296-4301. https://doi.org/10.1073/pnas.1516047113. [18] Pacheco, C. M., S. M. Daley, T. Brown, M. Filipp, K. A. Greiner, and C. M. Daley. 2013. “Moving Forward: Breaking the Cycle of Mistrust Between American Indians and Researchers.” American Journal of Public Health. 103 (12): 2152-9. https://doi.org/10.2105/AJPH.2013.301480. [19] Velasco-Mondragon, E., A. Jimenez, A. G. Palladino-Davis, D. Davis, and J. A. Escamilla-Cejudo. 2016. “Hispanic Health in the USA: A Scoping Review of the Literature.” Public Health Reviews 37:31. https://doi.org/10.1186/s40985-016-0043-2. [20] Cameron, K. A., J. Song, L. M. Manheim, and D. D. Dunlop. 2010. “Gender Disparities in Health and Healthcare Use Among Older Adults.” Journal of Women’s Health (Larchmt) 19 (9): 1643-50. https://doi.org/10.1089/jwh.2009.1701. [21] Bierman, A. S. 2007. “Sex Matters: Gender Disparities in Quality and Outcomes of Care. Canadian Medical Association Journal 177 (12): 1520-1. https://doi.org/10.1503/cmaj.071541; Fowler, R. A., S. Sabur, P. Li, et al. 2007. “Sex-and Age-based Differences in the Delivery and Outcomes of Critical Care. Canadian Medical Association Journal 177 (12): 1513-9. https://doi.org/10.1503/cmaj.071112. [22] McLaughlin, D. K., and C. S. Stokes. 2002. “Income Inequality and Mortality in US Counties: Does Minority Racial Concentration Matter?” American Journal of Public Health 92 (1): 99-104. https://doi.org/.10.2105/ajph.92.1.99; Shea, S., J. Lima, A. Diez-Roux, N. W. Jorgensen, and R. L. McClelland. 2016. “Socioeconomic Status and Poor Health Outcome at 10 years of Follow-up in the Multi-ethnic Study of Atherosclerosis.” PLoS One 11 (11): e0165651. https://doi.org/10.1371/journal.pone.0165651. [23] Han, X., K. T. Call, J. K. Pintor, G. Alarcon-Espinoza, and A. B. Simon. 2015. “Reports of Insurance-based Discrimination in Health care and its Association with Access to Care.” American Journal of Public Health 105 Suppl 3 (Suppl 3): S517-25. https://doi.org/10.2105/AJPH.2015.302668. [24] Aldridge, R. W., D. Menezes, D. Lewer, et al. 2019. “Causes of Death Among Homeless People: A Population-based Cross-sectional Study of Linked Hospitalization and Mortality Data in England.” Wellcome Open Research 4:49. https://doi.org/10.12688/wellcomeopenres.15151.1. [25] Richardson, E. T., M. M. Malik, W. A. Darity Jr., et al. 2021. “Reparations for Black American Descendants of Persons Enslaved in the U.S. and their Potential Impact on SARS-CoV-2 Transmission.” Social Science and Medicine 276: 113741. https://doi.org/10.1016/j.socscimed.2021.113741. [26] Wispelwey, B., and M. Morse. 2021. “An Antiracist Agenda for Medicine.” Boston Review. http://bostonreview.net/science-nature-race/bram-wispelwey-michelle-morse-antiracist-agenda-medicine. [27] Johnson, S. F., A. Ojo, and H. J. Warraich. 2021. “Academic Health Centers’ Antiracism Strategies Must Extend to their Business Practices.” Annals of Internal Medicine 174 (2): 254-5. https://doi.org/10.7326/M20-6203; Golub, M., N. Calman, C. Ruddock, et al. 2011. “A Community Mobilizes to End Medical Apartheid.” Progress in Community Health Partnerships: Research, Education, and Action 5 (3): 317-25. https://doi.org/10.1353/cpr.2011.0041. [28] New York State Bar Association. 2020. “New York State Bar Association House of Delegates: Revised COVID-19 Resolutions.” https://nysba.org/app/uploads/2020/10/Final-Health-Law-Section-COVID-19-Resolutions_10-8-20-1-1.pdf. [29] Egede, L. E. 2006. “Race, Ethnicity, Culture, and Disparities in Health Care.” Journal of General Internal Medicine 21 (6): 667-669. https://doi.org/10.1111%2Fj.1525-1497.2006.0512.x

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