Pregnancy and Public Health Hypocrisy
Pregnancy and Public Health Hypocrisy
By Dr. Gene Tinelli, MD, PhD.
Pregnancy and Public Health Hypocrisy
In a sane society, public health policy toward pregnancy aims to maximize
those behaviors that enhance maternal and prenatal health and minimize
those behaviors that harm maternal and prenatal health. To optimally use
limited public resources, a rational policy would use available medical
research to support the most beneficial behaviors and target the riskiest
behaviors. However, we do not have a sane society. Instead, we have a
society where almost everything is corrupted by the War on Drugs,
including our health policies regarding pregnancy. Currently, these
policies put both the health of the mother and the child at risk.
Criminal Justice Professionals, not Doctors, Set Current Policy
Until recently, health care professionals set policy toward pregnancy and
prenatal development. This was certainly appropriate. Now, however, drug
warriors and prohibitionists at the state level, many with little to no
health care expertise, have taken over policy. They and only they - not
mothers, not doctors or other health professionals - dictate what is and
what is not appropriate health care.
Although the Drug War has gone on for almost a century, pregnant women
were not targeted by drug warriors until the 1980s. This was due to the
rising use of cocaine during that decade, and to the media’s response to
a 1985 study(1) that was headed by Dr. Ira Chasnoff. Dr. Chasnoff’s study
reported that mothers who use cocaine had babies with a variety of
developmental problems, such as low birth weight, small head size,
increased rates of prematurity and increased rates of abruptio placenta,
where the placenta separates from the wall of the uterus. In addition,
the study reported that there were some neuro-behavioral problems, such
as irritability, difficulty focusing, and some feeding problems. When it
was published in The New England Journal of Medicine, the study created a
media frenzy about an “epidemic” of crack babies that was going to
inundate America. (2)
Chasnoff was not alone in finding problems with pregnancies where cocaine
was used. Other research has reported problems associated with cocaine
use during pregnancy, including increased exposure to sexually
transmitted diseases, maternal weight loss, nutritional deficits and
polydrug use, premature detachment of the placenta, premature birth and
reduced/low birth weight, reductions in newborn body length and head
circumference, and rare birth defects including genito-urinary tract
malformations and extremely rare bone and neural tube abnormalities.
Limited Treatment Facilities
A sane response to these findings would be to reach out in as many ways as
possible to drug-using women, offering them prenatal care and treatment.
But America had then, and has now, limited treatment facilities. Of
these, only a small number take pregnant women and even fewer offer
residential treatment for pregnant women with children. (3)
Prohibitionists did not respond to the need for such facilities by
offering more treatment centers. Instead, a number of states modified
their civil child protection laws to mandate that doctors report pregnant
drug-using mothers to child welfare authorities. In addition, the
definition of child neglect was expanded to encompass cases in which a
newborn is “physically dependent on” or tests positive for an illegal
drug. (4)
Up until recently, no state had enacted a law that specifically
criminalizes prenatal conduct. (5) According to the Center for
Reproductive Law and Policy, prosecutors have used statutes prohibiting
abuse or neglect of children to charge women for actions that potentially
harm the fetus. (6) Some have also argued that pregnant women “delivered”
drugs to “minor” children — fetuses — through the umbilical cord. (7) In
addition, a mother’s or newborn’s positive drug test has led to charges
of assault with a deadly weapon (cocaine), contributing to the
delinquency of a minor, and possession of a controlled substance. (8) In
cases in which infants tested positive and died soon after birth, women
have been charged with homicide or feticide. (9) Some women have even
been prosecuted for drinking alcohol (10) or failing to follow a doctor’s
order to get bed rest or refrain from sexual intercourse during
pregnancy. (11)
Over 200 Women Prosecuted
Estimates based on court documents, news accounts, and data collected by
attorneys representing pregnant and parenting women indicate that at
least 200 women in more than thirty states have been arrested and
criminally charged for their alleged drug use or other actions during
pregnancy. (12) The majority of women prosecuted have been low- income
women of color, (13) despite the fact that rates of illegal drug use are
similar across race and class lines. (14) According to one analysis,
“poor Black women have been selected for punishment as a result of an
inseparable combination of their gender, race, and economic status.” (15)
Often, information indicating possible drug use has been provided to law
enforcement officials by medical personnel — possibly in violation of
constitutional and statutory guarantees of confidentiality. (16) In many
of the cases, women have been pressured into pleading guilty or accepting
plea bargains, some of which involve jail time. However, those women who
have challenged their charges have succeeded in reversing penalties
imposed on them for their prenatal conduct. In fact, every appellate
panel and most trial courts to rule on the use of existing criminal
statutes to punish women for their conduct during pregnancy have found
that these prosecutions are without legal basis, or are unconstitutional,
or both.
Currently, only some states have modified their civil child protection
laws to mandate reporting to child welfare authorities or to define child
neglect to encompass cases in which a newborn is “physically dependent
on” (17) or tests positive for (18) an illegal drug. A few of these
states also require reporting of fetal alcohol syndrome or evidence of
alcohol use, (19) while only one mandates reporting a positive drug test
prior to birth. (20) In some instances, such a report may only trigger an
evaluation of parenting ability and the provision of services; in others,
it may become the basis for temporarily removing custody of the newborn.
(21) One state specifically prohibits the use of a lone positive drug
test as the basis for a report to child welfare authorities, (22) and
several others prohibit basing criminal proceedings solely on a positive
toxicology. (23) Another state, recognizing that such reporting raises
serious issues of doctor-patient confidentiality, provides reporting to
the health department for “service coordination,” but only if the woman
consents. (24) Still another state provides that, if a woman is informed,
health care providers may test new mothers and newborns for alcohol and
other drugs, but allows a physician discretion in determining whether
abuse or neglect has occurred and reporting is required. (25)
Nevertheless, hundreds, if not thousands, of women across the country have
had their children taken away from them because of a single positive drug
test. As in the criminal context, women of color have been particularly
vulnerable to losing their children, even though white women use illegal
drugs at the same rate as women of color. A study by Dr. Chasnoff,
conducted in Pinellas County, Florida, found that black women were ten
times more likely than white women to be reported to civil authorities if
an infant was prenatally exposed to an illegal drug. (26)
Although pregnant women in other states continue to face attempts to
civilly commit them for the purpose of protecting their fetuses from
potential harm, (27) South Carolina went further. Though most criminal
charges filed against women for their behavior during pregnancy are the
result of individual prosecutors who pursue a few cases, in 1989 the city
of Charleston, South Carolina, established a joint effort among its
police department, prosecutor’s office, and the Medical University of
South Carolina (MUSC), to punish pregnant women and new mothers who
tested positive for cocaine. (28) The policy, which ultimately would set
a standard for the state, required that pregnant women seeking
obstetrical care at MUSC must submit to non-consensual drug testing. It
is important to note that MUSC is a state-funded hospital and the only
medical facility in the Charleston area to treat indigent and Medicaid
patients, a majority of whom are African-American.
If a mother went to MUSC to give birth or for prenatal care and tested
positive for cocaine, the physicians would be forced to immediately
report her to the authorities, and she would be arrested and prosecuted.
When this policy began, there was no drug treatment available in
Charleston for pregnant or parenting women. Mothers who tested positive
at MUSC were simply jailed, often moments after giving birth.
The eventual result of this policy was a 1996 South Carolina Supreme Court
decision, Whitner v. State, which allowed a woman to be criminally
prosecuted for drug use during her pregnancy. The ruling came in the case
of Cornelia Whitner, who in 1992 pleaded guilty to child neglect after
her baby was born with traces of cocaine in its system. Ms. Whitner was
sentenced to eight years in prison.
“This case is about ensuring newborns a healthy future,” said Margaret
Crawford, board chair of The Alliance for South Carolina’s Children.
“South Carolina’s Attorney General Charles Condon thinks jail will deter
substance abuse. However, treatment centers are already reporting that
far fewer women are seeking treatment and prenatal care due to this
policy - causing further harm to women, children and families. ”
“South Carolina Attorney General Condon’s War on Drugs has turned into a
war on pregnant women who need treatment,” said Daniel Abrahamson,
Director of Legal Affairs for the Lindesmith Center and one of the
attorneys representing the broad array of health organizations in this
case before the High Court. “Sadly, Attorney General Condon has ignored
the countless pleas of physicians and alcohol and drug treatment
providers to treat, not prosecute, pregnant women suffering from chemical
dependence. Now, the women and children most in need of help are
suffering horribly as a result of Mr. Condon’s misguided and Draconian
policies.”
Uniting Against Punitive Policies
Public health organizations, including the American Medical Association
and the American Public Health Association, oppose the prosecution of
pregnant women who use drugs. In addition, the Lindesmith Center’s Office
of Legal Affairs, in conjunction with nearly two dozen medical and public
health organizations, has submitted an amicus (”Friend of the Court”)
brief to the U.S. Supreme Court in support of plaintiffs in Ferguson v.
The City of Charleston. In addition, 10 women, including nine women of
color, arrested for testing positive, challenged the policy on various
constitutional and statutory grounds and are now asking the United States
Supreme Court to overturn the Fourth Circuit’s decision to uphold the
policy.
All these groups recognize that South Carolina’s current approach will
only keep the women who most need prenatal care from seeking it for fear
of being imprisoned and prosecuted and losing their children. In
addition, this policy harms the mothers by keeping them from going to a
doctor for drug treatment. The American Academy of Pediatrics has stated,
“punitive measures taken toward pregnant women, such as criminal
prosecution and incarceration, have no proven benefits for infant health.”
(29) In fact, studies indicate that drug-using women who receive prenatal
care have healthier children. (30)
Studying the Cocaine Studies
Before we fill overcrowded prisons with pregnant women and mothers, a look
at the research that followed Chasnoff’s initial study is warranted.
A meta-analysis of most 1980s studies on prenatal cocaine use found
serious methodological flaws, such as a lack of control groups, failure
to distinguish cocaine use from the use of other drugs, failure to study
the ensuing health of the newborn, and the use of case reports alone.
(31)Presented with children randomly labeled “prenatally cocaine-exposed”
and “normal,” childcare professionals ranked the performance of the
“prenatally cocaine-exposed” children below that of “normal,” despite the
actual performance. (32) But when medical personnel did not know
beforehand which infants were exposed to cocaine, they could not detect
cocaine withdrawal syndrome. (33) Well-controlled studies found no
increase in Sudden Infant Death Syndrome. In addition, no causal link
could be established between cocaine use and poor fetal development, even
though cocaine, like many drugs and medicines, enters the bloodstream of
the developing fetus and has the potential to affect development. Among
the general population, there has been no detectable increase in birth
defects that may be associated with cocaine use during pregnancy. (34)
The problem with making a direct causal link comes from the fact that the
problems suffered by children exposed to cocaine can stem from many
factors. For example, many are born prematurely to mothers who had little
or no prenatal care and are returned to a neglectful environment. The
lack of quality prenatal care is associated with undesirable effects
often attributed to cocaine exposure: prematurity, low birth weight and
fetal or infant death. (35) But cocaine itself has not been proven to be
any more damaging than any other drug used by pregnant women, and
children with Fetal Alcohol Syndrome are much more likely than crack or
cocaine babies to suffer from mental retardation that is permanent.
(36-40)
Research paid for by the National Institute on Drug Abuse and the Albert
Einstein Medical Center in Philadelphia states that, “Although numerous
animal experiments and some human data show potent effects of cocaine on
the central nervous system, we were unable to detect any difference in
performance, verbal or full scale IP [intelligence] scores between
cocaine-exposed and control children at age 4 years.” (41)
Alcohol, Tobacco, Do the Most Harm
Abuse of alcohol, more than any other recreational drug, causes the
greatest number of and most severe birth defects: 9.1/1000 or
approximately 1/100 live births are diagnosed with Fetal Alcohol Syndrome
or alcohol-related neuro-developmental disorder, and a larger number
experience “fetal alcohol effects.” (42)
Tobacco use is also strongly associated with low birth weight, prematurity
and growth retardation, Sudden Infant Death Syndrome, low cognitive
achievement, behavioral problems, and, in some cases, mental retardation.
Also, urine samples collected from newborn infants of mothers who smoked
during pregnancy detected breakdown products of nitrosaminoketone, a
known carcinogen and a chemical found only in tobacco. (43-47)
Ill Effects of Poverty on Children Can Last a Lifetime
Nevertheless, the risks of alcohol and tobacco are not what caught the
media’s attention. Crack babies caught its attention. Chasnoff painted a
dark picture behind society’s morbid embrace of crack babies. “The image
of the crack baby really moved out there,” he said. “Politicians really
picked it up. It worked into the trend of writing about the underclass.
It’s sexy, it’s interesting, it sells newspapers and it perpetuates the
us-versus-them idea.” In fact, said Chasnoff, “Poverty is the worst thing
that can happen to a child.” (48)
Indeed, factors strongly associated with poor fetal development include
the stressors and health risks associated with poverty: lead exposure,
psychiatric problems such as major depression and depressive symptoms
associated with life stress, lack of social support, low weight gain, and
polydrug use. (49-52)
These factors also affect children long after they are born, making it
difficult for them to succeed in school and increasing the risk that they
will develop poor relationships with drugs or develop other
self-destructive or abusive behaviors. The 6-year-old boy who lived in a
crack house where he stole a gun and shot a classmate is a tragic case in
point.
What do we make of all the research to date? Most of the evidence points
to the lack of quality prenatal care and the use of alcohol and tobacco
as primary factors in poor fetal development among pregnant cocaine
users. Of all birth defects, 10-15% are due to environmental agents (53),
10-15% are hereditary (54), 1- 5% are from chemical (including drug)
exposure (55,56) and the rest are due to unknown factors. (57)
Poor prenatal care often results in premature births, low birth weight,
and other fetal development problems, while provision of quality prenatal
care to heavy cocaine users (with or without drug treatment) has been
shown to significantly improve fetal health and development and reduce
substance use. (58)
So what should we do now? If we are truly concerned about maternal and
fetal health and we want to follow the War on Drugs mentality and the
South Carolina court decision, then we should also begin to criminally
prosecute pregnant women who use alcohol or smoke nicotine cigarettes. If
this sounds insane, at least it is not hypocritical. What is insane is
that not only are we punishing pregnant women and mothers who are
chemically dependent, we are reducing drug treatment for women, thus
locking poor women in a cycle of poverty, worsening the most noxious
factor for their fetuses, poverty. (59,60) Criminalizing substance abuse
during pregnancy discourages substance- using or abusing women from
seeking prenatal care, drug treatment, and other social services, and
sometimes leads to unnecessary abortions. (61, 62)
Punishing substance users and abusers during their pregnancies threatens
the health of the mothers and children, and seriously compromises women’s
rights to privacy. It also ignores the serious shortage of drug treatment
programs for pregnant and parenting women and fails to address the
overall lack of access to reproductive health care services. The author
of a recent study on the effectiveness of mandatory treatment concluded,
“the children of drug-using mothers may be most effectively served by the
development of available, efficacious, and welcoming services for women
and families.” (63)
We have created a system that severely punishes those who use certain
illicit substances that cause mild to moderate harm, virtually ignores
the use of substances that cause much greater harm, and encourages the
creation of a poorer prenatal environment for those most at risk. This is
not an optimal public health policy.
We need to stop this insanity. Our children and our future are at grave
risk. We need to end the Drug War now.
.
REFERENCES:
1. Chasnoff IJ, Bruns, WJ, Schnoll WJ, Burns KA, Cocaine use in pregnancy,
New England Journal of Medicine 313: 666-669 (1985)
2. Greider, Katharine. “Crackpot Ideas.” Mother Jones. July/Aug,, pp 53-56 (1995)
3. Humphries D.,et al, Mothers and Children, drugs and crack: Reacton to
maternal drug dependence, Women and Criminal Justice 199w;1:81-99
4. Wendy Chavkin et al., Efforts to Reduce Perinatal Mortality, HIV, and
Drug Addiction: Survey of the States, 50 JAMWA 164: 164-65 (1995)
5. The Center for Reproductive Law & Policy, Punishing Women for their
Behavior During Pregnancy: An Approach That Undermines Women’s Health and
Children’s Interests. New York: Center for Reproductive Law & Policy, 1996
6. See, e.g., Commonwealth v. Welch, 864 S.W.2d 280 (Ky. 1993) (affirming
reversal of child abuse conviction,finding that to construe the child
abuse statute to apply to a woman’s prenatal conduct would make the
statute impermissibly vague and violate legislative intent); Sherriff v
Encoe, 885 P.2d 596, 598 (Nev. 1994) (child abuse statute inapplicable to
woman who used methamphetamines during pregnancy; to hold otherwise would
“open the floodgates to prosecution of pregnant women who ingest such
things as alcohol, nicotine, and a range of miscellaneous, otherwise
legal, toxins”); Commonwealth v Kemp, 75 Westmoreland L.J. 5 (Pa. Ct.
C.P. 1992), aff’d, 643 A.2d 705 (Pa. Super. Ct. 1994) (affirming dismissal
of charges of recklessly endangering another person or endangering the
welfare of a child against a pregnant woman who allegedly ingested
cocaine while pregnant; finding that neither “child” nor “person” include
an unborn “fetus”).
7. See, e.g., Johnson v. State, 602 So. 2d 1288 (Fla. 1992) (reversing a
woman’s convictions for “delivering drugs to a minor” via the umbilical
cord); People v Hardy, 469 N.W.2d 50 (Mich. Ct. App.) (statute
prohibiting delivery of cocaine to children was not intended to apply to
pregnant drug users), leave to appeal denied, 471 N.W.2d 619 (Mich. 1991).
8. See, e.g., State v Inzar, Nos. 90CRS6960, 90CRS6961 (N.C. Super. Ct.
Robeson Cty. Apr. 9, 1991), appeal dismissed, No. 9116SC778 (N.C. Ct.
App. Aug. 30, 1991) (dismissing charges against a woman who allegedly
used “Crack” during her pregnancy under statutes prohibiting assault with
a deadly weapon and delivery of a controlled substance because a fetus is
not a person within the meaning of the statutes); State v. Alexander, No.
CF-92-2047, Transcript of Decision (Okla. Dist. Ct. Tulsa Cty. Aug. 31,
1992) (dismissing charges of unlawful possession of a controlled
substance and unlawful delivery of a controlled substance to a minor
brought against a woman who ingested illegal drugs while pregnant,
finding that the presence of drugs in defendant’s system does not
constitute possession and transfer of the drug through the umbilical cord
is not “volitional”).
9. See People v. Jones, No. 93-5, Reporter’s Transcript (Cal. Juv. Ct.
Siskiyou Cty. July 28, 1993) (dismissing homicide charges against woman
whose newborn died allegedly as a result of prenatal drug use, finding
that legislative history did not support application of murder statute to
fetus’s death); Jaurigue v Justice Court, No. 18988, Reporter’s Transcript
(Cal. Super. Ct. San Benito Cty Aug. 21, 1992) (dismissing fetal homicide
charges against woman who suffered stillbirth allegedly as a result of
her prenatal drug use, finding that neither legislative history nor the
statute’s language suggested that a mother could be prosecuted for murder
for her fetus’s death), writ denied, (Cal. Ct. App. 1992); State v
Barnett, No. 02DO4-9308-CF-00611 (Ind. Super. Ct. Allen Cty. Feb. 11,
1994) (notice accepting state’s motion to withdraw child abuse charges
and dismissing homicide charges brought against woman whose infant tested
positive for cocaine and (lied shortly after its premature birth).
10. See State v. Pfannenstiel, No. 1-90-8CR (Wyo. Cty. Ct. Albany Cty.
Jan. 5, 1990) (pregnant woman charged with child abuse for drinking
alcohol); Joan Little, Woman Jailed After Baby Is Born Intoxicated, St.
Louis Post-Dispatch, Nov. 26, 1991, at 3A (woman was charged with
second-degree assault and child endangerment after her son was allegedly
born with signs of fetal alcohol syndrome).
11. See People v. Stewart, No. M508197, Reporter’s Transcript, at 4 (Cal.
Mun. Ct. San Diego Cty. Feb. 26, 1987) (pregnant woman charged under a
criminal child support statute for failing to follow doctor’s advice to
get bed rest, to abstain from sexual intercourse, and to seek prompt
medical attention when she experienced bleeding).
12. Lynn M. Paltrow, Criminal Prosecutions Against Pregnant Women:
National Update and Overview (1992): The Center for Reproductive Law and
Policy, In the Courts: Decisions Involving Penalties Imposed Against
Women for Their Conduct During Pregnancy (Feb. 1996).
13. Gina Kolata, Bias Seen Against Pregnant Addicts, N.Y Times, July 20,
1990, at A13.
14. As a survey by the Southern Regional Project on Infant Mortality concluded:
Newspaper reports in the 1980s sensationalized the use of crack cocaine
and created a new picture of the typical female addict: young, poor,
black, urban, on welfare, the mother of many children, and addicted to
crack. In interviewing nearly 200 women for this study, a very
different picture of the typical chemically dependent woman emerges. She
is most likely white, divorced or never married, age 31, a high school
graduate, on public assistance, the mother of two or three children,
and addicted to alcohol and one other drug. It is clear from the women
we interviewed that substance abuse among women is not a problem
confined to those who are poor, black, or urban, but crosses racial,
class, economic and geographic boundaries. — Shelly Gehshan, Southern
Regional Project on Infant Mortality, A Step Toward Recovery 1 (1993).
15. Dorothy E. Roberts, Punishing Drug Addicts Who Have Babies: Women of
Color, Equality, And the Right of Privacy, 104 Harv. L. Rev. 1419, 1424 (1991).
16. One federal law provides that, except under limited circumstances,
“[r]ecords of the identity, diagnosis, prognosis, or treatment of any
patient … maintained in connection with the performance of any program
or activity relating to substance abuse education, prevention, training,
treatment, rehabilitation, or research, which is conducted, regulated, or
directly or indirectly assisted by any department or agency of the United
States shall … be confidential …” 42 U.S.C. 290dd-2 (1995). See also
Legal Action Center, Confidentiality: A Guide to the Federal Laws and
Regulations (1991); Legal Action Center, Dispelling the Myth: Legal Issues
of Treatment Programs Serving Pregnant Addicts (1994).
17. See, e.g, Fla. Stat. ch. 415.503 (1995); Mass. Ann. Laws ch. 119, 51A
(Law. Co- op. 1995); Okla. Stat. tit. 63, 1-550.3(A) (1995); Utah Code
Ann. 62A-4a-404 (1995).
18. See, eg, Ill. Comp. Stat. Ann. ch. 325, para. 5/3 (1995); Ind. Code
31-6-4-3.1 (a) (1) (B) (1995); Iowa Code 232.77(2) (1995); Minn. Star.
626.5562(2) (1995). A survey of state maternal/child health and drug
treatment agency directors found that other states may, as a matter of
policy, require reporting to child protective authorities of pregnant
women or infants with positive toxicology results, and/or define a
positive result as evidence of child neglect or abuse. Wendy Chavkin et
al., Efforts to Reduce Perinatal Mortality, HIV, and Drug Addiction:
Survey of the States, 50 JAMWA 164: 164-65 (1995).
19. See, eg., Ind. Code 31-6-4-3.1 (a) (1) (1995); Utah Code Ann.
62A-4a-404 (1995).
20. See Minn. Stat. 626.5662(2) (1995).
21. See Bonnie Baird Wilford & Jacqueline Morgan, Intergovernmental Health
Policy Project, Families at Risk: Analysis of State Initiatives to Aid
Drug-Exposed Infants and Their Families 34- 47 (1993).
22. See Cal. Penal Code 11165.13 (Deering 1995).
23. See, eg., Iowa Code 232.77(2) (1995); Ky. Rev. Stat. Ann. 214.160(5) (Michie 1995).
24. See Kan. Stat. Ann. 65-1,163 (1994).
25. See Ky. Rev. Stat. Ann 214.160 (Michie 1995).
26. Ira J. Chasnoff et al., The Prevalence of Illicit-Drug or Alcohol Use
During Pregnancy and Discrepancies in Mandatory Reporting in Pinellas
County, Florida, 322 New Eng. L Med. 1202: 1204 (1990).
27. Wendy Chavkin, Mandatory Treatment for Drug Use During Pregnancy, JAMA
266: 1556 (1991)
28. Philip H. Jos, et al., The Charleston Policy on Cocaine Use During
Pregnancy: A Cautionary Tale, 23 J.L. Med. & Ethics 120 (1995). See also
Plaintiffs’ Memorandum in Support of their Partial Cross-Motion for
Summary Judgment and in Opposition to Defendants’ Motion for Summary
Judgment, Ferguson v City of Charleston, No. 2:93-2624-2 (D.S.C. filed Oct. 5, 1993).
29. American Academy of Pediatrics, Committee on Substance Abuse,
Drug-Exposed Infants, Pediatrics 86: 639-641 (1990).
30. Andrew Racine et al., The Association Between Prenatal Care and Birth
Weight Among Women Exposed to Cocaine in New York City, JAMA 270: 1581 (1993).
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