Vol. 199 September 15, 2018 Nature vs. Nurture . . . an update

September 15, 2018

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“The closer scientists get to understanding the impact of individual genes,
the smaller that impact seems to be.”
– Evan Horowitz, Boston Globe, 9/11/18,C1

The discussion about what influences our upbringing the most, the environment (“nurture”) or our genes (“nature”), has been going on for decades. Sets of twins, particularly comparison of fraternal twins (two genetically different people born at the same time) and identical twins (two genetically identical people born at the same time), have been the subjects of much research trying to tease out the answer to which has the most influence. Why is one twin smarter than the other? Why does one love football and the other the violin? Why do they have the same walk, the same tastes in clothing, and the same gestures, but one has no sense of humor and the other is the class clown?

Despite the revelations in the recent movie, “Three Identical Strangers, many ethical and scientifically-rigorous twin studies have added a great deal of insight into the nature vs. nurture conundrum, and the discussion continues in the absence of consensus. The completion of the human genome project in 2003 was heralded as an historic step in finally settling this question. The hope was that, at last, we would be able to correlate a specific gene, or maybe just two or three genes, with a human characteristic, a human condition, and even a human disease.

In a recent study of the human genome, researchers found 1,271 different genes that seemed to improve educational outcomes. However, the cumulative effect of these educationally significant genes explained only about 11-13% of real world, actual educational attainment. (1) In a separate study by other researchers, the role of inherited genes in height, obesity, and education seemed to have much less influence than previously estimated . . . and a drastically much smaller role than suggested by twin studies. The influence of genes was highest for height (55%) and lowest for years of schooling (17%). The gene effect on cholesterol level was about 31% and the gene effect on determining your body mass index (BMI) was 29%.(2) There is no single “fat gene.”

One group of researchers suggested that perhaps the genes of the parents that are NOT passed to their offspring are important. What if the parents’ genes made them “slightly more attentive to kids and more willing to sacrifice their own happiness for the benefit of the kids”? Perhaps that could result in those children receiving a richer education. They suggested calling this influence of the parents’ genes on the children’s environment “genetic nurture”. (Thanks a lot for mudding the waters some more!)

There is no doubt that the genes we inherit from our parents influence our health and longevity. The adage, “To enjoy a long life, pick your parents right”, was dramatically brought home to me one day in the hospital cafeteria many years ago. A dozen of us physicians were discussing over lunch the pros and cons of a new study that daily baby aspirin could prevent some heart attacks, and different opinions about this brand new data were being voiced. A cardiologist espousing the strong genetic influence on heart disease interrupted our lively discussion with the question, “How many of you can call your father on the phone right now?” Only three could.

So the discussion of nature vs. nurture continues despite our growing knowledge of the human genome, but we have nothing to worry about as long as we have picked our parents right.

References
1. Nature Genetics, July 2018, as reported in Boston Globe, September 11, 2018
2. Ibid

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Vol. 198 September 1, 2018 A RX for Play

September 1, 2018

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“Unfortunately both the value and the meaning of play are poorly understood in our hurried society.”
The Hurried Child, 1981

“Play for children buffers toxic stress, builds parental relationships,
and improves executive functioning.”
-The Power of Play,  2018

This month the American Academy of Pediatrics (AAP) recommended that all clinicians write a “prescription for play” for all children at each well child visit. The AAP first touted the benefits of play in 2007.  What’s new about this 2018 report, “The Power of Play”,  is 1) the compilation of 139 scientific studies supporting the benefits of childhood play, 2) the specific recommendation that clinicians give a “prescription to play” to the parents of children at every well child visit in the first two years of life, and 3) the inclusion of a list of specific parental actions and behaviors to help parents actually “fill the prescription”.

What is not new is the knowledge that play is very important for children’s cognitive (academic), social, language, and emotional development. In 1981 (almost 40 years ago!) David Elkind, Ph.D. in The Hurried Child, Growing Up Too Fast Too Soon (1) catalogued how play was one of the antidotes to the toxic stresses on our children at that time. His 1981 list of the sources of that stress on children sound still familiar to us in 2018:

  • early pressure to gain academic skills
  • early intervention to help learning in the early years (concept of “readiness” was disputed)
  •  media presentations of adult clothing and behavior as models for children
  •  changes in the traditional family model (dual-career couples, increased single parent families, single parent dating, increased divorce rate )
  • summer camps (and after school programs) becoming competitive training sites for specific skills
  • Cutting of recess, physical education (“gym period”), art, music and drama from school curriculum
  • increasing modes of passive play (no real-time human interaction; media play is passive).

“Play has been transformed into work. Perhaps the best evidence of the extent to which our children are hurried is the lack of opportunities for genuine unstructured play available to them. Genuine play involves human interaction, mostly child to child but also child to adult. Play is nature’s way of dealing with stress for children as well as adults.” – All written in 1981 by Dr. Elkind.

What are some of the specific ingredients listed by the AAP to fill the 2018 “prescription for play”? (2)

Newborn- 6 months

  • talk to your infant, mimic his or her sounds
  • make various faces at the infant so he or she can mimic you
  • let him or her put safe objects in their mouth

7-12 months

  • put infant in different positions so that he or she can view the world from different angles (“tummy time”)
  • use a mirror to show different faces to your infant
  • Peek a boo is a BIGGIE !
  • give him or her more toys to drop (teaches that actions have effects)
  • let infant safely crawl and explore freely

1-3 years

  • give paper, crayons, etc. to encourage scribbling
  • play make-believe with the child
  • read regularly to the child
  • sing and play rhythms to the child

4-6 years

  • allow child to move between make-believe and reality (pretend making biscuits and then tolerate the “spreading of flour all over the kitchen table”; if you can’t tolerate the mess, maybe change this play into ‘actions have effects’?)
  • tell stories and ask your child what she or he remembers about it
  • encourage a variety of safe physical movements (climbing, somersaults, etc.)

“Play with parents and peers is fundamentally important for developing a suite of 21st century skills in a competitive world that requires collaboration and innovation.”(3)

Dr. Elkind won me over completely when he explained why young children are entranced by dinosaurs; something that has perplexed me for years.
“Dinosaurs provide children with a symbolic and safe way of dealing with the giants in their world, namely adults.” (pg. 196)

Refernces:
1. Also “The Power of Play, Learning What Comes Naturally”, 2007, David Elkind, Ph.D
2. from www.pathways.org
3. Michael Yogman, MD, lead author of The Power of Play, AAP, 2018


Vol. 196 July 15, 2018 Consequences of Separating Children From Their Parents

July 15, 2018

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“Home Security and Family Values –
Is that an oxymoron?”

 

 

Hundreds of children in immigrant families wishing to enter the U.S. from Mexico have been separated from their parents by U.S. policy. The administration has not released the actual number, but the number of unaccompanied children held in U.S. detention centers jumped up by 20% from 8,000 to a little over 10,000 children after implementation of the “zero tolerance policy”.

In 2016 the Secretary of Home Security John Kelly began to talk about such a separation policy as a deterrent to families seeking entrance either illegally or even if legally seeking asylum on our Mexican border. In response to that proposed policy a coalition of pediatricians, psychiatrists, and social scientists published “Separating Families at the Border – Consequences for Children’s Health and Well-Being” in the New England Journal of Medicine (NEJM) June 15, 2017 and founded the Child Advisory Network   to advocate against the “zero tolerance policy”.

Now, nobody really believes that separating children from their parents, unless the children are being maltreated or abused, is good for the children. Our own legal system has a very high threshold for removing children from their parents. And maybe, administration policy makers were probably counting on this universal belief (in all languages, of course) to make their action an effective deterrent to immigration.

The NEJM article summarized the many studies that document the deleterious effects of separating children from parents; all based on the over-activation of the stress response system of the child’s brain and specific hormone producing organs. Proper balance of that system is necessary for normal physical growth, proper and appropriate regulation of emotions, and maintenance of good health. In fact, such stress and anxiety is apparently cumulative and can ever result in an earlier-than-expected death!

The high costs of separating and detaining the children, especially the costs of finding and supporting foster care for U.S.-citizen children of parents who have already been deported, was cited in this review. In many states the foster care system for American children is overwhelmed and an occasional source of horror stories of maltreatment by foster parents.

Perhaps you’re thinking that these are moot points after the announcement of the reversal of the “zero tolerance policy”, but NPR reported on July 12 that in a response to a court order deadline only 57 of the 100 under the age of 5 years had been reunited with their parents (49 other were not). NPR also reported that the total number of separated children is 3000. The next court order deadline in about two weeks calls for 2000 families to be reunited. Both court orders stem from suits brought by the ACLU against the U.S. Department of Home Security.

Reason cited by the Home Security Department for some “failures to reunite” include criminal charges against a parent(s), parent not available since already deported, and a lack of match between the child’s DNA and the parents’ DNA. Wow, talk about opening up another Pandora’s box for the U.S. border staff, Home Security Department, and our judicial system, already creaking under “zero tolerance policy” consequences. Resolution of those instances of DNA “mismatch” will become another nightmare for already stressed-out families and children who were seeking sanctuary from the stress of living in their own country in the first place; a uniquely modern negative consequence of political policy once again trumping science.


Vol. 193 May 15, 2018 Antibiotics are Beneficial: A Reminder

May 15, 2018

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A disease outbreak anywhere is a risk everywhere.”
-Dr. Tom Frieden, Director U.S. CDC

 

We read a lot about the dangers of using too many antibiotics. The popularity of “organic foods” is due in part to their claim to be from “antibiotic-free” animals and plants. Concern about the increasing antibiotic resistance of germs due to antibiotic overuse is real as is frequently described in scientific journals as well as the general press. Why, then, would the New England Journal of Medicine publish an article describing the benefits of random, mass distribution of an oral antibiotic to nearly 100,000 children who had no symptoms or diagnosis! Maybe because that effort reduced the death rate of children aged 1-5 months by 25%!

As you’ll remember in my last blog,  I was impressed by Bill Gate’s knowledge of the medical literature because during his presentation he cited this antibiotic clinical trial which had been published that very same week. Well, full disclosure, he knew about the study because his foundation funded it! This study is the kind of innovative medical study related to global health that the Bill & Melinda Gates Foundation supports. I think it is worthwhile to review the details of the study, if just to remind us that antibiotics are good, that medical science advances on the shoulders of previous work, and that sometimes simple answers, like putting iodine into salt or fluoride into water, can prevent a whole lot of disease.

Previous studies in sub-Saharan Africa showed that blindness caused by trachoma, an infectious disease, could be reduced markedly through the mass distribution of an oral antibiotic, azithromycin. Other studies suggested that the same antibiotic could prevent other infectious deaths like malaria, infectious diarrhea, and pneumonia. It is known that azithromycin affects the transmission of infectious disease, so that treatment of one person might have benefits on others in the same community. The data in two of these studies of trachoma prevention in Ethiopia suggested that mass distribution of azithromycin “might” reduce childhood deaths. Since death (after the neonatal period) is a relatively rare event, even in these settings, the trial had to be conducted in a large population. Hence the need for a large grant to carry it out.

A single dose of oral azithromycin was given to 97,047 children aged from 1 month to 5 years in three African countries during a twice-yearly census. 93,191 children in different communities of the same countries were given a placebo. Over the two-year study the “treated” children received 4 oral doses of azithromycin, each about 6 months apart. Children were identified by the name of the head of the household and GPS coordinates of their location for subsequent censuses. Approval for the study was obtained from 9 ethics committees in 6 countries (3 in the US, 1 in the UK, and 2 in Africa).

The average reduction of annual death rates of children receiving a single dose of the antibiotic every 6 months was 13.5% . Children aged 1 month to 5 months receiving the antibiotic had a mortality rate reduction of 25%. At the conclusion of the trial all the children in the communities of Niger, which has one of the highest child mortality rates in the world and a mortality rate reduction of 18% for all ages in this study, were offered treatment with azithromycin.

This study is a beautiful example of the testing of a simple hypothesis, generated by the results of previous work, using innovative methods, requiring a large population for validity,  and implemented by a multi-national team of medical scientists with a large grant from a private foundation that resulted in clear benefits for better global health.

I, for one, am happy to trumpet some good news about antibiotics and this example of “medical research for all” at its best.

Reference:
Azithromycin to Reduce Childhood Mortality in Sub-Saharan Africa, NEJM 378;17, April 26, 2018

 

 

 

 


Vol. 184 January 1, 2018 To the Dark Side of EMR

January 2, 2018

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“… a fundamental barrier [to successful EMR implementation] that has not received due attention is the disconnect between health IT developers and users.” (1)

I was a solid advocate of electronic medical records (EMRs). Now I am a skeptic.

Primary care physicians are currently paying a big price, in terms of both time and money for the elusive promises of EMRs. As a quality reviewer of hospital medical records, an experienced office-based pediatrician, and a medical director working with an excellent medical staff, I believed that EMRs would really help us to improve the delivery of quality care. I happily jumped on the “evidenced-based medicine” bandwagon and believed that EMR data would help us. After three years of working with two different EMRs in a primary care practice, I have now “gone over to the dark side.” I have slowly realized that EMR “data” does not equate with “useful information” for primary care providers.

I have never belonged to the AMA, for me a “too-conservative” medical organization that I considered primarily a bastion of physician resistance to positive change. A definite sign of my conversion from EMR advocate to EMR skeptic is my agreement with a recent AMA statement by the Executive Vice-President and CEO of the AMA:

“Harnessing the power of health data is an enormous and important challenge, and one that should be led by physicians. The solution must be useful for physicians, and it must allow us to spend more time with our patients and deliver better care.”

Of course, there are all kinds of physicians in all kinds of practice settings, and “one size fits all” does not seem to be working for primary care EMR.

Use of EMR in our office is slowing us down, is decreasing the time we spend with patients and their families, is increasing the chances of provider communication gaps or slips, and has increased the frequency of “work arounds” for the delivery of quality care. “Work arounds” is a traditional quality improvement term that describes the methods that workers in any setting develop to skirt the system problems that hinder them from doing their best job. The presence of “work arounds” is one of the cardinal signs of a dysfunctional system. “Work arounds” often serve as the first target of any effort to analyze quality performance.

So why have I “gone over to the dark side”.
EMR has become way too complicated – There are too many screens requiring too many clicks, too many switches from scrolling wheel to cursor pointer, too many inconsistent navigation routes using tiny icons or miniscule, barely-noticed arrows. To see the basic clinical information I need before entering an exam room with our EMR ,  I need to review 2 or 3 computer screens, make 4 or 5 clicks with the mouse, and both scroll and/or drag with a cursor for the information that I use to be able to read quickly on two facing pages in the paper record.

In the quest for the versatility that is necessary to serve thousands of different physicians in hundreds of different settings, the award-winning EMR we use is awkward and time-consuming for us in primary care. It is driven by the need for reimbursement documentation in specialized (expensive) care settings. Workaround? – I read the paper encounter forms completed by my patients and my staff before I start the patient encounter. It is faster, sometimes more reliable (because there is no absent entry), and is more focussed on today’s encounter than those multiple computer screens which are trying so hard not to “miss” any data, no matter how irrelevant to today’s tasks.

EMRs have too many ways to record information from multiple sources – Valuable patient encounter information from nurses, social workers, and medical assistants can be hard to find in the mass of data. It usually requires purposeful clicking on tiny icons or miniscule arrows (again) on multiple screens. Boiler plate checklists tend to make every patient’s chart read the same. Workaround? – I know how to type. The actual, and helpful, differentiation between my patient encounters is almost always found in my “free text” note. But, not all providers in my office know how to or like to type. When I have to track down another provider to find out the information I need, there are now two of us not seeing patients.

Safeguarding patient privacy in an EMR is more complex. Sensitive results or comments are sometomes consciously avoided in the EMR or are deeply buried underneath a number of more clicks, scrolls, and screens. Workaround? – See above about physically tracking down another provider or more likely, that valuable information is not available in the medical record at the time that you need it. The route(s) of clinical information coming in from outside our office like lab results, X-ray readings, and specialists’ consultations are multiple, varied , and often obscure in our EMR. The vigilance required to NOT miss such reports is INCREASED, not decreased, in EMR. Workaround? – I ask the nurse, medical assistant, or front desk staff to track down the information by telephone or fax just like “in the old days.”

Correction of recorded errors like dates, or names, or even diagnosis can be tedious in the EMR.  A simple single line cross-out and rewrite did it in the paper record. The EMR requires multiple cursor clicks and several screens to do the same. The timing of the clicks, or more nearly correct, the sequence of clicks can be important for success. Workaround? – Sometimes I will delete a whole section of generic computer-speak in an EMR section because I can’t easily change one or two lines  (2 screen colors, at least 3 clicks, and a small check box way down at the bottom of the screen are often involvedin making an EMR correction).

The EMR has reduced the delegation of accepted clinical tasks. Renewing or initially writing common prescriptions ordered by me is not permitted to be done by the nurse practitioners or nurses on our EMR. Instead of a verbal request to a trusted professional, my time and attention is required on at least three computer screens, up to half a dozen clicks, and my entry of my unique password to do that. True, the prescription is sent electronically to the correct (usually) pharmacy, but the nurse or office staff used to do that quite quickly via fax, and it took less of my time. Work around? – Perhaps patient safety clearly trumps convenience here, so I have not spent much time thinking about a work around for this, but it does continue to disrupt a previously smooth work flow.

My computer keyboard is in one room, and I use three other rooms as exam rooms, To complete a note, look up a growth chart,  check results, answer an unexpected question from a parent, or order a medication I often do a far amount of time-consuming walking back and forth between rooms. Workaround? – Why not just get a tablet?, you ask. Well for some mysterious reasons neither of our EMRs support that functionality in our office. After several frustration attempts we know that the tablet works beautifully at IT headquarters, but  not in our office.

What benefits most from EMR in the office setting?
Reimbursement and research.
Clinically the only useful information to know about an ear infection is whether it is “left” or “right”. Our EMR requires a half dozen more adjectives before the diagnosis is “recorded”. It has no effect on reimbursement now (what we are paid for that office visit) ,as far as I know, and I can only hope that such minutiae won’t affect reimbursement in the future.
There are also half a dozen adjectives required to record the diagnosis of “nose bleed”, and I can only imagine that somewhere out there exists a researcher just waiting to write the definitive article on “recurrent, non-injury, chronic, episodic nosebleed” which happen more often on the “right” than the “left”.

Both these R&R benefits of EMRs are quite removed from improving actual clinical care. That is another reason for my move to “the dark side”, and this current blog that deviates from my founding pledge to NOT publish personal rants.

If you chose to dismiss this particular rant as “just another doctor complaining about his poor lot in life”, you should read a more scholarly short treatise on the same subject: “Accelerating Innovation in Health IT”,  New England Journal O f Medicine, 375:9, September 1, 2016, 815-7 (1).

 


Vol. 176 September 1, 2017 Sexual Anatomy, Gender Identity, and Orientation

September 1, 2017

“Sexual orientation means ‘who you go to bed with’.
Gender identification means ‘who you go to bed as’.”

 -Norman Spack, MD, Pediatric Endocrinologist,
Chief of Gender Management Service, Childrens Medical Center, Boston

Discussion about transgender people is back on the front page since President Trump tweeted his wish, and then ordered the Defense Department, to ban the enlisting of transgender persons and to ban transgender soldiers from continuing to serve in our armed forces. The ACLU notes that there are currently about 8000 transgender U.S. soldiers.

The appearance of your genitals at birth, if anatomically correct, tells everyone in the delivery room what you are; “sexual anatomy”. “It’s a boy, or it’s a girl” are the first three words an infant “hears”. In the first decade of life we begin to think of ourself as a boy or as a girl; “gender identification”. In our second decade, as we approach and go through puberty, we begin to realize that we are attracted to boys or girls, or both; “sexual orientation“. These three terms are often confused and intermixed in our discussion. which can make rational, unemotional consideration of new policy, laws, and societal changes very difficult.

When do children begin to identify themselves as a boy or a girl? (1)
Studies show that it can be as early as third grade. (7-9 yo.) By then, most children associate themselves with one or the other sexes and understand that it is permanent; “girls grow up to be women and boys grow up to be men.”

What about “cross-gender” play which is very common at young ages?
By age 2 years all children know sex stereotypes (“women are associated with lipstick”,”boys don’t wear pink tutus”) ). It is remarkable that transgender children understand and accept the same stereotypes as their peers. Studies show that “cross-gender” play (“boys wearing dresses”, “girls excelling as tom-boys”) is very common in pre-school children, is normal, and is temporary in most children. 

Where are all these transgender children?
Everywhere. Since 2007 when Childrens Hospital started its Gender Management Service as part of their Sexual Disorders and Dysfunctions Clinic, they have treated about 200 transgender children, 95% of whom came from within 150 miles of Boston.

What causes transgender identification, nature or nurture?
Both probably. No one really knows. One twin study revealed that of 23
identical same-sex twin pairs, one twin in 9 of the pairs was identified as transgender. No twin in the 21 fraternal same-sex twin pairs were transgender. The suspected genetic basis of this is completely unknown. In 1895 an article in Scientific American expressed concern that riding bicycles threatened women’s health. In 1948 only 32% of adults believed women should wear slacks in public. (1)

What is the “treatment”? (2)
The Dutch taught us that the best time to change a person’s gender is before the onset of puberty (10-12 yo. in girls and 12-14 yo. in boys).

Dr. Spack and others thought that was a pretty young age for the patients (and their families) to make such a life-changing and permanent decision. Therefore, the U.S. standard of care is to delay puberty to buy some time.

At age 12 years after extensive psychometric testing of gender identification by a multi-specialty team, treatment with appropriate sex hormones that block progression of puberty of the “birth gender” is started. This puberty “blockage” is reversible and is continued for years.

At age 16 after the repeat of extensive psychometric testing of gender identification, the decision to move on to irreversible body-changing sex hormone treatment is considered. . If the decision is to NOT GO on with the change, that hormonal treatment is stopped and normal puberty appropriate to the “birth gender” occurs. If the decision is to proceed with a change, treatment with different sex hormones appropriate to the “affirmed gender” is started. The goal is to achieve the physical appearance of the “affirmed gender”. This treatment is usually very successful (“girls develop normal sized breast and have normal heights”).

After age 18 years and years of hormonal therapy, surgical reconstruction of genitalia can be considered. (Male-to-female surgery is much easier and can be successful enough to “fool a gynecologist”.)

Are there any barriers to treatment?
Yes. Very expensive (about $1000 a month for several years of hormonal treatment), misunderstanding about the reversibility of early treatment, and continued classification in the DSM-V (Diagnostic and Statistical Manual of Mental Disorders) of “Gender Identification Disorder” as one of a dozen “Sexual Disorders and Dysfunctions” (which exempts the treatment from most insurance plans). Note: Homosexuality was removed in 1973 from the DSM-III as a mental health disorder as it is NOT amenable to psychiatric therapy. Neither is transgender identity. There is no evidence that people can be talked out of, or therapized away from, their transgender identity.

What if the transgender child is not treated?
In the scheme of things the number of transgender children is limited. But, of the 100 patients seen by the Gender Management Service by 2012, 20% had performed self-mutilation and 10% had attempted suicide. Other studies have documented a much higher-than-average suicide rate in persons with gender identity issues.

So, gender identity can trump anatomy,
and sexual orientation can be completely unrelated to either.

This can get a bit confusing, but have no fear, it may even get harder to keep track of the players without a scorecard.
N
ew research is focussing on “nonbinary” children. These children  see themselves as in the middle of the spectrum and neither male nor female.

Refrences:
1. Scientific American, “Everybody has a stake in the new science of sex and gender”, September 2017
2. TED talk, Norman Spack, MD

 


Vol. 174 July 15, 2017 Dumb Government and Smart Guns

July 15, 2017

Gun violence injuries and deaths in the U.S. is a public health crisis.”   – AMA

Gun violence kills roughly 30,000 Americans each year, about as many people as car accidents. The federal government has been restricted in gathering and analyzing gun violence data since 1996 when a CDC study linked the presence of a gun in the house with an increased risk of homicide. The NRA responded with a successful lobbying effort to pass the restriction that the CDC may not use any money allocated to it for “activities that advocate or promote gun control.” It stripped $2.6 million from the CDC budget for firearm injury research. After the Newton School shooting in 2012 Obama issued an Executive Order (one of his relatively few) commanding the CDC to renew their research into gun violence and requested Congress to allocate $10 million for that. Congress never did, and research never resumed.

The NRA has also successfully limited the federal government’s ability to trace guns involved in crimes, “crime gun-tracing”. Some states have developed data bases of crime-gun tracing to identify sources of and reduce illegal gun trafficking. Massachusetts established crime-gun tracing in 2014, but has not published a meaningful analysis of the data which might lead to some action. The 2017 Massachusetts legislature has inserted into their budget proposal a request that the governor produce such an analytical report.

Doctors, particularly pediatricians, are keenly aware of the dangers of having guns in the  house. 90% of accidental gun injuries to children happen in a home with a gun. The American Academy of Pediatrics has explicitly recommended that pediatricians routinely ask gun-safety questions during health and wellness visits. But in 2011, Florida passed a “Privacy of Firearm Owners” law levying $10,000 fines and loss of medical license to any pediatrician that inquired about the presence of firearms in the house. The law was upheld by a Florida state court in 2014 based on “2nd Amendment infringement”. The law was just struck down this year by a Federal Appeals Court that ruled that “there was no evidence that the law infringed on the Second Amendment.” By the way, the Affordable Care Act (aka Obamacare… remember Obamacare?) specifically prohibits physicians from keeping records on gun ownership. an assurance to any paranoid, conspiracy-theory-believing gun owner that docs were now not in league with big government. (see “Docs vs. Glocks”, Scientific American, August 2015. pg. 10)

The solutions to gun violence deaths are mostly focussed on mass shootings including either/or/and:
1. eliminate mental illness,
2. eliminate terrorists,
3. eliminate humane treatment (put water boarding video of terrorists on You Tube),
4. eliminate Muslims,
5. eliminate political correctness  (utter the words “Radical Islam Terrorists” which Obama refused to say (sic.) (1)

The truth is that “mass shootings”, though a big part of media attention, are a small part of the  30,000 annual gun death toll. 62% of  gun deaths are due to suicides committed with guns that DO NOT BELONG to the victim (particularly among the young). Criminals steal about 250,000 guns per year. 1.7 million children live in homes with unlocked, loaded firearms. (2)

The NRA consistently raises the spectrum of the need for the home owner to have a means of self-defense, but a gun is 22 times more likely to be used in a criminal assault, an accidental death or injury, a suicide attempt, or a homicide than it is for self-defense. 61% of gun homicides are by people who know each other.(3)

Making a gun as smart as an iPhone is one way to prevent to a large portion of gun injuries and deaths. Previous attempts to develop such a smart gun have been fraught with problems, have been actively boycotted by gun manufacturers, and have been opposed by gun advocates and the NRA. Kai Kloepfer, a 15-year-old high school student in Colorado, in response to the Aurora theater shooting near his home, started a science project in 2015  to design a pistol that will only fire when a sensor in the grip recognizes the fingerprint of the owner. His project won awards, and Kloepfer delayed his entrance to MIT for a year when he got a grant to develop a working model of such a smart gun. By 2017 he successfully built and demonstrated a smart pistol. The gun takes 1 second to unlock, its battery lasts a year, a light indicates the battery status, and a second light indicates it is unlocked and ready to fire. Neither a child nor a thief can fire the gun. The owner may store up to 10 “authorized user” fingerprints (like for a spouse or domestic partner ). The smart gun is smart enough to NOT  connect with the internet, so it can not be hacked or hijacked.

The NRA response has been predictable: “NRA does not oppose new technological developments in firearms; however, we are opposed to government mandates that require the use of expensive, unreliable features, such as grips that would read your fingerprints before the gun will fire.”(2)

Hey, at least the NRA didn’t evoke the 2nd Amendment argument. That is progress!  Technology can deal with “expensive” and “unreliable”. Technology is far faster to upgrade than the Constitution.

References:
1. “A Nation Captive To The Gun”, Garry Wills, Boston Globe 6/15/2016
2. “The Future of Everything”, Wall Street Journal, 2017, Geoffrey Fowler
3. Journal of Trauma and Acute Care Surgery, 1998

 

 


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