Brains “Hijacked”

By Drugs ? or by a Fictional Medical Model and Multibillion Dollar Criminal Treatment Scam ?

by Clark Miller

July 24, 2018

     Protecting the brand of addiction as a medical condition and its payoffs required that the story change from a genetic cause – never supported by evidence – to current messaging of diseased brains “hijacked” by drugs. But the facts and research have never changed: the behavior of compulsive substance use concocted as a medical condition is falsified by all relevant lines of evidence.

In a previous post, some of those lines of evidence were examined: whether decades and $billions in medical model funding and research  have led to evidence of gains in identified physical cause, in development of effective treatments, of slowing or reversing of trends in population substance use problems.

To Review:

Historically, when medical funding and research campaigns target public health problems that are actual medical problems, gains are expected and realized. Conversely, when conditions that are evidenced as entirely non-medical, like common chronic pain, are inappropriately medicalized and inappropriately medically treated, outcomes ranging from no long-term benefit, to harm, to lethal crisis are predicted and realized, as with the opioid crisis.

As summarized in a previous post –         A runaway national substance use problem is not just worsening, but is a recognized crisis and epidemic that:

The lethal false promise of medical treatments for substance use is invalidated by the evidence and lack of expected outcomes over decades of wasted research funding. But its falsification does not depend entirely on clinical trial research, is also debunked by common sense reasoning.

If there were effective medical treatments, there would be supporting bodies of replicated randomized controlled trials (RCT) – the type of scientific study needed to support with confidence a cause-and-effect relationship for a treatment-and-benefit –  generated over past decades and $billions allocated to research. Then proponents of the chronic disease model could point to and cite these bodies of research, rather than continuing to promise cures “just around the corner”. For credible medical conditions with medical treatments that do provide benefit – for example diabetes, cancer and AIDS – there are such bodies of research, congruent with real, established benefit for the conditions.

Where is the evidence for benefit to public health?

If there are such effective medical treatments, the result of decades and $billions of public funds diverted to medical research, then why is there no evidence for gains in treatment success, instead clear evidence of worsening epidemics?

Individuals and families with loved ones trapped in life-threatening substance use problems are generally desperate for help, for change:

  • Are the effective medical treatments simply too expensive for those in need to obtain? – no evidence for that
  • Are insurance providers refusing to reimburse for the effective medications? – no evidence for that either
  • Are there any barriers to distribution of the effective medications, despite overwhelming need by Americans trapped and dying in opioid and substance use epidemics? – no indication of that either

 

So far, the evidence is strikingly inconsistent with the longstanding, near-universally accepted construction of the compulsive behavior of problem substance use as a medical condition of some type, a “Chronic Disease of The Brain”, just as the unfortunate outcomes of medicating common chronic pain as a medical condition form one line of evidence falsifying that fiction.

Let’s take a more thorough look at the relevant evidence and considerations:

 

1. Does the phenomenon of “addiction” fit with our conception of “disease”
2. Is there an identified disease (biological) etiology, pathology?
3. Is the epidemiology of substance use congruent with a chronic disease or medical condition course?
4. Are medical model explanations logically coherent?
5. Are predictions for causes, patterns and course of relapse based on the “hijacked brain” model supported by the evidence?
6. Are there alternative conceptualizations supported by evidence that are incongruent with a medical condition model?
7. Are the course, epidemiology, and population patterns of the most pervasive and costly substance use problem – Food Use Disorder – congruent with a disease, or “hijacked brain” model?

1. What is the cultural understanding of problem substance use?

The ways that a culture uses language to describe something does not provide its scientific understanding. Yet it is hard to ignore the remarkable discrepancies in how we talk about substance use versus medical industry portrayal of the same thing. Through persistent and pervasive exposure, problem use of alcohol has become culturally accepted as the disease condition of “alcoholism” despite lack of establishment of evidence and required features to constitute a disease: disease agent or pathology, characteristic disease course and progression (see below), medical interventions with evidence of effectiveness.

 

But alcohol use is a notable exception as an “ism”.

 

We don’t talk about someone dying of “tobaccoism” because we apparently don’t think of problem tobacco use – the public health costs of which eclipse those of alcohol and opioids combined – as a chronic disease at all, let alone a chronic disease of the brain. That’s most likely because, as we’ll see below, it simply can’t be –

 

the large majority of smokers (individuals with that “chronic brain disease”):

1. Quit and don’t return to smoking.

2. Quit on their own, without treatment and certainly without medical treatments.

3. Quit by deciding to, and then stopping a behavior on their own accord.

4. Quit then regain health and functioning without signs of an ongoing or former brain disease.

That’s not the picture of a chronic relapsing brain disease

Nor do we talk about “foodism” as a chronic disease of the brain, despite the fact that compulsive use of food, leading to obesity and related problems, is understood biologically as and meets criteria for a substance use disorder no less than any other “addiction”.

 

Problem compulsive food use, driven by stress and other mood disturbance, among other public health problems is fueling national childhood and adult obesity and looming diabetes epidemics that will eclipse in illness and public health costs all other substance use problems combined.

But problem food use, in neurobiology, behavior, and diagnostic criteria just like any other substance use problem, or “addiction”, is nowhere to be found in the medical industry’s psychiatric manual of diagnoses, nor in the medical industry’s version of America’s substance use problem.

There are reasons for that, as we’ll see – as a problem epidemic in children, highly variable across time and cultures, and involving a substance used by all humans every day of their lives, “emotional eating” is a compulsive substance use problem clearly inconsistent and with and falsifying the fiction of compulsive substance use as genetic, as a disease, as a “hijacked brain”.

Obese children are using food compulsively, driven by stress, the same way adults are driven to. They do not have a chronic brain disease.

Culturally we do not talk about smokers or stress-eating, obese children in terms of disease, or brain disease, or medical conditions because it makes no sense to us. No sense because substance abuse as a medical condition is nonsensical, an absurd fiction. A made-up story generating billions in profits and millions of victims provided sham, ineffective medical “treatments”.

It’s not just general cultural understanding that is incongruent with the disease model, but within the medical field as well. As a phenomenon, “addiction” is an objectively observable repetitive behavior that over time results in psychological, physical, and other effects. That’s entirely congruent with reliable, consistent reports of problem substance users – that they are compelled by some type of inner distress or need to engage in the use to gain some desired effect from the behavior.

Other harmful compulsive behaviors driven by inner distress and with physical effects are not constructed as diseases, instead in the medical field’s diagnostic manual of mental disorders as symptoms of internal disturbed emotional/mental states like, for example:

1. Head-banging in children or adults
2. Compulsive skin washing in Obsessive-Compulsive Disorder
3. Compulsive over-eating in depressive disorders, eating disorders
4. Compulsive hair-pulling, skin picking

What chemical substance, by the way, hijacks and creates a disease state in the brains of individuals trapped by the behavior of compulsive gambling?

2. Is there an identified disease pathology  = biological cause or “etiology” ?

No.

Consider conditions of illness that are actual diseases or medical conditions: heart disease, hypertension, diabetes, kidney disease, thyroid and other endocrine disorders, cancer. In each case, a specific abnormality at the cellular or biochemical level can be identified as causing the condition, established by:

- Presence of the illness when the abnormality is present
- Absence of the illness when the abnormality has never been present
- Gains in health when biomedical interventions target and physiologically change the abnormality

For substance use problems, there are no such identified abnormalities or medical treatments to impact them, after decades of diversion of public resources to those efforts.

Instead – the brain changes typically  and naturally resulting from regular substance use are in fact adaptive, protective responses evolved to maintain stability, “homeostasis”. As regular use of mood-altering substance exposes the brain to increased levels of activity of mood-altering neurotransmitters, the brain adaptively decreases its own production of those neurotransmitters. When substance use decreases or stops, the brain adjusts again, increasing natural production and over time restoring normal brain physiology.
During the period of regaining normal brain physiology – when neither abused mood-altering substances nor the brain’s integral capacity to moderate pain, fear, worry, other distress are operating to moderate distress – substance users are at risk of turning back to substances to escape distress.

Just as when someone rehabilitating long-unused muscles that have atrophied – changed physiologically due to disuse through injury, illness or other cause – and experiencing the associated pain, worry, and frustration of lack of functioning while regaining normal use is at risk of turning back to inactivity or external sources of compensation to avoid that distress, a potentially self-defeating response. Like becoming dependent on external aids (like driving instead of walking, prolonged use of motorized or assisted movement substituted for the work and discomfort of increasing physical activity) that become barriers to regaining functioning.

That process is not merely analogous to substance use effects, instead describes the same biological phenomenon: loss of physiological functioning due to disuse of that function followed by risk of self-defeating choices in response to the discomfort and distress of the work (physical and mental) of regaining normal functioning. Medical imaging of the atrophied muscles would picture marked differences compared to normal muscle tissue, just as the captivating brain images picture differences in brain tissue after prolonged substance use and adaptive brain response to that use.

Neither type of loss of physiological functioning through disuse – of natural brain neurotransmitters due to substance use or of muscle and coordination physiological competence through incapacitation – strikes us as a disease. Because neither is. And in neither case does the recovery process of distress and frustration in rehabilitation with risk of regression or “relapse” to dependence on external compensation represent a disease, let alone a chronic disease of the brain.

If individuals facing the work of rehabilitating from atrophied muscles were convinced by the medical and rehab industries of the absurd fiction that their condition was a chronic, relapsing medical disease, that would predict lower effort and investment in the hard work of rehab, lower motivation, likely much higher risk of remaining dependent on external supports or compensations that would otherwise be unnecessary – wheelchairs and other equipment forming a barrier to recovery, avoidance of normal activity. Similarly, it’s established that a key factor predicting return to problem substance use is belief in the fictional disease model.

What about the “hijacked brain”? – A modern medical truth that Goes Without Saying

Dr. Nora Volkow, Director of the National Institute on Drug Abuse (NIDA) at the National Institutes of Health where "Dr. Volkow’s work has been instrumental in demonstrating that drug addiction is a disease of the human brain."

3. “Epidemiology” – the distribution and determinants of health conditions

Examining the incidence and course, the patterns,  of substance use problems in a culture is a powerful way to evaluate the disease model, because occurrence of the conditions in the population must be either consistent or inconsistent with characteristics of a chronic disease of the brain, with a medical condition.

Fortunately, there are large bodies of data and evidence that allow evaluation of incidence (occurrence), progression, and outcomes for large numbers of Americans over past decades for substance use problems including alcohol, opioids, tobacco, and cannabis, in the form of national epidemiological studies with numbers of individuals studied in the tens of thousands for each survey. Those include multiple NESARC studies – National Epidemiological Studies of Alcohol and Related Conditions – and related, similar studies over past decades.

Because of the importance of these studies in allowing evaluation of the very nature of substance abuse problems, their treatment, and associated public policy:

 

1) Heterodox, advocacy, and research and academic voices have mined the studies and data toward gaining understanding of the nature of “addiction” and its treatment in the context of a longstanding and increasingly worsening national substance use epidemic.

 

2) In contrast, medical, media, and establishment academic institutions – with the cultural capital to construct “knowledge” as needed – have ignored the longstanding surveys.

The surveys and how results are inconsistent with any medical or disease model of compulsive substance use are thoroughly discussed and analyzed here, and here for example.

More formal academic research and statistical analyses of the data are the focus of work by Dr. Gene Heyman, a research psychologist at Harvard University, for example here, here and here. Heyman, for example, applies statistical and analytical methods to demonstrate that consistent findings of these surveys – that the large majority of individuals with substance use disorders (the purported chronic brain disease of “addiction”) quit and don’t return to problem substance use – represent persistence of avoidance of problem use, rather than individuals repeatedly stopping and relapsing again.

IT’S IMPORTANT TO UNDERSTAND SOME FEATURES OF THESE SURVEYS

They start with identification of a study population – relatively large groups of individuals representing a cross-section of the national population.

Individuals included were identified as initially meeting criteria for substance use dependence – until recently the term for the most severe substance use problem. So, survey individuals were identified as initially having an “addiction”- under the medical or disease model the chronic, relapsing brain disease.

Surveys have tracked over years individuals identified with alcohol, cannabis, tobacco, and opioid dependence.

Those individuals, identified as having the medical industry’s model of substance use as a chronic brain disease, were tracked over the ensuing years and decades and surveyed regularly regarding their use of mood-altering substances, along with whether they had been in treatment for substance use.

As described above for epidemiology of compulsive tobacco use, results of these large surveys for alcohol use, opioid use, cocaine, and cannabis use, consistently established that the large majority of individuals with the most severe form of compulsive substance use (diagnosed with the “disease”) quit without treatment of any type and do not return to problem use.

These results, available for years, are sufficient to render the disease model and “hijacked brain” suggestion unsupported and invalidated.

Think about it. As established by multiple, large surveys, available for many years:

  • Individuals with the “chronic relapsing brain disease” stop because they decide to
  • After years of use
  • Most often with no treatment at all, essentially never involving medical treatment of any kind
  • With fully “hijacked” brains according to the medical model

Think a bit more about it – the patterns cannot be spontaneous remission of a disease state

Because these individuals identified with the “disease” are ending the disease consciously and intentionally as a choice to change a behavior. That’s not remission or anything that can be consistent with the model of a diseased or “hijacked” brain.

4. Is the diseased brain model logically coherent?

Under the “hijacked brain” medical disease model of compulsive substance use, regular, extended, heavy use (but not apparently moderate or infrequent regular use, as many individuals engaging in these levels of use would not meet criteria for a substance use problem) of substances over time biologically degrades brain functioning related to impulse control, associated vulnerability to urges and cravings that are part of the disease state, so that the user no longer has the ability to stop using. Urges, or impulses, are not effectively moderated by the diseased brain, so reflexively, unavoidably lead to the use of a substance – the individual has lost control. Addiction, therefore, is a medical condition, caused by altered neurophysiology.

There are numerous features of the fabricated model that simply do not hold up, not just to scientific evidence, epidemiology, other measures, but additionally to internal coherence and logic, to consistency, expected outcomes based on predictions of the “model”, to critical examination. To a critical discourse.

The logic of causality

Under current cultural and intellectual contexts, we do not believe that causality works backwards in time. For example, we do not believe that the microvascular or macrovascular damage (to kidneys, eyes, other tissues) over an extended period of blood sugar dysregulation in diabetes could have caused the initial abnormalities in insulin and blood sugar regulation that led to the condition of diabetes, simply because causes don’t work backwards in time.

The “hijacked brain” story holds that the chronic brain disease of “addiction” is caused by extended regular use of a substance, causing over time changes in the brain that then impair functions like impulse control and emotional regulation, increasing impulsivity and causing abuse of substances.

But that leaves out something critical – and falsifying

What was driving in the first place the extended regular use of an addictive substance – not moderately but in great enough quantity that over time caused the brain changes severe enough to produce a disease state? What drove the behavior that places health, relationships, economic security, and employment at risk and that is expensive and risks criminal justice involvement, before there was any disease agent or state causing it? And given that some explanatory factors were already driving compulsive, excessive substance use, how can a disease state be established to have taken over to cause continuing use? After other factors were sufficient to drive problem use initially?

The logic just doesn’t work out.

Actually, we know exactly what caused it – a topic of multiple upcoming posts – because extensive evidence and models of human development and psychology tell us that problem substance use starts and is driven by attempts to alter mood (hence “mood-altering substance”) or inner distress of some type: the behavior is a symptom, the underlying distress the cause. There is no brain or other disease state involved.

Coherence with neurobiology, epidemiology and behavior

Brain images, or scans, have become the “research” it seems, for the age of Xbox and PlayStation, the vibrant patterns of colors captivating and exciting viewers. But research has not linked changes in those images to changes in neurophysiology that would explain control of behavior.

Those images have largely formed the basis for the fictional brain disease model that we have seen already has been invalidated by longstanding evidence, independently by multiple lines of evidence including epidemiology and lack of an identified biological disease mechanism.

But there are multiple lines of evidence that are wholly inconsistent with the proposal that these images represent a disease state, or any state that predicts, explains, or causes compulsive substance use.

 – There is no evidence for a general effect of use-induced neurobiological changes driving return to problem substance use
          – Heyman GM. Addiction and Choice: Theory and New Data. Frontiers in Psychiatry. 2013;4:31

 – PET scans of dopamine release are the same for recreational and dependent cocaine users, an inconsistency – do recreational drug users have the brain disease? Do individuals using alcohol in moderation ?

 – Many methamphetamine-dependent users stop and stay stopped, with or without treatment, while experiencing protracted withdrawal with low mood

 – Many meth-dependent users don’t experience protracted withdrawal or anhedonia, and do relapse.

 – Brain scans of problem methamphetamine users change back to normal over time after use has stopped, but as noted by Steven Slate at The Clean Slate, there have been no medical treatments of any type to address a disease state over those periods.

-  In neurobiology, barring pre-existing abnormality, a brain is a brain is a brain – basic neurobiological processes are the same, including in the way mood-altering substances have their effects e.g. alcohol affects everyone about the same as do other substances.

How to possibly explain, then, for example, that of all brains exposed to moderate to long-term use of opioids, only 8% to 12 % of brains develop the disease state? It’s not like a contagious, airborne disease – the exposure is direct and bathes the brain’s neurobiology no matter who or where you are.

The disease model has no explanation for this discrepancy, genetic or other.

Most glaringly, the brains of all humans on the planet are exposed to the biochemical changes in the brain each time food is ingested and tweaks neurotransmitters, the pleasure-reward center, and other areas of brain neurophysiology in the same ways that other mood-altering substances with potential for “addiction” do. Yet, despite rising rates of compulsive, harmful food use especially in the U.S., less than a majority of all individuals develop the brain disease of addiction, and this varies widely across historical time periods, environments, demographic groups, and cultures. A brain is a brain, is a brain.

Coherence with other maladaptive (problem-causing) behaviors driven by inner states

Consider chronic pain

We know that centralized chronic pain is a condition in which patients have the inner experience (involving complex, integrated perception of sensations, emotional states, and thoughts) of “pain” as real as any pain. And we know that it is psychogenic – generated or associated with those inner states, not by physical conditions like damaged tissue, inflammation, the physical impact of a tumor on nerve endings.

We also know from those patients’ consistent reports – which we have no reason to doubt, do not doubt, and have experienced ourselves – that compulsive pain behaviors, like wincing, grimacing, moaning, changing body position, restricting movement, “favoring” body areas, etc., are compelled by those inner states that include beliefs, or thoughts about the sensations

We do not and never will construct their behavior, reports, and symptoms as “a chronic disease of the brain” because we know that is not supported by the evidence – at all. It makes no sense. It is clear that they are engaging in self-defeating behaviors – including limiting their activity and compulsive, harmful use of substances – as driven compulsively by distressing, discomforting inner states we call “pain”. It is clear that the self-defeating behaviors, including misuse of substances, are behavioral symptoms compelled by distressing, unwanted inner states.

Illegitimate medicalization, against all lines of established evidence, of common chronic pain, an entirely non-medical condition, created the opioid crisis with associated deaths and illness, a predictable and avoidable outcome.

Illegitimate medicalization, against all lines of established evidence, of compulsive use of mood-altering substances, or “addiction”, an entirely non-medical condition, has diverted decades of support and $billions away from psychotherapies established as effective, for the false promise of a magic pill, and perpetuated and worsened a national substance use epidemic with associated deaths and illness, a predictable and avoidable outcome.

5. Are predictions for causes, patterns and course of relapse based on the “hijacked brain” model supported by the evidence?

In the field of substance use treatment, the term “relapse” is used most often to mean a return to compulsive use of a substance leading to problems in life or functioning, after a period of lack of problem use, following a period of problem use typically associated with diagnosis of a substance use disorder.

Relapse is common and may occur within days of stopping use, or years into a period of no problem use. The patterns of relapse for individuals and populations have been studied and described, including by for example researcher Alan Marlatt of the University of Washington.

Predictions of pattern of relapse based on the hijacked brain model would follow from the proposed direct effects of the diseased brain on generation of cravings for the drug, impaired regulation of impulses like cravings, and degraded cognitive functioning and emotional regulation. Because these triggers all tie directly to “hijacked” neurophysiology, the diseased brain model predicts a course for frequency of relapse after quitting correlated with severity of the disease state, consistently lessening over time in a process of biological healing:

Initially high through first weeks of withdrawal, with frequent intense urges

Reducing over time as a function of gradual neurophysiological disease state healing but remaining apparently at a level of pathology to account for the disease as a “chronic relapsing disease”

Factors independent of the disease state are secondary

Impulses, or “cravings”, or urges, that the individual cannot control are triggers for return to use

But it turns out based on decades of research, that the course, triggers for, and pattern of relapse is nothing like that.

I.  Part of that research establishes that two primary predictors of relapse are not urges or cravings at all, but instead:

Lack of skills for coping with stress

Belief in the disease model of addiction

II. Additional study of the natural history and correlates of relapse provide evidence inconsistent with predictions of a diseased brain model:

In this survey relapsers to alcohol, tobacco, other substances reported on their experience of antecedents, or “triggers” to use again

“Inner states”, not urges or cravings per say, were reported by 58%. Of those: negative emotions accounted for 37%; urges for 7%

Interpersonal stressors were reported by 42%.  Of those: 15% reported conflict; 24% reported social pressure

There were no reports of a sense of “loss of control” or of a brain with baseline urges or compulsions untied to inner or environmental stressors

In summary, results of these surveys highlighted the importance of mood states versus impulses with lack of control, and of situational, environmental stressors especially social stressors.

III. A large survey of individuals who had stopped compulsive use of tobacco, by smoking, provides further evidence inconsistent with the diseased brain fiction. This was a four-country survey of relapsers to smoking from a general, non-clinical population in Australia, Canada, United Kingdom and United States.

There were no effects of urges or severity of smoking (HSI) on relapse risk over days 1 – 30 after stopping “during which nicotine dependence would be most likely to influence quitting success”

Self-efficacy (= self-confidence) had a strong effect (statistically significant), through duration of study, day 1 to 3 years

There was a negative correlation, statistically significant, between self-efficacy and frequency of urges – the stronger a participant’s beliefs about being empowered and competent in making changes, the fewer urges were experienced

In summary, results of this survey disconfirmed urges or impulsivity as a factor, even over the first 30 days after stopping, when the diseased or “hijacked” brain would be most vulnerable to those factors, instead confirmed deficiency in self-confidence, or belief in one’s ability to stop smoking as a strong factor, consistent with other findings that establish belief in having a chronic, relapsing disease as a factor predicting relapse.

IV. Additional evidence from the study of patterns and factors driving relapse includes:

Relapsers report situational (coming from their lives, not their brains), negative inner states driving those urges and lapses

Intensity of urges does not decline evenly over time, instead is modal (peaks unpredictably), increasing and peaking in episodes, associated with a lapse or relapse

The evidence we have on course and patterns of relapse are inconsistent with the unsupported fiction of compulsive substance use as a medical condition, disease state, or “hijacked brain”.

6. Are there alternative conceptualizations supported by evidence that are incongruent with a medical condition model?

Yes, supported by everything we know about problem substance use and described and discussed in multiple upcoming posts:

It is overtly and observably a compulsive behavior.

Affected patients reliably and consistently report moderation of inner distress and needs as driving the symptom of compulsive use – hence “mood-altering substance”

Drivers for compulsive use include inner distress, psychological associations, distorted beliefs

The behaviors are highly correlated with Adverse Childhood Experiences (ACE), adult trauma, inner and external stressors

Of numerous therapies with strong evidence for effectiveness, all are psychosocial, therapy interventions, none are medical.

In summary, the hijacked brain story of compulsive substance use is invalidated by available evidence and analysis, the alternative developmental, psychosocial model is strongly supported.

7. Are the course, epidemiology, and population patterns of the most pervasive and costly substance use problem – Food Use Disorder – congruent with a disease, or “hijacked brain” model?

As outlined above in this post, those features are incongruent with any medical, disease, or brain disease model of problem compulsive substance use, explored and evaluated further in an upcoming post.

OUR BRAINS HAVE BEEN HIJACKED

but not by drugs - instead by a useful fiction that falls apart on critical examination, a fabrication that protects and fuels billions in wasted resources, including public resources, to enrich and empower entrusted systems that do harm

HIJACKED

in childhood by “adverse experiences” that no child should be exposed to, experiences all too common and which families could be helped to prevent using public funding and resources that have been wasted on fictional medical approaches to substance use problems

HIJACKED

by the false promises of cures just around the corner but that never come, trapping those suffering in problem substance use in false hope

HIJACKED

by the false and ignorant assurances of appointed experts and authorities lacking understanding and ability to critically evaluate information crucial to the identification and provision of valid and effective health care, lacking the ability to know what’s true

HIJACKED

by stress, by worries and fears of illness, loss, destitution in a sick economy and sick systems that reward and enrich the unscrupulous few and punish the rest

AND HIJACKED

by mass media and healthcare system advice full of lies and false promises of help, expensive help, that turns out to be no help at all, fake treatment –

Hijacked by A criminal scam and public health threat,
Never subjected to -