Cuban Psychiatry --- The Perversion of Medicine

Author: 
Miguel A. Faria, Jr., MD
Article Type: 
Editor's Corner
Issue: 
September/October 2000
Volume Number: 
5
Issue Number: 
5

The Politics of Psychiatry in Revolutionary Cuba by Charles J. Brown and Armando M. Lago,(1) the subject of this issue's Editor's Corner, only came to my attention because its documentation value was mentioned in two special issues of The New American magazine chronicling the Elián González saga,(2,3) the story of the six-year-old Cuban boy who had been a point of contention between the Cuban-American community in Miami who wanted him to stay in American freedom, on the one hand, and the U.S. and the communist Cuban governments, on the other, which wanted him returned and succeeded in sending him to infernal tyranny.

The book was mentioned, of course, because government doctors were used by the State in the political tug of war. AAPS wrote to Attorney General Janet Reno about possible ethical violations in regards to American physicians making long distance armchair diagnoses and making recommendations to the U.S. government and the media rather than for the benefit of the patient --- without ever having seen the child. Moreover, AAPS filed a complaint regarding the legality of Cuban doctors who had come to the U.S. to "de-program" Elián and thus, were practicing medicine without a license in the U.S. One of them, Dr. Caridad Ponce de Leon, on April 27, 2000 was caught by U.S. Customs officials at Washington's Dulles International Airport with psychoactive drugs Miltown (meprobamate) and phenobarbital, which she was attempting to smuggle into the U.S. en route to minister to Elián at his temporary residence in Maryland at the Wye River Plantation. All of these physicians seem to be using their positions in a learned profession and placing them at the disposal of the State. As we shall see in this essay, subordination of medicine to the State is dangerous.

The Politics of Psychiatry graphically documents that the totalitarian government of Cuba has used (and continues to use) psychiatry for political purposes --- in this case, political repression, the crushing of dissent, and establishing conformity within the political structure and populace of the island prison which communist Cuba has sadly become.

The authors have carefully investigated the cases and personal stories of 27 Cuban dissidents who were charged with political crimes (non-violent opposition to the regime in one form or another), arrested and interrogated by the State Security apparatus, and then treated horribly as psychiatric cases confined among the criminally insane. In Cuba, psychiatrists must cooperate with the State Security apparatus or face reprisals, arrest, and punishment by the communist government; thus, there is no opposition to speak of within the medical profession to the regime.

Psychiatry in Cuba is misused for political purposes and used as a political tool against the political enemies of the communist regime. To bring down the number of those incarcerated classified as political prisoners in Cuba, dissidents are classified as either common criminals or psychiatric patients. Cuban criminal theory holds that capitalism is the cause of aberrant and most criminal behavior. The only reason that a socialist country like Cuba would have crime, therefore, is because of residual capitalism and recalcitrant non-socialist elements. Criminals must therefore be re-educated, conditioned, and re-programmed. Incarceration is not intended for punishment but for rehabilitation. Anyone with "recidivist political behavior" has to be pathological, afflicted with a form of mental illness that must be cured by the State.

As per Soviet psychiatry and as enunciated by Premier Nikita Khrushchev in 1959: "Can there be diseases, nervous diseases among certain people in the communist society? Evidently there can be. If that is so, then there also will be offenses which are characteristic of people with abnormal minds. To those who might start calling for opposition to communism on this 'basis,' we say that now, too, there are people who fight against communismbut clearly the mental state of such people is not normal."(4)

In other words, it is impossible for people in a socialist society to have an anticommunist morality. Criminality is impossible in a socialist society and those opposed to the socialist order are not really criminals requiring punishment but madmen who require treatment and rehabilitation in psychiatric facilities. And so, José Abrantes, then Minister of the Interior, speaking to Cuban psychologists in March 1987 admitted that his Ministry "has the most diverse, universal, and decisive application of psychology to law enforcement."(5)

Among the 27 cases cited in this book, a clear pattern emerged. After arrest, they were usually taken to Villa Marista State Central Security Headquarters for harsh interrogation, then to the Havana Psychiatric Hospital (also known by its old name, Mazorra) where they underwent unspeakable terror. They were not taken to the meticulously polished floors and corridors of the Paredes ward, where foreign dignitaries are taken to be shown the marvelous advances in psychiatry in the Cuban health care system, but to the horrible Salas Carbó-Serviá and Castellanos wards which are under the control of State Security.

In those horrible wards, it became obvious that the "patients" were not confined for the treatment of mental illness, but rather to terrorize them. Some were placed there for days, weeks, or months among the criminally insane to coerce them to submit and conform to the dictates of the State Security apparatus. Others were forced to ingest large amounts of psychotropic drugs (e.g., Thorazine and other phenothiazines), or undergo even more barbaric "treatment" with electroconvulsive therapy (ECT), usually without anesthesia or muscle relaxants, under the supervision of a sadistic orderly named Heriberto Mederos who was likely a State Security agent nicknamed El Enfermero!(6)

Every morning at 5 a.m., Heriberto Mederos, and his sadistic assistants, one of whom was nicknamed El Capitan, would select the unfortunate ones who would undergo ECT after being doused with cold water (for better electrical conduction!) and thrown on the hard cement floor where they would undergo the procedure. El Capitan would later sodomize young prisoners. Others would be brutally beaten. One of them was found hung and incinerated with gasoline. Everyday 80 to 90 of the inmates would have to stand like animals en La Perrera, "the dog kennel," the small enclosure measuring approximately 10 by 30 meters on a slab of cement which was in the courtyard behind the Sala Carbó-Serviá. They would stand on the crowded floor, under the sun, pitted against each other surrounded by other strangers and madmen, excrement and urine stench everywhere.

Psychiatrists were sometimes present in these wards that seemed to come straight out of Dante's Inferno. They would interview the prisoners, classify them, and sometimes approve of the "treatment," as in the case of the psychiatrist Dr. Orfilio Peláez. Other times they would admit to the prisoners in private that they had not specifically ordered their medication, torture, or rehabilitation. Charges brought against the dissidents included anti-regime activity or trying to leave the country illegally (salida ilegal). The case of Nicolás Guillén, the nephew of the former poet laureate of Cuba by the same name, is noteworthy. He was accused of "ideological deviationism" for making a short agricultural film, Arabian Coffee, which contained a scene of Fidel climbing a mountain while the Beatles' song, Fool on the Hill, played in the background. He was picked up by State Security and taken to Villa Marista, held without trial and interrogated for six months. He received at least eight sessions of ECT without anesthesia. Although he had fought in the Revolution, he was in and out of prisons and psychiatric hospitals for almost twenty years, from 1970 to 1989, until he was finally allowed to emigrate to Miami where he lives today as an artist.

After their detention and confinement, patients would be suddenly "dismissed" and transferred to prisons with or without a diagnosis. They would be told that they were "tried in absentia," and sentenced to long incarceration terms in such notorious prisons as Combinado del Este, Fortaleza de la Cabaña, El Castillo del Príncipe, El Morro Castle in Havana province, or other prisons or mental hospitals such as the Gustavo Machín Psychiatric Hospital (the old Jagua) in Santiago de Cuba, or other facilities throughout the island. Other times, they were taken back for further interrogation at Villa Marista. (This center, nationalized by Castro, was in pre-Revolutionary Cuba one of the religious school started by the Marist brothers.) At other times, attempts were made to force them to work for State Security. Almost always they lost their jobs and they continued to be harassed by agents of the State Security because of their political beliefs. The lucky ones made it to Miami where they were able to help with further documentation of this book.

What is most amazing of all is, that although these cases were verified by at least two sources, in some cases by civil rights organizations in the U.S. such as Freedom House, Of Human Rights, Americas Watch, as well as international groups such as Amnesty International and the United Nations Human Rights Commission, these cases have not received the attention they deserve. Yet, one of the cases, is that of a 16-year-old charged with trying to escape Cuba. Incidentally, documentation of abuse of children in Cuba's jails is also provided in Armando Valladares' book, Against All Hope.(7) As for women, a 1984 study at the Córdova forensic ward at Mazorra, found 4.6 percent of women were interned there either for "crimes against State Security" or "crimes against the public order." That for example was the case of poetess Maria Elena Cruz Varela who was incarcerated with mentally ill women and given psychotropic drugs. They represent only a small number among the thousands of known Cuban political prisoners languishing in Cuban jails.

The noted psychiatrist Vladimir Bukovsky, who was a leading dissident in the Soviet Union during the 1960s and 1970s and who spent twelve years in Soviet prisons, labor camps, and psychiatric hospitals, wrote the Introduction to this book.(1) He wrote: "After reading the documents and testimonies collected in this book, one can feel disgusted and outraged, but not surprised. We have learned long ago that Communist regimes, be they in Vietnam or Cuba, Ethiopia or China, are very much alike; just the sparks, the embers of the huge fire set in the world seventy-four years before."

In comparing Cuban psychiatry to that of the Soviet Union, he thought that the former was only a grotesque imitation of the latter. "Cuba," he wrote, "is unique only by the hasty pace of the disease: it covered in thirty-two years what the Soviet Union achieved in seventy-three. Within a single generation, Cuba advanced from "revolutionary justice" to "socialist legality," from liquidation of "class enemies" to "political re-education" and psychiatric treatment of those "apathetic to socialism."

Bukovsky believes that while both Cuban and Soviet psychiatry are derived from the Pavlovian school of psychology (i.e., conditioning, reprogramming, and rehabilitation rather than psychotherapy and analysis), both were used nefariously by the totalitarian states. While both used it for political repression and squelching dissents, the Cuban version became "just another form of torture," and, of course, the Cuban version continues to this day. Bukovsky who wrote the authoritative book, To Build a Castle: My Life as a Dissenter about the abuses of psychiatry in the Soviet Union, surmised that the originators of Soviet psychiatry, Dr. Daniil Lunts and Professor Georgy Morozov, "would have been outraged by seeing in Cuban psychiatry such a barbaric application of their elaborate theories."(8)

Indeed, this book documents the use of torture, as defined by the Amnesty International criteria as well as the American Association for the Advancement of Science Committee on Scientific Freedom and Responsibility. Psychiatric "rehabilitation" as practiced in Cuba against political dissidents is torture --- this, despite the fact that in 1986, Cuba signed the International Convention against Torture and Other Cruel, Inhuman, or Degrading Treatment or Punishment. The communist government of Cuba uses psychiatry and torture to coerce dissidents into cooperating with the regime and discontinue their political activities, as well as to intimidate and demoralize them as to eradicate their political beliefs.

It is obvious and the evidence is overwhelming that Cuban psychiatry has been perverted by the communist government of Fidel Castro, and it has become totally subordinate to the State's nefarious purposes. In the past, the World Psychiatric Association (WPA) has refused to investigate these charges because "complaints are examined in association with the WPA Member Society in the country in question. As the WPA has no Member Society in Cuba, we cannot examine the complaint appropriately." Perhaps it is time that the information in this book becomes widely available to the American public and a cry for justice may be made by an outraged public. Perhaps then the American public will recognize that by deporting Elián to Cuba for, as Fidel Castro stated, "re-programming" and reintegration in socialist society, that we have condemned him to a Hell on Earth.

And for us who will be left in America, perhaps a future Amerika, here is further food for thought. Consider the erosion of our individual rights in our own country including but not all inclusive:

* Erosion of our First Amendment right to free speech (for those who are not as equal as others) and the implementation

of stringent speech codes in colleges and universities enforcing political correctness;

* Infringement of our Second Amendment rights with the government using lawyers and lawsuits to bankrupt a legal firearm industry with a long honorable tradition in our history, and passing ever more laws leading step-by-step to citizen disarmament;

* Erosion of Fourth Amendment rights with increasing use of illegal searches and seizures (i.e., with warrants of dubious legalities or no warrants whatsoever) in the wars against drugs or fraud and abuse in health care, or raiding American homes looking for illegal aliens or drugs, etc. and carrying out "dynamic entries" (e.g., Waco) to impress the media and get increased funding for their own government agencies, etc.

The laws have become so cryptic and voluminous that any of us can be called guilty whenever Big Brother likes.

Consider the Hate Crime legislation that has passed in Canada and is being promoted in this country, criminalizing speech and motives. In George Orwell's 1984, he writes, "The first and simplest stage in the discipline, which can be taught even to young children, is called, in Newspeak, crimestop. Crimestop means the faculty of stopping short, as though by instinct, at the threshold of any dangerous thought. It includes the power of not grasping analogies, of failing to perceive logical errors, of misunderstanding the simplest arguments if they are inimical to Ingsoc, and of being bored or repelled by any train of thought which is capable of leading in a heretical direction."

And consider the raid and seizure of Elián González of April 22, 2000, instigated by the opinion of a physician who had never seen the patient and who, in the service of the State, opined, in Orwellian doublespeak, that the child was in imminent danger in the loving home of his Miami relatives.

Many of us in the Brave New World of an imponderable future in Amerika may be apprehended by the thought police, or institutionalized to be led to an American Mazorra to be treated, re-programmed, and rehabilitated for our own good or the good of the collective. Yes, it can happen here!

References/Notes


1. Brown CJ, Lago AM. The Politics of Psychiatry in Revolutionary Cuba. New York, NY, Freedom House, 1991.
2. Grigg WN. Children of the gulag. The New American 2000;16(6):20-23.
3. Grigg WN. The "cure" for freedom. The New American 2000;16(11):25-26.
4. From a May 24, 1959 article in Pravda and quoted by Sidney Bloch and Peter Reddaway in Russia's Political Hospitals: The Abuse of Psychiatry in the Soviet Union, London: Victor Gollancz, Ltd, 1977, p. 62. Also cited by Brown and Lago, op. cit., p. 32.
5. Brown and Lago, op.cit., p. 156.
6. Years later, this same Heriberto Mederos surfaced, of all places, near Miami working as a nurse at Hialeah Convalescent Home. Then 69-years-old and a widower, Mederos was living with his daughter. He claimed he had left Cuba in 1984 and defended himself stating he was following doctors' orders at Mazorra. Nevertheless, he was identified by former political prisoners as the same man they had known as El Enfermero. See "Havana hospital nurse evokes brutal memories" by Pablo Alfonso, Miami Herald, April 26, 1992; "A gulag recalled in Cuba - Inmates tell of torture" by Mirta Ojito and Alfonso Chardy, Miami Herald, April 26, 1992; and "Havana Hospital's Own Regulations Violated by Method of Applying Electroshocks," Miami Herald, April 26, 1992.
7. Valladares A. Against All Hope: The Prison Memoirs of Armando Valladares. New York, NY, Ballantine Books, 1986.
8. Bukovsky V. To Build a Castle: My Life as a Dissenter. Cited in Brown and Lago, op. cit., p. 32, and Grigg, The "cure" for freedom, op. cit., p. 25.

Dr. Faria is Editor-in-Chief of the Medical Sentinel, the official journal of the Association of American Physicians and Surgeons (AAPS), and author of Vandals at the Gates of Medicine (1995) and Medical Warrior: Fighting Corporate Socialized Medicine (Macon, Georgia, Hacienda Publishing, Inc., 1997).

Originally published in the Medical Sentinel 2000;5(5):160-162. Copyright ©2000 Association of American Physicians and Surgeons.

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Comments on this post

Where Were You When the World Stopped Turning-Alan Jackson

Alan Jackson-http://www.youtube.com/watch?v=fvj6zdWLUuk

Sure a lot of things going on in our Country these days! I find it rather interesting, all this discussion between doctors about the second amendment and whether they should act as government snitches about our habits and guns. I so far have figured out it appears some Doctors apparently feel obligated to the system and therefore, think it's their responsibility to aid the government against the people and patients they serve. Wonder if it's possible Doctors are becoming like most of our politicians, who think we are there for them instead of the other way around. The discussions in the MT are likewise rather humorous, the most recent appeared to be perhaps a novice trying to aid his superior or co-worker and certainly IMO only muddied the water and made things worse for "their" opinion! In his own letter to MT he actually rebutted his own comments which further indicated to me "he was on a mission" LMAO!

I don't know how much you have been paying attention to this but IMO there is something going on in this Country which is not good for the citizens. Obama's decision to ask our senior military officers will they fire on US citizens is certainly not good and has already caused some of them to retire. I find it "in your face" that he would be that outspoken about it but I guess when you get re-elected and give an inauguration address speech indicating you are in fact a "progressive collectivist", I guess he feels he can do anything! Please review this at your convenience and would love your comments. I am on a mission to document similar type situations and have several already comparable to this!

FBI Director Robert Mueller says he will have to check to see if our government can kill Americans “in this Country” This of course means without charge or trial. Basically he was saying he had to wait and check with Holder to see what he says.(March 2012)

This link is the one about Obama killing the guy (Al Alwaki) in Yemen. It's a Sad Day for America!

There's something going on I assure you, all these guns being ordered by Homeland Security, there's talk of FEMA camps, coffins have been ordered and distributed around the Country, a policeman in South Carolina says the same thing, that a lot of our law enforcement agencies around the Country are being asked to participate in some "plan" and he declined, so he didn't get to see the plan itself, lots of law enforcement agencies getting troop carriers, machine guns used in war, etc, and more I haven't mentioned but am aware of! Something is adrift and I don't like it and the last darn thing, they are not going to get my guns! Hope you all have been doing well at Hacienda! Your bud, BenCats1

Very disturbing!

Hi Ben,

Doctors should remember the lessons of the Nazi doctors and the psychiatrists both in Cuba and the USSR! It was not pretty, as shown in the article above and in Euthanasia, Medical Science, and the Road to Genocide.

There are many things going on that are very disturbing, Ben. I need to look into what you have written and suggested. A friend of mine sent me this link about the military exercises in Houston, and why did they choose Texas?

I think you need to continue looking into it using your Veteran sources, and keep us posted, Ben. MAF

Doctors Asking About Guns (round 2)

No Ethical lapses in physician efforts to protect public and patients By Richard L. Elliot — Special to The Telegraph, Jan 29, 2013

In his reply to my article, Dr. Miguel Faria, a very fine neurosurgeon and writer, states that it is unethical for physicians “to intrusively ask patients about the presence of guns in the home” and that by so doing, physicians become “snitches” against their own patients.

I agree that if the purpose of asking about guns is solely to report the possession of guns, and that if the physician asks “intrusively” and reports without the patient’s permission and in the absence of an imminent threat, it would be wrong.

But Florida law, which has been blocked in federal court, makes it illegal to ask about the presence of guns in the home in the absence of an emergency. The AMA supported the suit blocking the Florida law, as have a number of other physician groups. The basis for the objection is that encouraging patients to consider such safety measures as wearing seat belts and locking up guns goes a long ways towards preventing injuries and deaths. Nothing unethical about this at all.

Faria also suggests that I wrote “it is not OK for a psychiatrist to report a potential threat by a mentally disturbed patient.” I wrote nothing of the sort. What I did say is that mandatory reporting can create problems. Most, (but not all) states that have looked at this follow a Tarasoff-like policy that when a psychiatrist determines a patient presents an imminent risk to another person, the psychiatrist incurs a duty to protect that individual. This may involve reporting the threat, but a variety of other, potentially more protective means may be used to protect the person, e.g., involuntary hospitalization, notifying that individual, or perhaps reporting to authorities.

I agree with Faria that thoughtful consideration is needed in light of recent events and in the face of potential present danger. Knee-jerk reporting without considering measures which may be more effective protects neither the public nor personal rights.

Richard L. Elliott, M.D., Ph.D., is a professor of Medical Ethics at Mercer University School of Medicine.

Dr Faria Replies:

Very good response, Dr Elliot. I think our divergent positions as well as areas of agreement are clear now. I do believe that physicians asking their patients about guns is a ethical boundary violation for reasons stated by Dr Timothy Wheeler and myself in different articles. He wrote in 1999:

"The American Medical Association (AMA), American Academy of Pediatrics (AAP), and American College of Physicians (ACP) are urging doctors to probe their patients about guns in their homes. They profess concern for patient safety. But their ulterior motive is a political prejudice against guns and gun owners. And that places their interventions into the area of unethical physician conduct called boundary violations.

"Doctor-patient sex is the most well-known and sensational example of a boundary violation. More recent literature recognizes a wide variety of non-sexual violations. These cover such issues as finances, confidentiality, and gratification of the doctor's needs. Although boundary violations were first addressed in the psychiatry literature, it has become clear that they also occur in general medical practice." 

As far as the AMA, it ceased being a respected organization long ago because "of playing politics for a seat at the table" and because of inconsistent "flexible ethics" that swing with blowing political winds. It is an organization only interested in pocket book issues and everything else including ethics is sacrificed for a seat at the same table! (See my article, "Transformation of Medical Ethics Through Time.")

As Dr. Leo Alexander, the Chief U.S. Medical Consultant at the Nuremberg War Crimes Trials, wrote in his momentous article, "Medical Science Under Dictatorship" in the 1949 issue of The New England Journal of Medicine:

"It is the first seemingly innocent step away from principle that frequently decides a life of crime. Corrosion begins in microscopic proportions." This was substantiated not only by the behavior of Nazi doctors but also Soviet and Cuban psychiatrists. (See my article. "Cuban Psychiatry— the perversion of medicine."

You may be interested in my article that was just published this morning in Surgical Neurology International: "Faria MA. Shooting rampages, mental health, and the sensationalization of violence. Surg Neurol Int 2013;4:16."

As we continue to debate these issues in the MT pages, I have proposed that you and Professor David Oedel, also currently at Mercer, should set up an oral debate with myself and Eric Erickson (also a lawyer). Mercer would be a good place: 2 lawyers and 2 physicians. Subjects:

1) Doctors Asking patients about guns in the home.
2) Original intent and purpose of the Second Amendment.

Our disagreement does not detract from the fact that I also consider you an excellent psychiatrist and remember fondly when we collaborated in some writing projects years ago. We must be careful that science and medicine do not become subordinated to the state. As I have written elsewhere:

"The lessons of history sagaciously reveal that whenever and wherever science and medicine have been subordinated to politics, the results have been as perverse as they have been disastrous, as totalitarian examples of the 20th Century so aptly testify." —MAF

Doctors Asking About Guns (round 1)

Guns, violence, and mental health by Richard L. Elliot
Special to the Telegraph, Jan 23, 2013

I served in the Army. I own two pistols and have a Georgia Weapons Carry Permit. I am also a psychiatrist and concerned over some of the mental health approaches incorporated into our responses to recent mass shootings. No doubt measures aimed at increasing access to mental health services will benefit some patients, and measures aimed at training health care providers to recognize and respond to potentially dangerous behaviors may also carry benefits.

No doubt restricting access to weapons among certain groups of patients, e.g., among those previously committed for dangerous behavior, makes sense. And no doubt overturning legislation, such as a Florida law that prohibits physicians from asking about the presence of guns in the home, is good medicine…

Richard L. Elliott, M.D., Ph.D. is professor and director of Medical Ethics, Mercer University School of Medicine.

Reply

Determining who is dangerous?

In the commentary “Guns, violence, and mental health," psychiatrist Dr. Richard Elliott agrees with President Obama that it is OK for physicians to intrusively ask patients about guns in the home, that, as a medical ethicist, he should know constitutes an unethical boundary violation,(1) not to mention makes physicians potentially effective snitches for the state against their own patients who have not necessarily expressed a threat to anyone.(2)

But then it is not OK for a psychiatrist to report a potential threat by a mentally disturbed patient. Does that make sense? If not a psychiatrist, then who would be in a better position to determine with the greatest level of medical confidence that an individual is dangerous? With all due respect to Dr. Elliott, I believe psychiatrists, among physicians, to be most competent in recognizing mental illness and potential criminal insanity in their patients. And, as he pointed out, given limited resources, it should be those threats likely to be dangerous that should be reported to and investigated by law enforcement.

Moreover, it has been psychiatrists, who up to now, have been least likely to report threats because of the psychiatrist-patient medical confidentiality, that is most protected legally, second only to the attorney-client privilege.

I do agree with Dr. Elliott that we must proceed with caution to protect civil liberties and prevent the inception of a police state in the name of unattainable perfect security. But a reasonable balance should be reached. Just like with the First Amendment, we cannot scream “Fire!” in a crowded theater, and with the Second Amendment we cannot hunt deer off-season! A serious, specific threat made to a thoughtful psychiatrist by a disturbed patient, whether with guns, knives,(3) automobiles, baseball bats, or bare hands, should be reported. I remain less keen on the idea of family physicians asking intrusively about gun ownership in an otherwise non-threatening patient.

1. Wheeler T. Boundary Violations -- Gun Politics in the Doctor’s Office. Medical Sentinel 1999;4(2):60.

2. Faria MA Doctors to ask patients about gun ownership. Medical Sentinel 2001;6(4):115-117.

3. Bodeen C. China: 22 kids, 1 adult attacked by knife wielding suspect. GOPUSA.com, December 15, 2012.

Miguel Faria, Macon

[Miguel A. Faria, Jr., M.D. is a retired professor of Neurosurgery and a former member of the CDC Grant Review Committee for Injury Prevention and Control 2002-2005.]


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