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| May 5, 2009 Well Worry? Relax? Buy Face Mask? Answers on Flu Confused about swine flu? It’s no wonder, with all the seemingly mixed messages coming out of health agencies and news organizations. Last week, the World Health Organization raised the alert level for the virus, whose formal name is H1N1, indicating that a “pandemic is imminent.” Now, health officials report that although the virus is widespread, most cases seem to be mild. People are being told not to panic, but schools in some communities remain closed. It’s good news that the imminent threat appears to be abating, but questions remain about the virus and whether it will re-emerge in the Southern Hemisphere or back in North America next fall. Here are some answers. Regular flu kills 150 people a day during flu season. Why is everyone so concerned about this one? This is a new and unusual virus. Most flu viruses have two genetic elements, but H1N1 has four: two types of swine flu, a bird flu and some human flu genes, said Dr. Neil O. Fishman, an infectious-disease specialist at the University of Pennsylvania. The virus has also shown that it can quickly infect large numbers, as it did at a school in Queens. But it is a historical precedent that fuels most of the present concern. In the 1918 pandemic, the virus was relatively mild when it first appeared in the spring, but it came back with a vengeance in the fall. “That’s what has a lot of the experts frightened,” Dr. Fishman said. “When it recurs, there’s the possibility it could be more virulent.” Flu typically preys on the old and on those whose immune systems are compromised. This one seems to be infecting more young people. Why? It may be related to spring-break travel patterns or the fact that older people have more natural immunity after years of exposure to a variety of flu viruses, according to officials from the Centers for Disease Control and Prevention. In the 1918 flu pandemic and in the SARS outbreak in Asia this decade, the viruses appeared most deadly to young, healthy adults. The reason may be that the immune system of a healthy person responds with too much force when it detects a new virus, filling the lungs with fluid. This overreaction is called a “cytokine storm.” In 1918, there were reports of people dying within hours of developing symptoms. “That doesn’t happen because you have a virulent flu,” said Laurie Garrett, senior fellow for global health at the Council on Foreign Relations and the author of “The Coming Plague: Newly Emerging Diseases in a World Out of Balance ” (Penguin, 1995). “That happens because the whole body went bananas.” She added that even though many SARS patients were housed in the AIDS wards of hospitals, patients with H.I.V. and AIDS apparently did not contract the disease, suggesting that the real threat was a strong immune response rather than the symptoms of the virus itself. I am coughing and feverish. Should I be tested for swine flu? Most people who exhibit flu symptoms will not be tested for H1N1. There are a limited number of testing sites that can confirm a case, and whether you have swine flu or another type of flu, the medical advice is the same. Call your doctor to see if he or she considers you a candidate for an antiviral treatment like Tamiflu. In some cases, a doctor may order a rapid test. “Are you getting better or are you getting worse?” said Dr. Michael R. Anderson, chief medical officer for the University Hospitals Case Medical Center in Cleveland. “If you’ve got a low-grade temp and a cough for a few days, wait it out. If you’re into that second day of symptoms and your fever is 103, you’re coughing every five minutes to the point of respiratory distress, shortness of breath and you can’t keep things down, I don’t care what the virus is. I would seek medical treatment.” Don’t confuse flu with other respiratory illnesses. One characteristic of flu is that it does not creep up on you over a few days. “Give yourself the sledgehammer test,” Ms. Garrett said. “Are you vaguely off and then all of the sudden it feels like someone just whacked you over the head? That’s flu.” Are there reasons to be less worried about swine flu now than a week ago? Yes. In recent days, genetic sequencing analyses of this flu have suggested it is not as virulent as suspected. It lacks certain proteins and amino acids that would make it as deadly as other flus. And it appears similar enough to other common strains that most people may have some immunity. Researchers have even begun to speculate whether this year’s flu vaccine, which protected against a form of H1N1 flu, may have offered partial protection against the swine version. Should I buy a face mask just in case? The public health officials I interviewed are not stocking up on personal supplies of face masks for family members. “I haven’t brought any home,” Dr. Fishman said. Face masks aren’t particularly effective against the spread of flu. The main effect may be “social distancing”: masks scare people away from one another. If the flu does progress to a pandemic, the most effective response will be to limit public gatherings. In 1918, for example, the outbreak in St. Louis was mild, because the authorities closed schools, churches and theaters. Meanwhile, Philadelphia, which had one of the highest death rates, held a war bond parade at the start of the outbreak. “That’s circumstantial, but it’s the type of thinking that’s behind the community mitigation strategies,” Dr. Fishman said. Now that the swine flu scare seems to have died down, does this mean we all overreacted? “It’s the classic problem in public health, trying to prove a negative,” Ms. Garrett said. “If, after an intervention, nothing happens, then everybody says, ‘What was the big deal?’ ” But the course swine flu will take in the Southern Hemisphere — and, this coming fall, in the Northern Hemisphere — still isn’t clear. And it’s worth considering what might have happened if public health officials hadn’t sounded the alarm. “I think the whole world should be saying, ‘Gracias, amigos,’ to the Mexicans for the tremendous sacrifice they have made,” Ms. Garrett said. “That may have stopped what otherwise would have been a serious pandemic. “Some people will look back and say: ‘Wasn’t that ridiculous? Didn’t we overreact?’ But in New Orleans, wouldn’t we have preferred an overreaction that built too many levees too tall, than doing nothing and allowing the city to be flooded?” | | |
| May 5, 2009 10 Genes, Furiously Evolving Evolutionary biology may sometimes seem like an arcane academic pursuit, but just try telling that to Gavin Smith, a virologist at Hong Kong University. For the past week, Dr. Smith and six other experts on influenza in Hong Kong, Arizona, California and Britain have been furiously analyzing the new swine flu to figure out how and when it evolved. The first viruses from the outbreak were isolated late last month, but Dr. Smith and his colleagues report on their Web site that the most recent common ancestor of the new viruses existed 6 to 11 months ago. “It could just have been going under the radar,” Dr. Smith said. The current outbreak shows how complex and mysterious the evolution of viruses is. That complexity and mystery are all the more remarkable because a virus is life reduced to its essentials. A human influenza virus, for example, is a protein shell measuring about five-millionths of an inch across, with 10 genes inside. (We have about 20,000.) Some viruses use DNA, like we do, to encode their genes. Others, like the influenza virus, use single-strand RNA. But viruses all have one thing in common, said Roland Wolkowicz, a molecular virologist at San Diego State University: they all reproduce by disintegrating and then reforming. A human flu virus, for example, latches onto a cell in the lining of the nose or throat. It manipulates a receptor on the cell so that the cell engulfs it, whereupon the virus’s genes are released from its protein shell. The host cell begins making genes and proteins that spontaneously assemble into new viruses. “No other entity out there is able to do that,” Dr. Wolkowicz said. “To me, this is what defines a virus.” The sheer number of viruses on Earth is beyond our ability to imagine. “In a small drop of water there are a billion viruses,” Dr. Wolkowicz said. Virologists have estimated that there are a million trillion trillion viruses in the world’s oceans. Viruses are also turning out to be astonishingly diverse. Shannon Williamson of the J. Craig Venter Institute in Rockville, Md., has been analyzing the genes of ocean viruses. A tank of 100 to 200 liters of sea water may hold 100,000 genetically distinct viruses. “We’re just scratching the surface of virus diversity,” Dr. Williamson said. “I think we’re going to be continually surprised.” Viruses are diverse because they can mutate very fast and can mix genes. They sometimes pick up genes from their hosts, and they can swap genes with other viruses. Some viruses, including flu viruses, carry out a kind of mixing known as reassortment. If two different flu viruses infect the same cell, the new copies of their genes get jumbled up as new viruses are assembled. Viruses were probably infecting the earliest primordial microbes. “I believe viruses have been around forever,” Dr. Wolkowicz said. As new hosts have evolved, some viruses have adapted to them. Birds, for example, became the main host for influenza viruses. Many birds infected with flu viruses do not get sick. The viruses replicate in the gut and are shed with the birds’ droppings. A quarter of birds typically carry two or more strains of flu at the same time, allowing the viruses to mix their genes into a genetic blur. “Birds are constantly mixing up the constellation of these viruses,” said David Spiro of the J. Craig Venter Institute. From birds, flu viruses have moved to animals, including pigs, horses and humans. Other viruses, like H.I.V. and SARS, have also managed to jump into our species, but many others have failed. “It’s a very rare event when a virus creates a new epidemic in another species,” said Colin Parrish of Cornell University. In Southeast Asia, for example, a strain of bird flu has killed hundreds of people in recent years, but it cannot seem to move easily from human to human. Only a few strains of influenza have managed to become true human viruses in the past century. To make the transition, the viruses have to adapt to their new host. Their gene-building enzymes have evolved to run at top speed at human body temperature, for example, which is a few degrees cooler than a bird’s. Influenza viruses also moved from bird guts to human airways. That shift also required flu viruses to spread in a new way: in the droplets we release in our coughs and sneezes. “If the virus settles down on the floor, then it’s gone,” said Peter Palese, chairman of microbiology at Mount Sinai School of Medicine. Winter is flu season in the United States, probably because dry air enables the virus-laden droplets to float longer. Up to a fifth of all Americans become infected each flu season, and 36,000 die. During that time, the flu virus continues to evolve. The surface proteins change shape, allowing the viruses to evade the immune systems and resist antiflu drugs. Dr. Spiro and his colleagues have also discovered that human flu viruses experience a lot of reassortment each season. “Reassortment may be the major player in generating new seasonal viruses,” Dr. Spiro said. From time to time, a new kind of flu emerges that causes far more suffering than the typical swarm of seasonal flu viruses. In 1918, for example, the so-called Spanish flu caused an estimated 50 million deaths. In later years, some of the descendants of that strain picked up genes from bird flu viruses. Sometimes reassortments led to new pandemics. It is possible that reassortment enables flu viruses to escape the immune system so well that they can make people sicker and spread faster to new hosts. Reassortment also played a big role in the emergence of the current swine flu. Its genes come from several ancestors, which mainly infected pigs. Scientists first isolated flu viruses from pigs in 1930, and their genetic sequence suggests that they descend from the Spanish flu of 1918. Once pigs picked up the flu from humans, that so-called classic strain was the only one found in pigs for decades. But in the 1970s a swine flu strain emerged in Europe that had some genes from a bird flu strain. A different pig-bird mix arose in the United States. In the late 1990s, American scientists discovered a triple reassortant that mixed genes from classic swine flu with genes from bird viruses and human viruses. All three viruses — the triple reassortant, and the American and European pig-bird blends — contributed genes to the latest strain. It is possible that the special biology of pigs helped foster all this mixing. Bird flu and human flu viruses can slip into pig cells, each using different receptors to gain access. “We call the pig a mixing vessel because it can replicate both avian and mammalian influenza virus at the same time,” said Juergen Richt of Kansas State University. “The mixing of these genes can happen much easier in the pig than in any other species.” Fortunately, the new swine virus seems to behave like seasonal flu in terms of severity, not like the 1918 Spanish flu. “Right now it doesn’t have what it takes to be a killer virus,” Dr. Palese said. But could it? Dr. Palese said it was highly unlikely. If the swine flu peters out in the next few weeks, virus trackers will still pay close attention to it over the next few months. As flu season ends in the Northern Hemisphere, the virus may be able to thrive in the southern winter or perhaps linger in the tropics, only to return to the north next fall. It will no doubt change along the way as its genes mutate, and it may pick up new genes. The scientists will be watching that evolutionary journey with a mixture of concern and respect. “Viruses are incredibly adaptable,” Dr. Spiro said. “They have managed to exploit our modern culture and spread around the world.” | | |
| May 2, 2009 Emergency Rooms Fill With Record Numbers, but Many Aren’t Ill, Just Afraid Some hospital emergency rooms have seen record-breaking numbers of patients this week as those with coughs, sore throats and fevers — and sometimes no symptoms at all — have sought reassurance that they do not have the deadly H1N1 virus, also known as swine flu. Although the pattern is far from universal, the surges have been particularly heavy at children’s hospitals, presumably because the young are so susceptible to respiratory diseases with comparable symptoms. Some hospitals have had to increase staffing and enact specialized triage plans. Waiting times have billowed in some emergency rooms, even for the seriously ill. In many instances, patients are showing up at hospitals, sometimes referred by their doctors, even though they do not have symptoms, like fever and nausea, that could indicate swine flu. At San Joaquin Community Hospital in Bakersfield, Calif., none of the 188 patients — a daily record — who arrived at the emergency room on Tuesday had symptoms that met the criteria to even be tested, said Jarrod B. McNaughton, the hospital’s vice president. “It’s a major drain on resources,” Mr. McNaughton said. The burden has not been limited to states with confirmed cases. For instance, in Illinois, where the first three cases were confirmed only on Friday, Children’s Memorial Hospital of Chicago has been treating more than twice its usual volume of emergency room patients this week, said Dr. Sally R. Reynolds, the department’s medical director. “We usually see about 170 patients a day this time of year, sometimes as low as 150, and we had 392 on Wednesday and 369 on Thursday,” Dr. Reynolds said. “I think our previous record was 275.” Dr. Reynolds said some patients had waited as long as six hours to be seen, compared with normal waits of an hour or two. “Some of them have legitimate worries, like a fever and cough, but a lot of them just have a cold and no flu-like symptoms,” she said. “It’s hard for us because when you’re overwhelmed like that the goal is to sort out who’s really sick.” The hospital has increased emergency room staffing by plucking doctors and nurses from other departments, Dr. Reynolds said, but it is not clear how long she can sustain current levels without exhausting her staff. “I have a plan through Monday,” she said. In New York, the 12 emergency rooms operated by North Shore-Long Island Jewish Health Systems had more than 1,100 visits this week by patients complaining of flu-like symptoms, said Terry Lynam, a spokesman. “Our laboratories were getting overrun with specimens being sent in so we had to bring in additional staffing and expand hours up to 20 hours a day,” Mr. Lynam said. “Over six days this week, our largest laboratory, in Lake Success, N.Y., did two months’ worth of work.” At Texas Children’s Hospital in Houston, site of the only death caused by swine flu in the United States, emergency room volume increased by at least 40 percent in each of the last three days, said Dr. Joan E. Shook, the medical director of the emergency department. A neighboring hospital, Memorial Hermann, saw 50 percent increases, said Dr. James J. McCarthy, the emergency department medical director there. The death, Dr. Shook said, had made families understandably anxious. “People come in saying they had a fever a while ago or they thought they had a fever or they just want to be tested,” she said. “They just want to know. They just want to feel safe.” Because of record numbers at Texas Children’s, and the need to segregate anyone infected with the virus, patients complaining of flu symptoms are receiving initial screenings in an open-air parking deck, Dr. Shook said. | | |
| May 3, 2009 No Signs of Sustained Global Spread of Swine Flu The World Health Organization announced an increase in the number of confirmed cases of swine flu on Saturday, but said there was no evidence of sustained spread in communities outside North America, which would fit the definition of a pandemic. Health officials say the continuing outbreak must be closely monitored. “At the present time, I would still propose that a pandemic is imminent because we are seeing transmission to other countries,” Dr. Michael J. Ryan, the director of the World Health Organization global alert and response team, said in a teleconference from Geneva. “We have to expect that Phase 6 will be reached. We have to hope that it is not.” Phase 6, the highest level in the organization’s alert system, is a pandemic. But Dr. Ryan emphasized that the term describes the geographic spread of a disease, not its severity. There can be a pandemic of a mild disease. The current level, Phase 5, means that the disease is spreading in communities — not just within households or in returning travelers — in two countries in one of the World Health Organization’s six regions, in this case the United States and Mexico. Phase 5 also means a pandemic is imminent. To move up to Phase 6, community spread would have to occur in at least one other country in another region. On Saturday, Canadian health officials said that the virus had been found in sick pigs on one farm in Alberta, the first report of the swine flu’s actually being found in swine. Previously, there had been heated debate about whether the virus could infect pigs, even though its genetic makeup clearly points to its having originated in swine at some point. But people were infecting each other, and until Saturday, no pigs had been found with the virus — a fact that the pork industry used to bolster its argument that the virus should not even be named for swine. But researchers, busy with human cases, were not really looking for the disease in pigs. The news from Canada changes things. But it has a somewhat unexpected twist: a person appears to have spread the disease to the pigs, and not the other way around. A worker at the farm had traveled to Mexico, fallen ill there and unknowingly brought the disease back to Canada last month. The worker has recovered. About 10 percent of the 2,200 pigs on the farm got sick. According to the Canadian Food Inspection Agency, all recovered without treatment in five days. The entire herd remains under quarantine as a precaution. “One of the reasons for watching this very closely is the potential for the virus passing back from the pigs to human beings,” David Butler-Jones, the chief public health officer of Canada, said at a news conference in Ottawa. He emphasized that the infection of the pigs by the human virus does not pose any increased threat to human health or the food supply. “The eating of pork is absolutely not a problem,” Dr. Butler-Jones said. Despite assurances from the Public Health Agency of Canada and Canadian agriculture officials, some countries banned imports of pork and pork products from Canada even before Saturday’s announcement. Brian Evans, the executive vice president of the Canadian Food Inspection Agency, said that the Canadian government had informed the United States about the finding in Alberta. American officials, he added, indicated that they did not plan to ban Canadian products. On Saturday the W.H.O reported that there were 658 confirmed cases of the illness, officially known as Influenza A(H1N1) , in 16 countries. Dr. Ryan said that the health organization was sending 2.4 million doses of antiviral drugs to 72 countries, including many poor countries that do not have supplies of their own. In the United States, the Centers for Disease Control and Prevention reported Saturday that there were 160 cases confirmed by laboratory tests in 21 states. (The agency posts the case count once a day; states sometimes report new cases later the same day, but they are not added to the official total until the next day.) Thirteen people have been hospitalized. “It’s important to remember that with seasonal flu, we get 200,000 hospitalizations each year, mostly the very old or very young or those with other problems that put them at high risk,” Dr. Anne Schuchat, head of respiratory disease at the disease centers, said at a news conference. Some businesses are already trying to cash in on the outbreak, and the Food and Drug Administration and the Federal Trade Commission have begun advising consumers to watch out for Internet scams selling useless drugs and ineffective masks to treat or prevent swine flu. In Mexico, health authorities expressed cautious optimism about what they called a “stabilizing” situation. For the second day in a row, Mexico City, with most of the confirmed cases, did not record any deaths attributable to the virus. As of Saturday morning, Mexico had confirmed 473 cases of H1N1, out of the 1,303 suspected cases that had been tested, indicating that the outbreak may be much smaller than it initially seemed. The death toll was raised Saturday night to 19. Mexico had 159 deaths thought to be caused by swine flu. But many had other causes: 66 have now been attributed to other illnesses. Other cases have yet to be tested. Dr. Schuchat of the C.D.C. took a cautious view of the optimistic reports from Mexico. “I’m encouraged by what I’ve heard out of Mexico, but it’s important that we remain vigilant,” she said. “We’ve seen times when things appeared to be getting better and then got worse. For example, in Canada’s outbreak of SARS, things were said to be getting better, then there was a second wave in nursing homes. I suspect that in Mexico we’ll be holding our breath for some time.” One source of concern and puzzlement in Mexico is the breakdown of deaths by gender. Of the 16 whose causes of death had been confirmed on Friday, 12 were women, including one who was pregnant. Mexico’s health secretary, José Ángel Córdova, confirmed that the flu seems to have struck harder at women than men in Mexico, but he could not explain why. Like many of the new or emerging infections that have taken the world by surprise — SARS and avian flu are examples — this one seems to have arisen at what scientists call the “animal-human interface.” “I think this is a phenomenon we’ve been observing over the last few decades,” Dr. Ryan said. He noted that some major threats to human health were of animal origin, including viruses that can wreak havoc when they jump from one species to another. “We have seen in the past that disease can spread from pigs to humans,” Dr. Ryan said. “It usually dead ends with one or two cases.” But in this case, he said, the disease is now spreading from person to person, with no evidence that pigs were transmitting it to people. Still, he said, “the animal-human interface needs to be watched carefully.” Infectious disease experts say it will be important to watch what this virus does over the coming weeks and months, particularly in the Southern Hemisphere, which will soon confront its winter flu season. If H1N1 takes hold there, that will be a red flag to scientists. “What could indeed happen is that this virus could dampen here during the summer per usual, and go to the Southern Hemisphere and pick up steam there and come back to bite us in our winter season next January and February, and it might come back in a more virulent form,” said Dr. William Schaffner, a public health and infectious disease expert at Vanderbilt University. “It’s an influenza virus, and you just can’t predict what those critters are going to do.” Particularly worrisome is that a seasonal flu strain, common in the Southern Hemisphere and elsewhere, is resistant to Tamiflu, and could in theory pass that resistance to the new virus. Dr. Harvey V. Fineberg, president of the Institute of Medicine, also said the new virus could head south, and should be tracked closely. “It will presumably give some insight into how this virus is evolving both in transmissibility and in virulence,” Dr. Fineberg said. Meanwhile, as officials in the United States and elsewhere make plans for vaccine production, Dr. Schaffner said, “All that activity is very prudent.” Donald G. McNeil Jr. contributed reporting from New York, Ian Austen from Ottawa and Larry Rohter from Mexico City. | | |
| April 30, 2009 Doctor and Patient The Surgeon and the Torture Memos By PAULINE W. CHEN, M.D. Having trained medical students, I’ve come to recognize a familiar pattern of behavior when young doctors hold a scalpel for the very first time. Most people — actually anyone who has experienced even a paper cut — are hesitant to slice through flesh. Aspiring surgeons are no different. Their first efforts are tentative and almost always memorable. “Really, me?” I asked, the first time I was handed the knife. I cupped my hand as if to accept a communion wafer but was taken aback by the scalpel’s weight, a sure sign in my mind of the instrument’s gravitas. Like doctors-in-training before and after me, I wrapped my fingers around the handle in a kind of death grip and winced as the belly of the blade touched the patient’s body. And as much as I’d like not to admit it, my hand shook, so great was my fear of pushing too hard and slicing too deep. In the end, my first attempt at a surgical incision left barely a line on the patient’s skin. The mark was so tentative and so puny that even my cat wouldn’t have deigned to claim the scratch as her own. These days I have to try hard to remember the surge of adrenaline and the extent of my fear that very first time. After years of training, cutting began to feel second nature to me, the scalpel merely an extension of my fingers. So when a friend earlier this week told me that she could never imagine cutting into another person and wondered how young doctors learn to do so, I had to stop and think before I could respond to her. “Habituation,” I finally said. “You get used it.” That response, and the idea of becoming habituated, has been haunting me ever since. Is it possible for all of us to become habituated to the horrific? Two weeks ago, the Justice Department declassified four memos regarding the interrogation techniques approved by the Bush Administration and used by the C.I.A. with senior level Al Qaeda members. The details of these documents made my skin crawl; there are cool descriptions of dousing detainees with water at 41 degrees, forced nudity, slamming detainees into walls and waterboarding. But my mind kept wandering back to one thing: the seemingly ordinary professionals who were responsible. These were lawyers, psychologists, physicians, judges, and military and C.I.A. personnel, not just a rogue group of marginalized military grunts. In fact some of these individuals seemed hardly different from, well, me. A few were even the kind of hometown denizens I might admire. Take, for example, Jay Bybee, former assistant attorney general and now a judge on the United States Court of Appeals. In addition to his busy job, Mr. Bybee is a father to four children and has managed to serve as both a cubmaster for the Boy Scouts and an assistant coach for youth baseball and basketball. I am lucky if I can pack lunch for my two kids and get to work on time. The reason I keep thinking about my response to my friend’s question is that I know it is possible for even sensitive souls to become habituated to a range of grisly tasks. I am someone who has learned — become habituated — to performing a whole host of unusual and, depending on your point-of-view, potentially gruesome undertakings: poking sharp objects into other people, removing organs and extremities, and switching parts between the dead and the living. And as I implied to my friend, even cutting the flesh of another human being can become just another part of your day job. What renders a surgeon’s work different and humane, however, is not just the individual doctor’s desire to do the right thing by his or her patients (though I seriously wonder if Jay Bybee thought he was doing the right thing by his fellow Americans when he listed the 10 acceptable interrogation techniques, waterboarding among them). It is the surgeon’s commitment to and steadfast compliance with his profession’s code of ethical conduct. It is a constant awareness of the extraordinary trust that patients and the public place in their physicians, a trust that entails transparency and accountability in the patient-doctor relationship. As I see it, the problem now with these documents is not that our trust in those accountable has been shattered. It is that the rest of us are beginning to show signs of becoming habituated to such transgressions. Americans have been aware of brutal interrogation techniques for several years now: the first pictures from Abu Ghraib were shown five years ago this week, and the declassified documents in fact hold little new information. And while our current president speaks of moving forward, and not looking back at this chapter of our history, can we afford to turn away? In doing so, we accept how we have become habituated. We risk seeing the brutality not as an atrocity but as part of who we are. We become the surgeon who might have shook when first taking the knife in hand but who now dares to cut with eyes closed. Join the discussion on the Well blog, “”Getting Used to the Gruesome.” | | |
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