Journal articles on the topic 'National Cargo Bureau (U.S.)'

This study analyzes quantity impacts of imported crawfish tailmeat on Louisiana crawfish tailmeat prices, and demonstrates the statistical validity and proper interpretation of cross substitution within inverse demand systems. Among five inverse demand systems, the Differential Inverse National Bureau of Research (DINBR) model shows no violation of econometric assumptions for the data analyzed. By using Allais coefficients proposed by Barten and Bettendorf (1989), we show substitutability among the five fish species.

During August, 1988, I was asked by the United States Information Agency to go to Bangladesh to share information about AIDS with the Bangladesh National AIDS Committee and others. In the course of my stay in Dhaka, I met with the Deputy Prime Minister and Minister of Home Affairs, the Minister of Health, the Director of the American Cultural Center of the U. S. Information Service, the Dean of the University of Dhaka Medical School, the Director of the National Health Card Service (an organization administering hundreds of rural health clinics in Bangladesh), and the Chief of the Bureau of Health Education. I gave presentations before the Bangladesh National AIDS Committee, the faculty and student body of the University of Dhaka Medical School, and during a reception given by the National Health Card Service.

A specially designed high resolution ICP-MS was combined with an ultrasonic nebulizer to analyze trace amounts of various inorganic contaminants contained in water samples. It was confirmed that the detection limits of most elements obtained by the proposed method were well under 1 ppt. The Standard Reference Material 1643b (trace elements in water) provided by NIST (National Institute of Standards and Technology, formerly U. S. National Bureau of Standards) was also analyzed. Concentration values obtained by this work were in good agreement with certified values for all the elements examined except for Cu. It can be concluded from the foregoing that the combination of the above two instruments materializes an extraordinarily sensitive method and paves the way for direct determination of a considerable number of trace and ultra-trace elements in water samples with acceptable speed and accuracy.

Abstract Purpose The aim of this study was to evaluate regional disparities in access to EyeSi surgical simulation training among U.S. ophthalmology residency programs. Methods Access to EyeSi simulation was determined from sales data (2021) provided by VRMagic. Key demographic metrics of the primary counties of U.S. residency training programs were retrieved from the U.S. Census Bureau Database (2019) and PolicyMap (2021). Demographic metrics, Veterans Affairs (VA) hospital affiliation, and Doximity residency program ranking (2021) were compared using the Mann–Whitney U test and Fisher's exact test. Results A total of 124 residency training programs across 95 U.S. counties were included. Regional density (number of EyeSi simulators/million people) was calculated; the west had a significantly lower density when compared with the northeast (NE), south, and midwest (0.4 vs 1.0, 1.3, 1.1, respectively). In the NE, there was a significantly lower population of Blacks (p = 0.01), Hispanics (p = 0.028), and Native Americans (p = 0.008) residing in counties with access to EyeSi, compared with counties without EyeSi access. Programs with EyeSi access (N = 95) had a median Doximity ranking of 52.5, whereas programs without EyeSi access (N = 35) had a lower median ranking of 94 (p < 0.001). Conclusion Our analysis demonstrates significant disparities in access to EyeSi simulation training in the United States that could disproportionately impact minority communities. Access to an EyeSi simulator was associated with higher residency ranking independent of VA affiliation.

Rousseau H. Flower (1913-1988) described and figured more than hundreds of fossil taxa, collected throughout the world, during his long and colorful career (Wolberg, 1988). Most of the fossils Flower worked with remain at the New Mexico Bureau of Mines and Mineral Resources (NMBM&MR). Not surprisingly, given his interests in worldwide distributions of cephalopods and other groups, a rather small proportion of the fossils Rousseau worked with throughout his career were collected in New Mexico; a large proportion of the fossils actually belong to other institutions. The NMBM&MR continues to receive requests for published specimens and is making every effort to return loan material. The NMBM&MR also believes that the professional community would be best served by maintenance of the Flower/NMBM&MR fossils in a national repository. It was Rousseau's wish that the Smithsonian Institution/U. S. National Museum serve as one of the repositories of the NMBM&MR collections.

ABSTRACT The Department of Defense (DOD), operating through the Directorate of Military Support in the Department of the Army, supports state, local and other federal agency response operations in a wide range of natural and man-caused emergencies. Examples within the past six years include the Ashland Oil tank collapse in Floreffe, Pennsylvania, Exxon Valdez cleanup, Loma Prieta earthquake, hurricanes Hugo and Andrew, Mexico City earthquake, Armero (Columbia) volcanic eruption, and Puerto Rico floods and mudslides. From March 24 to September 27, 1989, the period of the Exxon Valdez initial cleanup operations, DOD provided military and civilian personnel, U. S. Navy ships for housing response workers, cargo and medical evacuation aircraft (fixed wing and helicopters), skimmers, modified dredges, landing craft, Dracones, Zodiak boats, radios, computers, and other miscellaneous equipment. This was in addition to assets of the Alaska Army and Air National Guard, which were committed by the governor. Support was provided to the U. S. Coast Guard on-scene coordinator and supervised by the Alaska Oil Spill Joint Task Force. The General Accounting Office, in its January 1990 report, Federal Costs Resulting from the Exxon Valdez Oil Spill, estimated that DOD spent $62.8 million through September 30, 1989, the largest expenditure by any federal agency. Use of military resources is a realistic scenario in certain situations. Primary responders at the federal and state level should understand how to request and employ these assets. This paper provides a background on DOD support to disaster relief operations, and discusses the types of support available to agencies responding to natural or man-caused emergencies, request and approval mechanisms, the Department of Defense organization to provide support, and reimbursement of the department.

BackgroundMacrophage activation syndrome (MAS) is a severe hyperinflammatory response that develops against the background of juvenile idiopathic arthritis (JIA). It is known that the clinical feature of MAS on biologic therapy has other clinical manifestations, different from biologically naive patients.ObjectivesTo study the clinical and laboratory features of macrophage activation syndrome in patients with juvenile idiopathic arthritis with systemic onset (sJIA) on the biologic therapy.MethodsThe study included 100 patients with MAS (114 cases of MAS) who observed in the rheumatological department of the National Medical Research Center for Children’s health of Ministry of health. All patients met the criteria for the diagnosis of sJIA and MAS. There were children in our study who did not receive biologic therapy – 84 (74%) cases, and children who had MAS in the biologic therapy – 30 cases (26%). The drugs are distributed as follows: tocilizumab - 7 cases (6%), kanakinumab - 20 cases (17%), etanercept – 2 cases (2%), adalimumab – 1 case (1%). For pairwise intergroup comparisons of quantitative variables, the nonparametric Mann-Whitney test was used.ResultsIn comparative analysis of biologic-naive and on biologic patients, the greatest differences were obtained for the following clinical manifestations: rash, lymphadenopathy, myalgia (p<0.05). Fever was the most common symptom in both groups and was present in almost all patients (99%). All patients had elevated level of ferritin in the blood serum (773 ng/ml to 130149 ng/ml). Laboratory picture of MAS in the group of on biologic patients differed significantly from the group of patients naive for biologic therapy (Table 1). The most significant differences were found among the following laboratory parameters: hemoglobin level, the number of erythrocytes and platelets, erythrocyte sedimentation rate (ESR), levels of C-raective protein (CRP), ferritin, lactatedehydrogenase (LDH), albumin.Table 1.Laboratory data of patients with MAS.nReference valuesMedianMinimumMaximumMann-Whitney Criterion (p)Biologic-naive cases of MAS(n= 84)Hemoglobin, g/l84120-14596,5061,00145,000,008Red blood cells, 1012/l844,5-5,33,782,135,010,001Platelets, 109/l84150-440149,0041,00523,000,025White blood cells, 109/l844,5-11,54,420,6925,840,074ESR, mm/h842-2045,002,00111,000,001CRP, mg/l840-5111,567,54368,310,006Ferritin, ng/ml8414-1244195,21702,38130149,200,022LDH, U/l8491-295413,50162,005245,000,059Albumin, g/l8438-5429,0016,1063,000,001On biologic cases of MAS(n = 30)Hemoglobin, g/l30120-145104,5067,00163,000,008Red blood cells, 1012/l304,5-5,34,173,106,150,001Platelets, 109/l30150-440101,504,00362,000,025White blood cells, 109/l304,5-11,53,220,7015,580,074ESR, mm/h302-2017,502,0098,000,001CRP, mg/l300-555,771,86407,120,006Ferritin, ng/ml3014-1242319,59773,90121396,000,022LDH, U/l3091-295600,0010,602148,570,059Albumin, g/l3038-5432,8020,3051,900,001ConclusionOn biologic patients may also develop MAS, which is often difficult to diagnose due to the poor clinical picture and low laboratory activity. In this case, hyperferritinemia remains as a highly specific marker of MAS.References[1]Crayne CB, Albeituni S, Nichols KE, Cron RQ. The Immunology of Macrophage Activation Syndrome. Front Immunol. 2019 Feb 1;10:119. doi: 10.3389/fimmu.2019.00119. PMID: 30774631; PMCID: PMC6367262.[2]Henderson LA, Cron RQ. Macrophage Activation Syndrome and Secondary Hemophagocytic Lymphohistiocytosis in Childhood Inflammatory Disorders: Diagnosis and Management. Paediatr Drugs. 2020 Feb;22(1):29-44. doi:10.1007/s40272-019-00367-1. PMID: 31732958; PMCID: PMC7334831.[3]Ravelli A, Davì S, Minoia F, Martini A, Cron RQ. Macrophage Activation Syndrome. Hematol Oncol Clin North Am. 2015 Oct;29(5):927-41. doi:10.1016/j.hoc.2015.06.010. Epub 2015 Aug 25 PMID: 26461152Disclosure of InterestsIvan Kriulin Speakers bureau: Speaker for Novartis., Ekaterina Alexeeva Speakers bureau: Speaker for Roche, AbbVie, Bristol-Myers, Squibb, MSD, Novartis and Pfizer., Grant/research support from: Financial grants from Roche, Pfizer, Centocor, Eli Lilly, AbbVie, Bristol-Myers Squibb, MSD, Sanofi, Amgen and Novartis., Tatyana Dvoryakovskaya Speakers bureau: Speaker for Roche, AbbVie, Bristol-Myers, Squibb, MSD, Novartis and Pfizer., Grant/research support from: Financial grants from Roche, Pfizer, Centocor, Eli Lilly, AbbVie, Bristol-Myers Squibb, MSD, Sanofi, Amgen and Novartis., Rina Denisova Speakers bureau: Speaker for Roche, AbbVie, MSD, Novartis., Grant/research support from: Financial grants from Roche, Pfizer, Centocor, Sanofi and Novartis., Ksenia Isaeva Grant/research support from: Financial grants from Roche, Novartis and Sanofi., Aleksandra Chomakhidze: None declared, Anna Mamutova Speakers bureau: Speaker for Novartis., Grant/research support from: Financial grants from Eli Lilly., Olga Lomakina Grant/research support from: Financial grants from Pfizer, Eli Lilly., Anna Fetisova Grant/research support from: Financial grants from Amgen., Marina Gautier: None declared, Kristina Chibisova: None declared, Elizaveta Krekhova Speakers bureau: Speaker for Novartis., Irina Tsulukiya: None declared

BackgroundSystemic sclerosis (SSc) patients often become refractory to proton pump inhibitor (PPI)—a standard treatment for gastroesophageal reflux disease (GERD)—and intolerant to PPI in combination with domperidone. PPI with alginic acid is an alternative treatment option, but alginic acid is costly.ObjectivesWe compared the costs and effectiveness of alginic acid plus proton pump inhibitor (PPI) versus standard treatments (PPI with/without antacids as needed and lifestyle modifications) for gastroesophageal reflux disease (GERD) in systemic sclerosis (SSc) patients unsuitable for, or intolerant to, domperidone.MethodsAn economic evaluation using the Markov model was conducted among SSc patients between 40 and 65 with GERD, having a partial or non-response to 4 weeks of standard-dose omeprazole (40 mg/d) and being unsuitable for or intolerance to domperidone. Using a societal perspective, we computed the incremental cost-effectiveness ratios (ICERs) in terms of Thai baht (THB) per quality-adjusted life-years (QALY) between a combination of alginic acid plus PPI and standard treatment for GERD. The lifetime time horizon was used.ResultsThe ICER for alginic acid plus PPI versus standard treatments was 377,101THB/QALY. According to the one-way sensitivity analysis, the cost of alginic acid was the most impactful parameter. If the market prices of alginic acid plus PPI were reduced by 61%, this treatment option would become cost-effective at the willingness-to-pay threshold of 160,000THB/QALY (34.71 THB/USD data on 3 December 2022). Furthermore, if alginic acid were included in the public health insurance program, the national budget would be increased by 66,313THB per patient resulting in an overall budget increase of 5,106,101 to 8,885,942THB compared to the standard treatment.ConclusionAlginic acid plus PPI does not represent good value for money compared to the standard treatment among such SSc patients in Thailand unless its price is reduced significantly.References[1]Foocharoen C, Peansukwech U, Mahakkanukrauh A, Suwannaroj S, Pongkulkiat P, Khamphiw P, et al. Clinical characteristics and outcomes of 566 Thais with systemic sclerosis: A cohort study. Int J Rheum Dis 2020;23:945–57.[2]Chunlertrith K, Noiprasit A, Foocharoen C, Mairiang P, Sukeepaisarnjaroen W, Sangchan A, et al. GERD questionnaire for diagnosis of gastroesophageal reflux disease in systemic sclerosis. Clin. Exp. Rheumatol. 2014;32:S-98-102.[3]Foocharoen C, Chunlertrith K, Mairiang P, Mahakkanukrauh A, Suwannaroj S, Namvijit S, et al. Prevalence and predictors of proton pump inhibitor partial response in gastroesophageal reflux disease in systemic sclerosis: a prospective study. Sci Rep 2020;10:769.[4] Foocharoen C, Chunlertrith K, Mairiang P, Mahakkanukrauh A, Suwannaroj S, Namvijit S, et al. Effectiveness of add-on therapy with domperidone vs alginic acid in proton pump inhibitor partial response gastro-oesophageal reflux disease in systemic sclerosis: randomized placebo-controlled trial. Rheumatology (Oxford) 2017;56:214–22.[5] Lei WY, Chang WC, Wen SH, Yi CH, Liu TT, Hung JS, et al. Predicting factors of recurrence in patients with gastroesophageal reflux disease: a prospective follow-up analysis. Therap Adv Gastroenterol 2019;12:1756284819864549.[6] Teerawattananon Y, Chaikledkaew U. Thai health technology assessment guideline development. J Med Assoc Thai 2008;91 Suppl 2:S11-15.[7] BOI: The Board of Investment of Thailand [Internet]. [cited 2022 Apr 19];Available from:https://www.boi.go.th/index.php?page=demographic.[8] Nimdet K, Ngorsuraches S. Willingness to pay per quality-adjusted life year for life-saving treatments in Thailand. BMJ Open 2015;5:e008123.Acknowledgements:NIL.Disclosure of InterestsChingching Foocharoen Speakers bureau: Boehringer Ingelheim, Norvatis, Janssen, Pritaporn Kingkaew: None declared, Yot Teerawattananon: None declared, Ajanee Mahakkanukrauh: None declared, Siraphop Suwannaroj: None declared, Witsarut Manasirisuk: None declared, Jitjira Chaiyarit: None declared, Apichat Sangchan: None declared.

BackgroundClinical predictors of mortality in systemic sclerosis (SSc) are diversely reported due to different healthcare conditions and populations. A universal and simplified predictive model for SSc mortality is needed so that practitioners can be used for managing their patients appropriately.ObjectivesWe aimed to develop and validate a simple predictive model for predicting mortality among patients with SSc.MethodsPrognostic research with a historical cohort study design was conducted between January 1, 2013, and December 31, 2019, in adult SSc patients and attending the Scleroderma Clinic at a university hospital in Thailand. The data were extracted from the Scleroderma Registry Database. A deep learning algorithm with Adam optimizer and different machine learning algorithms (including Decision tree, AdaBoost, Random Forest, Gradient Boosting, and XGBoost) was used to classify SSc mortality. In addition, the model’s performance was evaluated using the area under the receiver operating characteristic curve (auROC) and its 95% confidence interval (CI) and values in the confusion matrix.ResultsThe analysis and predictive model development included 658 SSc patients, 416 (63.2%) females, 452 (69.1%) had dcSSc, and 218 died. The final model included the modified Rodnan skin score (mRSS) and the WHO functional class (WHO-FC) ≥II (model 1). The final model provided the highest predictive performance, followed by model 2 (mRSS and WHO-FC ≥III). After internal validation, the accuracy and auROC were good, and the specificity was high in models 1 and 2 (81.1%, 0.84, and 95.5% in model 1 vs. 82.7%, 0.82, and 87.1% in model 2).Table 1.Generalizability of selected model(s) presented as accuracy, area under ROC, positive predictive value, positive likelihood ratio, specificity, and sensitivitySelected ModelAccuracyAUC (95%)PPV (95%)+LR (95%CI)Specificity (95%)Sensitivity (95%)Model 1 mRSS and WHO FC ≥ II81.183.6 (77.5 – 89.6)84.6 (69.5 - 94.1)11.3 (5.0-25.7)95.5 (90.4 - 98.3)51.6 (38.7 - 64.2)Model 2 mRSS and WHO FC ≥ III82.782.4 (75.8 - 88.9)73.4 (60.9 - 83.7)5.7 (3.6-9.187.1 (87.2 - 92.3)73.4 (60.9 - 83.7)95%CI 95% confidence interval, AUC Area Under the receiver operating characteristics (ROC), mRSS modified Rodnan skin scoreConclusionThis simplified machine learning model for predicting mortality among patients with SSc could guide early referrals to specialists and help rheumatologists with close monitoring and management planning. External validation across multi-SSc clinics should be considered for further study.References[1]Ferri C, Valentini G, Cozzi F, Sebastiani M, Michelassi C, La Montagna G, et al. Systemic sclerosis: demographic, clinical, and serologic features and survival in 1,012 Italian patients. Medicine (Baltimore). 2002;81(2):139–53.[2]Rubio-Rivas M, Royo C, Simeón CP, Corbella X, Fonollosa V. Mortality and survival in systemic sclerosis: systematic review and meta-analysis. Semin Arthritis Rheum. 2014;44(2):208–19.[3]Foocharoen C, Peansukwech U, Mahakkanukrauh A, Suwannaroj S, Pongkulkiat P, Khamphiw P, et al. Clinical characteristics and outcomes of 566 Thais with systemic sclerosis: A cohort study. Int J Rheum Dis. 2020;23(7):945–57.[4]Tyndall AJ, Bannert B, Vonk M, Airò P, Cozzi F, Carreira PE, et al. Causes and risk factors for death in systemic sclerosis: a study from the EULAR Scleroderma Trials and Research (EUSTAR) database. Ann Rheum Dis. 2010;69(10):1809–15.[5]Peduzzi P, Concato J, Kemper E, Holford TR, Feinstein AR. A simulation study of the number of events per variable in logistic regression analysis. J Clin Epidemiol. 1996;49(12):1373–9.[6]Elhai M, Meune C, Boubaya M, Avouac J, Hachulla E, Balbir-Gurman A, et al. Mapping and predicting mortality from systemic sclerosis. Ann Rheum Dis. 2017;76(11):1897–905.[7]Wangkaew S, Prasertwitayakij N, Phrommintikul A, Puntana S, Euathrongchit J. Causes of death, survival and risk factors of mortality in Thai patients with early systemic sclerosis: inception cohort study. Rheumatol Int. 2017;37(12):2087–94.AcknowledgementsThe authors thank (a) Thailand’s National Science, Research, and Innovation Fund for funding support, (b) the Scleroderma Research Group for research assistance, and (c) Mr. Bryan Roderick Hamman—under the aegis of the Publication Clinic Khon Kaen University, Thailand—for assistance with the English-language presentation.Disclosure of InterestsChingching Foocharoen Speakers bureau: By Boeringer Ingelheim, Bandit Thinkhamrop: None declared, Wilaiphorn Thinkhamrop: None declared, Nathaphop Chaichaya: None declared, Ajanee Mahakkanukrauh Speakers bureau: By Boeringer Ingelheim, Norvatis, Johnson & Johnson, Siraphop Suwannaroj Speakers bureau: By Boeringer Ingelheim, Johnson & Johnson, Norvatis

BackgroundCOVID-19 has become a common disease in patients with rheumatic immune-mediated diseases (R-IMID). A risk stratification of the patients at COVID-19 onset is important to predict possible unfavorable results.ObjectivesTo identify predictive severity factors in patients with COVID-19 with R-IMID.MethodsCross-sectional study in a single University Hospital. We included all consecutive patients with a R-IMID and COVID-19 up to November 6th, 2020. Confirmed infection was defined if the patient had a positive nasopharyngeal swab for SARS-CoV-2.COVID-19 case severity was divided into mild, moderate, severe and critical according to the United States National Institute of Health (NIH) COVID-19 guidelines (1).We performed a multivariable analysis and calculated de odds ratio of critical COVID in patients with R-IMID, adjusting by age, sex and comorbidities.ResultsWe included 274 patients with R-IMID complicated with COVID-19. At COVID-19 onset, the main comorbidities, analytical values, underlying R-IMID and treatments received are shown in Table 1.Table 1.General features patients with R-IMID and COVID-19General featuresOverall patients (n=274)Critical COVID (n=21)General features (continuation)Patients (n=274)Critical COVID (n=21)Age, years59 ±1876.32 ± 13.4Analytical values, mean ± SDFemale, n (%)185 (67)11 (52.4)-CRP (mg/dl)4.7 ± 5.2511.7 ± 8.6CV risk factors, n (%)-Creatinine (mg/dl)0.91 ± 0.41.4 ± 0.7-Current smoker27 (10)2 (9.5)-Platelets (x103/ul)179 ± 78163 ± 72-Obesity49 (18)5 (23.8)-Hemoglobina (g/l)13.0 ± 1.812.5 ± 2.1-Hypertension119 (43)18 (85.7)-Neutrophils (x103/ul)4.5 ± 2.54.9 ± 3.2-Diabetes Mellitus36 (13)5 (23.8)-Lymphocytes (x103/ul)1.1 ± 10.7 ± 0.5-Dyslipidemia119 (43)15 (71.4)-Ferritin (ug/L)426 ± 417664 ± 469Comorbidities, n (%)-LDH (U/L)257 ± 92314 ± 143-Chronic pulmonary disease12 (4.4)3 (14.3)-D-Dimer (ng/ml)999±12561890 ± 1893-Established cardiovascular disease45 (16.4)10 (47.6)Underlying R-IMID, n (%)-Cancer21 (8)6 (28.6)-RA79 (28.8)9 (42.9)-Chronic kidney disease27 (10)6 (28.6)-PsA55 (20.1)3 (14.3)-Chronic liver disease11 (4)3 (14.3)-SpA34 (12.4)0Treatments received, n (%)-PMR22 (8)6 (28.6)-Methotrexate // Hydroxychloroquine62 (23) // 50 (18)3 (14.3) // 2 (9.5)-SLE22 (8)0-TNFi31 (11.3)0-Vasculitis8 (2.9)1 (4.8)-Anti-CD208 (2.9)3 (14.3)-Sjogren’s syndrome8 (2.9)2 (9.5)-Other biologic DMARDs // JAKINIBs16 (5.8) // 6 (2.2)1 (4.8) // (4.8)-Others46 (16.8)0CRP: C-reactive protein; ILD: Interstitial lung disease; LDH: Lactate dehydrogenase; PMR: Polymyalgia rheumatica¸PsA: Psoriatic arthritis, RA: Rheumatoid arthritis; SLE: Systemic lupus erythematosus; SpA: Axial spondyloarthritis*Adjusted by age, cardiovascular risk factors and comorbiditiesAccording to COVID-19 severity, patients were mild (n=209; 76.3%), moderate (n=35; 12.8%), severe (n=9; 3.3%) and critical (n=21; 7.7%).The predictive variables at COVID-19 onset related statistically to critical COVID were older patients, hypertension, dyslipidemia, previous cardiovascular disease, cancer, chronic kidney disease, and chronic liver disease. The only underlying R-IMID and treatment was polymyalgia rheumatica and Rituximab, respectively. Regarding analytical values were higher values of C-reactive protein, LDH, platelets and lymphopenia (Figure 1).Figure 1.Predictive factors for critical COVID-19 in R-IMID (Multivariable analysis)COPD: Chronic obstructive pulmonary disease; CRP: C-reactive protein; CV: Cardiovascular; HCQ: Hydroxychloroquine; ILD: Interstitial lung disease; LDH: Lactate dehydrogenase; MTX: Methotrexate; PsA: Psoriatic arthritis; RA: Rheumatoid arthritis; SLE: Systemic lupus erythematosus; TNFi: TNF inhibitors.*p< 0.005Data in graphic are presented in a logarithmic scale.ConclusionWe identified various factors associated with a worse prognosis of COVID-19 in patients with R-IMID. This can help to identify which patients can present a worse course of the disease at the moment of the diagnosis.Disclosure of InterestsDavid Martínez-López: None declared, Iván Ferraz-Amaro: None declared, Diana Prieto-Peña: None declared, Fabricio Benavides-Villanueva: None declared, Cristina Corrales-Selaya: None declared, Lara Sanchez-Bilbao: None declared, Alba Herrero-Morant: None declared, Carmen Álvarez-Reguera: None declared, Martin Trigueros-Vazquez: None declared, Miguel A González-Gay Speakers bureau: Consultation fees/participation in company-sponsored speaker´s bureau from Abbvie, Pfizer, Roche, and MSD, Grant/research support from: Dr. Miguel A. Gonzalez-Gay received grants/research supports from Abbvie, MSD, and Roche, Ricardo Blanco Speakers bureau: Consultation fees/participation in company-sponsored speaker´s bureau from Abbvie, Lilly, Pfizer, Roche, Bristol-Myers, Janssen, and MSD., Grant/research support from: Dr. Ricardo Blanco received grants/research supports from Abbvie, MSD, and Roche

BackgroundAdult-onset Still’s disease (AOSD) is a rare systemic autoinflammatory disorder with unknown etiology. The main problem for rheumatologists is a lack of generally accepted methods for assessing AOSD activity.ObjectivesTo compare the usefulness of traditional and novel biomarkers for assessing the AOSD activityMethodsThe cross-sectional study included 27 patients over the age of 18 with a relapse of AOSD who were examined at the Almazov National Medical Research Centre from 2018 to 2021.All patients fulfilled the AOSD classification criteria by Yamaguchi. Clinical manifestations were scored in a Pouchot AOSD activity score. The serum concentrations of IL-1, IL-6, IL-18, ferritin, calgranulin, procalcitonin and the level of glycosylated ferritin (GF) were examined. Standard commercial reagents were used for detection clinical analysis of blood, C-reactive protein (CRP) and aminotransferases. Statistical analysis was performed using the licensed statistical applications Statistica 10.0 for Windows (StatSoft Inc., USA), and Prisma GraphPad 8.0 (GraphPad Software, USA). Results were expressed as median (25th–75th percentile) and analysed for statistical significance using nonparametric tests. For quantitative features comparison, the Mann–Whitney U test was used. The correlation coefficient was obtained by nonparametric Spearman’s rank correlation test. P values < 0.05 were considered statistically significant. Data from commercial test systems are taken as the basis for normal biomarker indicators.ResultsClinical data were available from 27 patients with AOSD (6 male and 21 female). The median age was 41.3 [26;50]. The median Pouchot activity score was 6 [4.5;7]. The course of AOSD was monocyclic in 1 patient, polycyclic in 23, and chronic in 3. Elevated leukocyte count > 10,000/μl was detected in 17 patients (63%), 9 patients (33%) had an elevated leukocyte count > 15,000/μl.An increase in biomarkers was detected in most patients: calgranulin was increased in 24 out of 26 patients (92.3%), ferritin was increased and GF was decreased in 21 out of 25 patients (84%). Among those 25 patients, the decrease in GF was less than 20% in 13 patients (52%). IL-18 increased in 17 patients (63%), IL-6 increased in 22 patients (81.5%), and procalcitonin increased in 16 out of 26 patients (61.6%). The median of procalcitonin concentration was 0.08 [0.01; 30.1]. No increase in IL-1 beta was detected.A correlation analysis revealed a direct relationship between the concentration of IL-18, ferritin and the Pouchot system score. An inverse relationship existed between these indicators and the level of GF (rs=0.803, p=0.001) and between calgranulin and IL-6 (rs=0.46, p=0.02). It was noted that the younger the age of the patients, the higher the concentration of IL-18 (rs=-0.449, p=0.019).ConclusionThe most promising additional laboratory biomarkers for assessing AOSD activity are calprotectin, IL-18, and ferritin. Despite a slight increase in procalcitonin as one of the indicators of the acute phase of inflammation, it remains an effective biomarker of sepsis; however, it is recommended to focus on threshold concentrations above 0.5.References[1]Ruscitti P, Cipriani P, Masedu F, Iacono D, Ciccia F, Liakouli V, Guggino G, Carubbi F, Berardicurti O, Di Benedetto P, Valenti M, Triolo G, Valentini G, Giacomelli R. Adult-onset Still’s disease: evaluation of prognostic tools and validation of the systemic score by analysis of 100 cases from three centers. BMC Med. 2016 Dec 1;14(1):194. doi: 10.1186/s12916-016-0738-8.[2]Feist E, Mitrovic S, Fautrel B. Mechanisms, biomarkers and targets for adult-onset Still’s disease. Nat Rev Rheumatol. 2018 Oct;14(10):603-618. doi: 10.1038/s41584-018-0081-x.[3]Lapin S, Maslyansky A., Lazareva N., Vasilyeva E., Totolyan A. The significance of the quantitative determination of procalcitonin for the diagnosis of septic complications in patients with autoimmune rheumatic diseases. Clinical laboratory diagnostics. 2013. No. 1.Disclosure of InterestsValentina Myachikova Speakers bureau: Novartis, Sobi, Evgenii Kuvardin: None declared, Kira Zotkina Speakers bureau: Novartis Amgen, Olga Tkachenko: None declared, Sergey Lapin: None declared, Alexey Maslyanskiy Speakers bureau: Boehringer Ingelheim Pharmaceuticals, Novartis, R-PHARM. Eli Lilly

Introduction/Aim: Gerontology institutions present objects with the presence of a great number of partly mobile or immobile persons. In emergency conditions, their evacuation because of noted reasons can take longer, so the aim of the research was to present several ways for the evacuation of partly mobile and immobile persons older than 70, from gerontology institutions, and to evaluate necessary evacuation time. Methods: For this research, the software Pathfinder 2020 was used for the calculation of evacuation times and predicting of potential situations during evacuation. The gerontology institution, as a used model, presents an object with a basement and four floors. All floors have 16 rooms with two patients in every room. Floors are connected with main stairs, emergency stairs and with four elevators (two cargo elevators for 12 persons per elevator, and two passenger elevators for 6 persons per elevator). The total number of medical and administrative staff is 44, and the number of users of gerontological institution services is 128. The simulation of evacuation from gerontology institution was realized for four different scenarios: The first, when all the elevators are in function and all stairs are accessible; the second, when none of the elevators works but stairs are accessible; the third, when only emergency stairs are in function; the fourth, when only main stairs are in function. Each of these four scenarios has four different situations that depend on the evaluated speed of patient`s movement. Results: The evacuation time when it is possible to use all elevators and stairs is from 895 seconds (14.9 minutes) (for the fastest movement of persons - the first situation) to 958 seconds (16 minutes) (for the slowest movement of persons - the fourth situation), for main and emergency stairs from 984 to 1111.1 seconds (16.4-18.5 minutes), only for emergency stairs from 1997.6 to 2765.3 seconds (33.3-46.1 minutes), and only for main stairs from 1365 to 2342 seconds (22.8-39.0 minutes). Conclusion: The usage of computer software Pathfinder 2020 for the simulation of evacuation presents a very important, safe and cheap way for predicting evacuation way and speed, which can contribute to the national strategy for emergency situations.

BackgroundGSK is investigating an autologous TCR T-cell therapy for solid tumors that recognizes the cancer testis antigen, NY-ESO-1, presented on the cancer cell surface by specific HLA-A*02 sub-types. The aim of this study was to estimate the number of patients in the US in 2020 with HLA-A*02 genotype subtypes HLA-A*02:01, 02:05, 02:06 across selected cancer types (invasive lung, ovarian, gastric, esophageal, invasive and in-situ bladder and multiple myeloma), accounting for racial variation.MethodsThis study was carried out in three parts utilizing three national datasets.1. The prevalence of each cancer type was estimated by race utilizing prevalence rates from US Surveillance, Epidemiology, and End Results (SEER) 1975–2018 data.1 2. The US population coverage for the specific HLA-A*02 subtype (%) by race in 2020, was estimated utilizing Hardy Weinberg Principles and allele frequencies extracted from the allele frequency net database (US National Marrow Donor Program (NMDP) population only).2 3. The estimated population coverage for the specific HLA-A*02 subtype expression (%) by cancer subtype, was calculated using US Census (2019) data.3 For the purpose of this analyses, single race population estimates were used. Race was categorized as ‘White’, ‘Black’, ‘Asian/Pacific Islander’, ‘Native American’ and ‘Other’. The Hispanic population was included as a proportion of each category, where appropriate. Limitations include the seven assumptions underlying Hardy-Weinberg equilibrium, which were met, and the assumption that the NMDP, SEER and US Census data are reflective of the US population. Predictive and prognostic clinical characteristics including histological subtypes were not accounted for in this analysis.ResultsAcross selected cancer types, the most prevalent race category was White, reflecting the racial distribution of the US (table 1). Of these cancer types, multiple myeloma and invasive gastric cancer are represented by the lowest proportion of White patients and the highest proportion of Black patients. Results of the HLA sub-type distribution by race are presented in the table below. The overall proportion of patients who are HLA-A*02:01, *02:05 or *02:06 positive is estimated to be between 41.7% (multiple myeloma) and 45.8% (invasive and in-situ bladder) in the US accounting for the racial variations in each cancer type of interest.Abstract 899 Table 1Proportion of patients who are HLA-A*02:01, *02:05, or *02:06 positive by race and cancer subtypeConclusionsThe proportion of patients with specific HLA-A*02 subtypes is similar across selected cancers, accounting for racial variation in the US. Racial variation by cancer type is an important consideration when estimating the size of eligible populations for T-cell therapies requiring specific HLA-A*02 histocompatibility.AcknowledgementsFundingGlaxoSmithKlineReferencesHowlader N, Noone AM, Krapcho M, Miller D, Brest A, Yu M, Ruhl J, Tatalovich Z, Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds). SEER Cancer Statistics Review, 1975–2018, National Cancer Institute. Bethesda, MD, [https://seer.cancer.gov/csr/1975_2018/], based on November 2020 SEER data submission, posted to the SEER web site, April 2021 (Accessed July 2021).Gonzalez-Galarza FF, McCabe A, Santos EJ, Jones J, Takeshita LY, Ortega-Rivera ND, Del Cid-Pavon GM, Ramsbottom K, Ghattaoraya GS, Alfirevic A, Middleton D, Jones AR. Allele frequency net database (AFND) 2020 update: gold-standard data classification, open access genotype data and new query tools. Nucleic Acids Res 2020;48:D783–8.U S Census Bureau (2011). ACS demographic and housing estimates. [https://data.census.gov/cedsci/table?q=United%20States&g=0100000US&tid=ACSDP1Y2017.DP05&vintage=2017&layer=state&cid=DP05_0001E] (Accessed July 2021).

Introduction Pregnancy in sickle cell disease (SCD) is associated with an exacerbation of SCD-related complications and an increased risk of maternal complications. The increased risk is partly due to physiologic adaptations in pregnancy, which include increased metabolic demands and a hypercoagulable state. The maternal death rate for SCD is 629 per 100,000 deliveries, compared to 12 per 100,000 deliveries in black women and 6 per 100,000 deliveries in the general population (Raider et al., 2016). Studies on maternal and perinatal outcomes of patients with SCD present inconsistent and conflicting results. Some studies have reported an increase in maternal complications such as pre-eclampsia, acute chest syndrome and thromboembolic events, while other studies have reported no significant risk in adverse maternal outcomes. The inconsistent findings reported in prior studies may be attributed to small sample sizes and single-centered sites. Our study aims to determine the prevalence and predictors of maternal morbidity among participants enrolled in the SCD Implementation Consortium (SCDIC) registry, which is the largest, most geographically diverse SCD participant sample in the United States. Methods This cross-sectional study included women enrolled in the SCDIC registry who had at least one pregnancy event. The SCDIC is composed of eight academic SCD centers across the United States and one data-coordinating center. Participants were enrolled in the SCDIC registry if they were 18 to 45 years of age and had a confirmed diagnosis of SCD. Enrolled participants completed a series of surveys that collected sociodemographic information, SCD and pregnancy history and data abstractions of participants' medical records was completed. Medical complications queried during pregnancy included: vaso-occlusive episodes, acute chest syndrome, blood transfusion requirement, preeclampsia, maternal diabetes and deep venous thrombosis. Descriptive analysis of sociodemographic, clinical and maternal characteristics was conducted. Bivariate analysis was performed using Chi-Square test, Mann-Whitney U test, t-test, and logistic regressions, as appropriate. A p-value of ≤ 0.05 was considered statistically significant for all analysis. Results The study sample included 743 women who had at least one pregnancy event, and a total of 1066 live births. Almost all women (96.3%) were African American, with a median age of 21 years (inter-quartile range of 19 to 23 years) at first birth. The majority had Hb SS SCD genotype (69.5%; 513 of the 738 with SCD genotype data). Of all reported pregnancies, participants did not use hydroxyurea during conception (78%), and pregnancy (84.5%). Only 2.7 % of the women reported using fertility drugs or assisted reproductive procedures. Seventy five percent of the pregnancies that ended in live births had maternal complications. The leading complications were vaso-occlusive episodes (61.2%), pregnancy requiring blood transfusion(s) (33.2%), preeclampsia (15.4%), deep venous thrombosis (5.6%) and acute chest syndrome (7.7%). When the pregnancies were stratified by SCD genotype, women with Hb SS had a higher occurrence of acute chest syndrome (63.4% vs. 26.7%), transfusion requirement (70.8% vs. 21%) and preeclampsia (66.7% vs 22.4%). In the univariate logistic regressions, multiparous women, with a history of adverse maternal outcomes in a previous pregnancy, had higher odds of vaso-occlusive episodes (OR: 3.42; 95% CI: 2.42-4.94) acute chest syndrome (OR:4.99; 95% CI:2.56- 9.48), transfusion requirement (OR:3.86; 95% CI:2.64- 5.69), and pre-eclampsia (OR:3.36; 95% CI:2.05-5.45). Conclusion In this large multicenter registry, we found pregnant women with SCD have significant maternal complications. Early antenatal care by healthcare providers knowledgeable about risk factors for adverse maternal outcomes in SCD is essential improve maternal and fetal outcomes and reduce the maternal death rate for SCD. Disclosures Hankins: Novartis: Research Funding; Global Blood Therapeutics: Consultancy, Research Funding; MJH Life Sciences: Consultancy, Patents & Royalties; UptoDate: Consultancy; National Heart, Lung, and Blood Institute: Honoraria, Research Funding; LINKS Incorporate Foundation: Research Funding; American Society of Pediatric Hematology/Oncology: Honoraria. Treadwell:Global Blood Therapeutics: Consultancy; UpToDate: Honoraria. King:Amphivena Therapeutics: Research Funding; Bioline: Consultancy; Celgene: Consultancy; Cell Works: Consultancy; Incyte: Consultancy; Magenta Therapeutics: Membership on an entity's Board of Directors or advisory committees; Novimmune: Research Funding; RiverVest: Consultancy; Tioma Therapuetics: Consultancy; WUGEN: Current equity holder in private company. Gordeuk:CSL Behring: Consultancy, Research Funding; Global Blood Therapeutics: Consultancy, Research Funding; Imara: Research Funding; Ironwood: Research Funding; Novartis: Consultancy. Kanter:SCDAA Medical and Research Advisory Board: Membership on an entity's Board of Directors or advisory committees; AGIOS: Membership on an entity's Board of Directors or advisory committees; BEAM: Membership on an entity's Board of Directors or advisory committees; Novartis: Consultancy; GLG: Honoraria; Jeffries: Honoraria; Cowen: Honoraria; Wells Fargo: Honoraria; NHLBI Sickle Cell Advisory Board: Membership on an entity's Board of Directors or advisory committees; Medscape: Honoraria; Guidepoint Global: Honoraria; bluebird bio, inc: Consultancy, Honoraria; Sanofi: Consultancy. Glassberg:Pfizer: Research Funding; Global Blood Therapeutics: Consultancy; Eli Lilly and Company: Research Funding. Shah:Novartis: Consultancy, Research Funding, Speakers Bureau; Alexion: Speakers Bureau; CSL Behring: Consultancy; Bluebird Bio: Consultancy; Global Blood Therapeutics: Consultancy, Research Funding, Speakers Bureau.

In 2016 and 2017, the Utah Geological Survey partnered with the U.S. Bureau of Land Management to conduct a paleontological inventory of the Morrison Formation south and west of Blanding, Utah, along the eastern margin of the Bears Ears National Monument. The Morrison in this region is critical to understanding Upper Jurassic stratigraphy across the Colorado Plateau because it is the type area for the Bluff Sandstone, Recapture, Westwater Canyon, and Brushy Basin Members of the Morrison Formation, which are the basis for nomenclature in New Mexico and Arizona as well. Researchers have disagreed about nomenclature and correlation of these units, which transition northward in the study area into the Tidwell, Salt Wash, and Brushy Basin Members. Numerous vertebrate localities make inclusion of the Bluff Sandstone and Recapture Members in the Middle Jurassic San Rafael Group, as suggested by some previous workers, unlikely. The Salt Wash Member does not separate the Bluff Sandstone and Recapture Members at Recapture Wash, but sandstone lenses of Salt Wash facies occur higher in northern Recapture exposures. Northward, along the outcrop belt east of Comb Ridge, the Bluff-Recapture interval thins, interlenses, and pinches out into the Tidwell and lower Salt Wash, with the main lower sandstone interval of the Westwater Canyon merging northward into the upper Salt Wash Member. The partly covered, 1938 type section of the Brushy Basin Member is identified along Elk Mountain Road at the southern end of Brushy Basin. We describe a detailed, accessible Morrison Formation reference section about 11.2 km (7 mi) to the south along Butler Wash. There, 81.68 m (268 ft) of Brushy Basin Member is well exposed along a road between the top of the Westwater Canyon Member and the base of the Lower Cretaceous Burro Canyon Formation. We informally call the upper sandstone bed(s) of the Westwater Canyon Member that cap mesas and benches in the region “No-Mans Island beds.” Smectitic mudstones between the No-Mans Island beds and the main sandstone body of the Westwater Canyon suggest that the Salt Wash-Brushy Basin contact to the north may be somewhat older than the base of the Brushy Basin Member as originally defined in its type area. Determining whether the No-Mans Island beds pinch out to the north or are removed by erosion below the regional basal Brushy Basin paleosol requires further research. Several significant fossil vertebrate and plant sites have been documented in the Brushy Basin type area. Newly identified volcanic ashes provided zircons for U-Pb ages of 150.67 ± 0.32 Ma from near the top of the Brushy Basin Member and of 153.7 ± 2.1 Ma and 153.8 ± 2.2 Ma for two zircons in lower part of Recapture Member. At the top of the Brushy Basin Member, ferruginous paleosols commonly overlying conglomeratic sandstone are speculated to be of Early Cretaceous age (detrital zircon age pending) and are assigned herein to the Yellow Cat Member of the Burro Canyon Formation. These iron-rich paleosols suggest wetter climatic conditions during the Jurassic-Cretaceous transition in the Blanding basin.

The World Trade Center Attack or 9/11 tragedy has awakened the international community, particularly the United States (US) to sharpen its foreign policy in facing security threats coming from ‘weak states’. One of the most prominent weak states examples that pose a grave threat to other countries are the Northern Triangle Countries of Central America that referred to Guatemala, Honduras, and El Salvador. Hence, this paper will discuss the rationale behind US initiatives in dealing with security threats in El Salvador as one of the Northern Triangle Countries. In analyzing the case, the writers will use the weak state concept and national interest concept. The result of this paper finds that El Salvador corresponds to the elements of a weak state and further poses security threats by giving rise to transnational criminal organizations, drug trafficking, and migrant problems in which overcoming those security threats has become US vital national interest. However, we also find that although decreasing security threats and strengthening El Salvador government capacity is highly correlated, strengthening El Salvador governance through the providence of aid and assistance is actually classified as US important national interest. Keywords: Security threats; Northern Triangle; weak state; El Salvador; national interest REFERENCES Ambrus, Steven. “Guatemala: The Crisis of Rule of Law and a Weak Party System.” Ideas Matter, January 28, 2019. https://blogs.iadb.org/ideas-matter/en/guatemala-the-crisis-of-rule-of-law-and-a-weak-party-system/. Andrade, Laura. Transparency In El Salvador. 1st ed. 1. El Salvador: University Institute for Public Opinion, Asmann, Parker. “El Salvador Citizens Say Gangs, Not Government 'Rule' the Country.” InSight Crime, August 19, 2020. https://insightcrime.org/news/brief/el-salvador-citizens-say-gangs-not- government-rules-country/. Accessed July 11, 2021. Art, Robert J. A. Grand Strategy for America. 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Based on the data of daily maximum temperature in 26 meteorological stations in the North Center Region, Vietnam over the period of 1980 to 2013, the authors conducted the research on the spatial distribution of the number of hot days. The initial result shows that in general, in the north of the study area, the large number of hot days occurred in the plain, and tended to decrease westward and eastward. In the south, this number tends to increase from the west to the east. Especially, the largest number occurred in two areas: The Ma and Ca River's valleys (Thanh Hoa and Nghe An provinces) and the coastal areas (Thua Thien Hue province), creating two heat centers in Tuong Duong district, Nghe An province and Nam Dong district, Thua Thien Hue province.ReferencesAdina-Eliza Croitoru, Adrian Piticar, Antoniu-Flavius Ciupertea, Cristina FlorinaRosca, 2016 Changes in heat wave indices in Romania over the period 1961-2015. Global and Plantary Change 146. Journal homepage: www. 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ABSTRACT Islamic banking in Indonesia and Malaysia experienced differences in asset growth and market share, potentially causing dissimilarity in profitability performance. This study aims to evaluate the factors that influence the increase in profitability of Islamic banking in Indonesia and Malaysia using signaling theory including market concentration (HHI), company size and financing risk (NPF), and national income (GDP) as control variables. It analyzed the Indonesian and Malaysian Islamic banks during the period 2017-2021. The method used in this study is comparative descriptive with panel data regression analysis measuring instruments. Based on the results of empirical analysis, factors that affect the profitability of Islamic banking in Indonesia are financing risk, while in Malaysia, it is financing risk and national income. The results of this study update the view on the profitability of Islamic banking in Indonesia and Malaysia. In addition, from the managerial side, this study contributes to creating NPF control in Indonesian Islamic banking because these factors can increase the profitability of the country's Islamic banking. The study also contributes to the development of market concentration strategies, company size, and financing risks in Malaysian Islamic banking as all these factors can increase the profitability of the country's Islamic banking. Keywords: Islamic Banking, Profitability, Market Concentration, Company Size, Financing Risk ABSTRAK Perbankan syariah Indonesia dan Malaysia mengalami perbedaan dalam pertumbuhan aset dan market share sehingga berpotensi menimbulkan perbedaan kinerja profitabilitas. Studi ini bertujuan untuk mengevaluasi faktor yang mempengaruhi peningkatan profitabilitas perbankan syariah di Indonesia dan Malaysia dengan menggunakan signaling theory diantaranya konsentrasi pasar (HHI), ukuran perusahaan dan risiko pembiayaan (NPF) serta pendapatan nasional (GDP) sebagai variabel kontrol. Studi ini menganalisis bank syariah di Indonesia dan Malaysia selama periode 2017-2021. Metode yang digunakan oleh studi ini adalah komparatif deskriptif dengan alat ukur analisis regresi data panel. Berdasarkan hasil analisis empiris, faktor yang mempengaruhi profitabilitas perbankan syariah Indonesia adalah risiko pembiayaan sedangkan di Malaysia adalah risiko pembiayaan serta pendapatan nasional. Hasil penelitian ini memperbaharui pandangan tentang profitabilitas perbankan syariah Indonesia dan Malaysia. Selain itu dari sisi manajerial, studi ini berkontribusi dalam menciptakan pengendalian NPF pada perbankan syariah Indonesia karena faktor tersebut mampu meningkatkan profitabilitas perbankan syariah negara tersebut. Selain itu studi ini juga berkontribusi dalam pengembangan strategi konsentrasi pasar, ukuran perusahaan dan risiko pembiayaan pada perbankan syariah Malaysia karena semua faktor tersebut mampu meningkatkan profitabilitas perbankan syariah negara tersebut. Kata Kunci: Bank Syariah, Profitabilitas, Konsentrasi Pasar, Ukuran Perusahaan, Risiko Pembiayaan REFERENCE Abbas, A., & Arizah, A. (2019). Marketability, profitability, and profit-loss sharing: evidence from sharia banking in Indonesia. Asian Journal of Accounting Research, 4(2), 315–326. doi:10.1108/AJAR-08-2019-0065 Adelopo, I., Lloydking, R., & Tauringana, V. (2018). Determinants of bank profitability before, during, and after the financial crisis. 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BackgroundOne in ten patients with hyperuricemia may develop gout over time, with urate deposition sometimes asymptomatic. Recent reviews support ultrasound (US) to assess asymptomatic hyperuricemic (AH) patients to detect gout lesions, showing double contour (DC) and tophus the highest specificities and positive predictive values. Hyperuricemia and gout are common in chronic kidney disease (CKD), especially with glomerular filtration rate (GFR) <60, and are associated with worse prognosis. US gout lesions have been found more frequently in AH (up to 35%) than in normouricemic (NU) patients, but evidence is scarce in CKD.ObjectivesTo assess the prevalence of urate deposit in stages 3-5 CKD detected by US, and to investigate if there are differences between AH and NU patients.MethodsCase-control study, recruiting patients aged ≥18 years with AH and stages 3-5 CKD in 4 hospitals from January 2020 to December 2021. Controls were patients with stages 3-5 CKD and NU. Exclusion criteria: previous diagnosis of gout, tophi. Hyperuricemia was defined as serum uric acid (sUA) >6.8 mg/dl, documented at least twice during the last 12 months. A standardized US exam of the knees and bilateral first metatarsophalangeal joints was performed to assess patients for DC/tophus as defined by OMERACT. Demographic, clinical and laboratory data were recorded. A descriptive analysis was performed using SPSS. Pre-clinical gout (PCG: DC and/or tophus) was considered as outcome variable. Chi-square and Fisher’s exact test were used for qualitative variables, and Mann-Whitney U test for quantitative variables; significant threshold p<0.05.ResultsForty-four patients with stages 3-5 CKD (59.6% stage 3, 19.1% stage 4, 21.3% 5) were recruited, 35 AH and 9 NU. Hyperuricemia was associated with a higher prevalence of US findings, with significant differences between cases (AH) and controls (NU): PCG 19 vs 1 (p=0.023), DC 13 vs 1, and tophus 11 vs 0. No significant differences were found in demographic variables, comorbidities and treatments. sUA levels, were higher in patients with PCG (8.3±1.4 vs 7.6±2.2; p=0.36), and these patients also showed lower GFR (31.4±14.1 vs 33.7±16.9; p=0.62). Patients with PCG also showed a non-significant trend towards shorter duration of CKD [6.3±5.7 vs 8.3±4.9 years; p=0.1] and younger age (66.4±15.1 vs 70.0 ±11.0; p=0.30).ConclusionWe found an outstanding prevalence of asymptomatic urate deposits in our cohort of patients with stages 3-5 CKD, that is higher in hyperuricemic than in normouricemic patients. The prevalence of DC and tophus in our cohort of AH patients with stages 3-5 CKD was higher than that reported in AH patients in studies conducted in general population (37% vs 16-31% and 31% vs 16%, respectively). Early diagnosis of pre-clinical gout by ultrasound might change therapeutic approach in CKD.References[1]Robinson PC, et al. Longitudinal development of incident gout from low-normal baseline serum urate concentrations: individual participant data analysis. BMC Rheumatol. 2021;5(1):33.[2]Jing J, et al.; GCKD Study Investigators. Prevalence and correlates of gout in a large cohort of patients with chronic kidney disease: the German Chronic Kidney Disease (GCKD) study. Nephrol Dial Transplant. 2015;30(4):613-21.[3]Stack AG, et al. Gout and the risk of advanced chronic kidney disease in the UK health system: a national cohort study. BMJ Open. 2019;9(8):e031550.[4]Stewart S, et al. Prevalence and discrimination of OMERACT-defined elementary ultrasound lesions of gout in people with asymptomatic hyperuricaemia: A systematic review and meta-analysis. Semin Arthritis Rheum. 2019;49(1):62-73.[5]Christiansen SN, et al. Ultrasound for the diagnosis of gout-the value of gout lesions as defined by the Outcome Measures in Rheumatology ultrasound group. Rheumatology 2021.[6]Peiteado D, et al. Value of a short four-joint ultrasound test for gout diagnosis: a pilot study. Clin Exp Rheumatol 2012.AcknowledgementsSpecial thanks to the Nephrology and Rheumatology departments of the 4 participating centers.Disclosure of InterestsEnrique Calvo-Aranda Speakers bureau: Menarini, Grünenthal, Laura Barrio Nogal: None declared, Boris Anthony Blanco Cáceres: None declared, Marta Novella-Navarro: None declared, Diana Peiteado: None declared, Jaime Arroyo Palomo: None declared, Eugenio de Miguel: None declared, Alejandro Prada Ojeda: None declared, Luis Sala Icardo: None declared, maria teresa navio marco: None declared, Mónica Vázquez Díaz: None declared, Claudia Maria Gomez-Gonzalez: None declared, Roberto Alcazar Arroyo: None declared, Juan Antonio Martin Navarro: None declared, Marco Vaga Gallardo: None declared, Milagros Fernandez Lucas: None declared, Martha Elizabeth Diaz Dominguez: None declared

The pandemic of COVID-19 has afflicted every individual and has initiated a cascade of directly or indirectly involved events in precipitating mental health issues. The human species is a wanderer and hunter-gatherer by nature, and physical social distancing and nationwide lockdown have confined an individual to physical isolation. The present review article was conceived to address psychosocial and other issues and their aetiology related to the current pandemic of COVID-19. The elderly age group has most suffered the wrath of SARS-CoV-2, and social isolation as a preventive measure may further induce mental health issues. Animal model studies have demonstrated an inappropriate interacting endogenous neurotransmitter milieu of dopamine, serotonin, glutamate, and opioids, induced by social isolation that could probably lead to observable phenomena of deviant psychosocial behavior. Conflicting and manipulated information related to COVID-19 on social media has also been recognized as a global threat. Psychological stress during the current pandemic in frontline health care workers, migrant workers, children, and adolescents is also a serious concern. Mental health issues in the current situation could also be induced by being quarantined, uncertainty in business, jobs, economy, hampered academic activities, increased screen time on social media, and domestic violence incidences. The gravity of mental health issues associated with the pandemic of COVID-19 should be identified at the earliest. Mental health organization dedicated to current and future pandemics should be established along with Government policies addressing psychological issues to prevent and treat mental health issues need to be developed. References World Health Organization (WHO) Coronavirus Disease (COVID-19) Dashboard. 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RESUMENEl objetivo de este artículo es reflexionar sobre los mecanismos de financiación y de control de las instituciones religiosas por los laicos en las primeras décadas de la conquista y colonización de Hispanoamérica. Investigar sobre la inversión laica en lo sagrado supone en un primer lugar aclarar la historiografía sobre laicos, religión y dinero en las sociedades de Antiguo Régimen y su trasposición en América, planteando una mirada desde el punto de vista de las motivaciones múltiples de los actores seglares. A través del ejemplo de restituciones, donaciones y legados en losAndes, se explora el papel de los laicos españoles, y también de las poblaciones indígenas, en el establecimiento de la densa red de instituciones católicas que se construye entonces. La propuesta postula el protagonismo de actores laicos en la construcción de un espacio cristiano en los Andes peruanos en el siglo XVI y principios del XVII, donde la inversión económica permite contribuir a la transición de una sociedad de guerra y conquista a una sociedad corporativa pacificada.PALABRAS CLAVE: Hispanoamérica-Andes, religión, economía, encomienda, siglos XVI y XVII.ABSTRACTThis article aims to reflect on the mechanisms of financing and control of religious institutions by the laity in the first decades of the conquest and colonization of Spanish America. Investigating lay investment in the sacred sphere means first of all to clarifying historiography on laity, religion and money within Ancien Régime societies and their transposition to America, taking into account the multiple motivations of secular actors. The example of restitutions, donations and legacies inthe Andes enables us to explore the role of the Spanish laity and indigenous populations in the establishment of the dense network of Catholic institutions that was established during this period. The proposal postulates the role of lay actors in the construction of a Christian space in the Peruvian Andes in the sixteenth and early seventeenth centuries, when economic investment contributed to the transition from a society of war and conquest to a pacified, corporate society.KEY WORDS: Hispanic America-Andes, religion, economics, encomienda, 16th and 17th centuries. BIBLIOGRAFIAAbercrombie, T., “Tributes to Bad Conscience: Charity, Restitution, and Inheritance in Cacique and Encomendero Testaments of 16th-Century Charcas”, en Kellogg, S. y Restall, M. 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Esta investigación nos sitúa frente a la temática de la demencia y da cuenta de las construcciones sociales que se tejen en relación a esta, considerando la vivencia y narrativas de quienes están en contacto cotidiano con los adultos mayores que han sido diagnosticados con esta enfermedad, como son los familiares, cuidadores, entornos comunitarios e institucionales. Se instala la pregunta: "¿cómo estructuran y significan la realidad de la demencia los agentes sociales que interactúan cotidianamente con las personas mayores con ese diagnóstico clínico?" (p. 30). En relación a lo anterior, es importante precisar que la perspectiva planteada en la investigación observa la demencia más allá de su categoría diagnóstica, abriendo paso a las percepciones de quienes conviven con esta realidad a diario, y que construyen significados propios, lidiando con la incertidumbre que la demencia tiene en sus vidas. Es así como vemos que las comunidades van generando sentido ante aquello que aparece como disruptivo, distinto y atemorizante, y donde los discursos médicos se hacen insuficientes como contexto explicativo. Como lo ilustran las experiencias a las cuales se les da voz en este libro, la demencia es una vivencia que fractura la realidad de quienes la padecen, así como su entorno más cercano, generando una crisis en las organizaciones previas de las familias. Sentimientos de extrañeza, miedo, confusión, vergüenza, son plasmados en los relatos, en los que se percibe la desesperanza, el aislamiento y sufrimiento de parte de familiares y protagonistas del cuidado. Hay una visión negativa y estigmatizada de la vejez, que a la vez alcanza en sus atribuciones a los cuidadores. Aparece una suerte de ‘contagio’ a la devaluación que se hace de la persona con demencia, la cual alcanza a su entorno familiar más cercano e influye en el proceso de marginación social de quienes son parte de este (pp. 95-189). Por otra parte, en el relato de los actores comunitarios se evidencia la falta de procedimientos y confusión frente a quienes quedan como responsables de manejar situaciones en las que existen personas identificadas con demencia en el espacio público. Entonces, se hace lo que se puede con los recursos disponibles, quedando expuesto que esta es una temática en la cual no hay claridad suficiente, preparación, ni dispositivos adecuados que puedan acoger las demandas de cuidado de adultos mayores con demencia, dejándolos muchas veces en situaciones de vulnerabilidad y desamparo (pp. 189-223 ). A partir de estos relatos en torno a la demencia y su complejo entramado, es posible reflexionar acerca de la forma en que los individuos y sociedades nos relacionamos, dando cuenta de la organización de los cuidados y regímenes de género presentes en nuestro país, las ideas en torno a la vejez, la enfermedad y la dependencia, experiencias que están fuertemente atravesadas por las profundas desigualdades en las realidades materiales y culturales de Chile. Todo esto, estructurado en un contexto neoliberal que mercantiliza la enfermedad (p. 141) y en el cual la lógica de derechos ha quedado subordinada a una segmentación de los recursos, reproduciendo a la vez la idea de un país que se divide en quintiles, y en el que las ofertas de ayuda son enmarcadas desde discursos asistencialistas (Aguirre, 2011, pp. 90-91; Arriagada y Todaro, 2012, pp. 63-64; Arriagada, 2011, pp. 5-6). Quisiera detenerme en torno a la temática del cuidado, que es uno de los protagonistas y ejes centrales de este libro. Preguntarse acerca de la organización de los cuidados conlleva observar la forma en la cual, desde los distintos sectores de la sociedad, este ha sido significado y distribuido, comprendiendo cuál es la participación del Estado, el mercado, las comunidades y las familias en este proceso, especialmente en los grupos que son considerados más dependientes, como es el caso de los adultos mayores diagnosticados con demencia (Lister et al., 2007, p. 2; Lutz, 2008, p. 2). El régimen de cuidados de una sociedad está conformado por las creencias y valoraciones asociadas a esta labor, incluyendo las expectativas relacionadas con la forma adecuada de proveerlo, las prácticas sociales existentes, los discursos dominantes, la historia en políticas públicas en la materia y las relaciones de poder que están insertas en la distribución del cuidado (Williams, 2010, p. 390). Chile y Latinoamérica han sido caracterizados como regímenes de cuidados ‘familistas’. Esto significa que las familias y, al interior de estas las mujeres, han sido históricamente las responsables de la provisión de cuidados en la sociedad (p. 141). Como podemos ver, desde los distintos subcampos investigados en este libro, el protagonismo del cuidado queda en manos de las mujeres, situación que es transversal en todas las clases sociales, en las llamadas cuidadoras formales e informales, incluso en quienes participan en este campo desde la producción científica. Sin embargo, esto aparece como una realidad que no es cuestionada en los discursos, observándose desde el relato de los sistemas familiares que el lugar del cuidador está prescrito (p. 107), y que resulta en una especie de continuidad de las labores previas que eran realizadas por una mujer del grupo familiar. El modelo de familia tradicional, conformado por el hombre proveedor y la mujer madre y dueña de casa, discurso realzado desde la arena política (Molano Mijangos, Robert y Domínguez, 2012, p. 17; Sunkel, 2007, pp. 175-176; Jelin, 2007, pp. 97-98), se ve reflejado en la forma en que las familias asumen el cuidado del adulto mayor con demencia, siendo las mujeres quienes tienen el rol de cuidadoras y los hombres de proveedores, distribuciones que se encuentran naturalizadas en los relatos de los entrevistados. Por otra parte, la devaluación del cuidado como un trabajo natural e intrínsecamente femenino (p. 29), se ha trasladado al mercado del trabajo, con precarización y bajos salarios en el rubro de las cuidadoras formales, definición de formalidad, que como se señala en el libro invita a ser cuestionada dadas las condiciones expuestas. En los relatos puede dimensionarse el grado de demandas y exigencias que esta labor requiere, y el desgaste físico y emocional que ella conlleva. Se observa, además, un carácter sacrificial del cuidado en los familiares, lo que se traspasa a quienes ejercen esta labor de forma pagada, respecto de quienes se espera una ‘vocación de servicio’, más allá de conocimientos específicos de las tareas que aquel implica (pp. 223-271). De esta forma se invisibilizan y devalúan las dificultades y grado de expertiz que se requieren para ejercer la labor de cuidado. Esto resulta muy conveniente en una lógica neoliberal de mercantilización de la salud (p. 141), ya que podemos hacer más ‘eficientes’ los servicios si lo que requerimos es un mano de obra barata, no calificada, es decir, mujeres haciendo lo que saben hacer por naturaleza: cuidar. Desde las experiencias expuestas, se concluye que el Estado y sus instituciones no son visibilizadas como una red de apoyo por parte de quienes conviven con la demencia en los entornos familiares, salvo proyectos concretos que aparecen como excepciones (p. 122). Junto con esto, la opción de institucionalización es devaluada, y existe una imagen negativa de los establecimientos de larga estadía, expresándose la creencia de que la familia es la que debe hacerse cargo del cuidado del adulto mayor con demencia, incluso por parte de quienes realizan esta labor dentro de las mismas instituciones. Esto nos invita a cuestionarnos respecto de la forma en que concebimos y actuamos frente a la vejez y la enfermedad, y en relación al cuidado de quienes quedan señalados como dependientes. Resulta fundamental dar espacio a que emerjan las experiencias de quienes se han sentido marginados, invisibilizados y desempoderados frente a las formas en que nos organizamos como sociedad ante la vejez y la enfermedad. A la vez, es necesario preguntarse cómo conectar estas realidades de quienes están en este contacto cotidiano, con la llamada ‘agenda institucional’, volviéndola una discusión que se abre al ámbito político, y no se queda restringida a la esfera familiar y femenina, reproduciendo las dicotomías de lo público y privado. Si bien en el libro se ilustra que existen esfuerzos en esta línea, estando en construcción un Plan para las Demencias en Chile para este año 2015 (pp. 63-78), se vuelve relevante que las intervenciones que emerjan de estas políticas públicas aparezcan vinculadas a las realidades materiales, de información y apoyo, que son expresadas por quienes conviven con la demencia a diario. Junto a esto, necesitamos políticas públicas que no sean neutrales a las diferencias estructurales que están insertas en nuestra sociedad, y que no sigan recreando segmentaciones sociales y reproduciendo desigualdades de género (Williams, 2001, p. 487). Por lo tanto, es necesario mirar el cuidado en su contexto de relaciones, visibilizándolo como una actividad significativa e indispensable para un desarrollo sustentable. Requiere cuestionar el régimen de cuidado actual, así como las políticas públicas existentes, que desde su acción u omisión excluyen a ciertos grupos y favorecen a otros. Además, resulta indispensable considerar las dimensiones materiales que caracterizan la provisión de cuidados, lo cual implica importantes esfuerzos en términos de tiempo y recursos financieros (Williams, 2001, p. 487). Por último, se necesita enfatizar la relevancia de desprivatizar el cuidado, y volverlo un asunto de interés público y prioridad política, respecto del cual se considere tanto a las personas dependientes, y sus cuidadores, especialmente en aquellas materias ligadas a la protección social, los sistemas de salud y servicios sociales (Williams, 2001, p. 487). Para finalizar, quisiera enfatizar que este libro representa una forma de conectar entre la llamada ‘agenda sistémica’ y la ‘agenda institucional’ (pp. 63-78). Nos permite mirar desde la perspectiva de quienes generalmente quedan marginados de los discursos dominantes, y cuestionar y desnaturalizar los órdenes actuales. El tema de la vejez, la demencia y el cuidado, constituyen una realidad que nos alcanza a todos, tarde o temprano, por lo cual este libro se convierte en una interesante invitación a observar y reflexionar en torno a las narrativas y creencias que se construyen en nuestra sociedad frente a estas experiencias. Referencias bibliográficas Aguirre, R. (2011). El reparto del cuidado en América Latina. En Duran, M. (coord..), El trabajo de cuidado en América Latina y España (pp. 89-104). Madrid: Fundación Carolina, Documento de trabajo. Arriagada, I. (2011). La organización social de los cuidados y vulneración de derechos en Chile. Santiago: ONU MUJERES, CEM (Centro de Estudios de la Mujer). Arriagada, I., Todaro, R. (2012). Cadenas globales de cuidados: El papel de las migrantes peruanas en la provisión de cuidados en Chile. Santiago: ONU MUJERES, CEM (Centro de Estudios de la Mujer). Jelin, E. (2007). Capitulo IV: Las familias latinoamericanas en el marco de las transformaciones globales. En Arriagada, I. (coord.), Familia y políticas publicas en Latino América: una historia de desencuentros (pp. 93-124). CEPAL UNFPA Santiago: Naciones Unidas. Lister, R., Williams, F., Anttonen, A., Bussemaker, J., Gerhard, U., Heinen, J., Johansson, S., Leira, A., Siim, B., Tobio, C., Gavanas. A. (2007). Gendering Citizenship in Western Europe: New Challenges for Citizenship Research in a Cross-National Context. Bristol: The Policy Press. Lutz, H. (2008). Introduction: Migrant Domestic Workers in Europe. En H. Lutz. (ed.), Migration and Domestic Work: A European Perspective on a Global Theme (pp. 1-10). Farnham and Burlingtonn: Ashgate Publishing Company. Molano Mijangos, A., Robert, E., García Dominguez M. (2012). Cadenas globales de cuidados: síntesis de resultados de nueve estudios en América Latina y España. Santo Domingo, República Dominicana: Onu Mujeres. Sunkel, G. (2011). Capitulo VII: Regímenes de bienestar y políticas de familia en América Latina. En I. Arriagada (coord.), Familia y políticas públicas en Latinoamérica: una historia de desencuentros (pp. 171-184). Santiago: CEPAL-UNFPA, Naciones Unidas. Williams, F. (2001). In and beyond New Labour: towards a new political ethics of care. Critical Social Policy 21, 467-493. (2010). Migration and Care: Themes, Concepts and Challenges. Social Policy and Society 9 (3), 385-396.

The UP Manila Health Policy Development Hub recognizes the invaluable contribution of the participants in theseries of roundtable discussions listed below: RTD: Beyond Hospital Beds: Equity,quality, and service1. Ma. Esmeralda C. Silva, MPAf, MSPPM, PhD,Faculty, College of Public Health, UP Manila2. Leonardo R. Estacio, Jr., MCD, MPH, PhD, Dean,College of Arts and Sciences, UP Manila3. Michael Antonio F. Mendoza, DDM, MM, Faculty,College of Dentistry, UP Manila4. Hilton Y. Lam, MHA, PhD, Chair, UP Manila HealthPolicy Development Hub; Director, Institute of HealthPolicy and Development Studies, University of thePhilippines Manila5. Irma L. Asuncion, MHA, CESO III, Director IV,Bureau of Local Health Systems Development,Department of Health6. Renely Pangilinan-Tungol, MD, CFP, MPM-HSD,Municipal Health Officer, San Fernando, Pampanga7. Salome F. Arinduque, MD, Galing-Pook AwardeeRepresentative, Municipal Health Officer, San Felipe,Zambales8. Carmelita C. Canila, MD, MPH, Faculty, College ofPublic Health, University of the Philippines Manila9. Lester M. Tan, MD, MPH, Division Chief, Bureau ofLocal Health System Development, Department ofHealth10. Anthony Rosendo G. Faraon, MD, Vice President,Zuellig Family Foundation (ZFF)11. Albert Francis E. Domingo, MD, Consultant, HealthSystem strengthening through Public Policy andRegulation, World Health Organization12. Jesus Randy O. Cañal, MD, FPSO-HNS, AssociateDirector, Medical and Regulatory Affairs, AsianHospital and Medical Center13. Christian Edward L. Nuevo, Health Policy and SystemsResearch Fellow, Health Policy Development andPlanning Bureau, Department of Health14. Paolo Victor N. Medina, MD, Assistant Professor 4,College of Medicine, University of the PhilippinesManila15. Jose Rafael A. Marfori, MD, Special Assistant to theDirector, Philippine General Hospital16. Maria Teresa U. Bagaman, Committee Chair, PhilippineSociety for Quality, Inc.17. Maria Theresa G. Vera, MSc, MHA, CESO III, DirectorIV, Health Facility Development Bureau, Departmentof Health18. Ana Melissa F. Hilvano-Cabungcal, MD, AssistantAssociate Dean for Planning & Development, Collegeof Medicine, University of the Philippines Manila19. Fevi Rose C. Paro, Faculty, Department of Communityand Environmental Resource Planning, University ofthe Philippines Los Baños20. Maria Rosa C. Abad, MD, Medical Specialist III,Standard Development Division, Health Facilities andServices Regulation21. Yolanda R. Robles, RPh, PhD, Faculty, College ofPharmacy, University of the Philippines Manila22. Jaya P. Ebuen, RN, Development Manager Officer,CHDMM, Department of Health23. Josephine E. Cariaso, MA, RN, Assistant Professor,College of Nursing, University of the Philippines Manila24. Diana Van Daele, Programme Manager, CooperationSection, European Union25. Maria Paz de Sagun, Project Management Specialist,USAID26. Christopher Muñoz, Member, Yellow Warriors SocietyPhilippinesRTD: Health services and financingroles: Population based- andindividual-based1. Hilton Y. Lam, MHA, PhD, Chair, University of thePhilippines Manila Health Policy Development Hub;Director, Institute of Health Policy and DevelopmentStudies, University of the Philippines Manila2. Ma. Esmeralda C. Silva, MPAf, MSPPM, PhD,Faculty, College of Public Health, University of thePhilippines Manila3. Leonardo R. Estacio, Jr., MCD, MPH, PhD, Dean,College of Arts and Sciences, University of thePhilippines Manila4. Michael Antonio F. Mendoza, DDM, MM, Faculty,College of Dentistry, University of the PhilippinesManila5. Mario C. Villaverde, Undersecretary, Health Policyand Development Systems and Development Team,Department of Health6. Jaime Z. Galvez Tan, MD, Former Secretary, Department of Health7. Marvin C. Galvez, MD, OIC Division Chief, BenefitsDevelopment and Research Department, PhilippineHealth Insurance Corporation8. Alvin B. Caballes, MD, MPE, MPP, Faculty, Collegeof Medicine, University of the Philippines Manila9. Carlos D. Da Silva, Executive Director, Association ofMunicipal Health Maintenance Organization of thePhilippines, Inc.10. Anthony Rosendo G. Faraon, MD, Vice President,Zuellig Family Foundation (ZFF) 11. Albert Francis E. Domingo, MD, Consultant, HealthSystem strengthening through Public Policy andRegulation, World Health Organization12. Salome F. Arinduque, MD, Galing-Pook AwardeeRepresentative, Municipal Health Officer, San Felipe,Zambales13. Michael Ralph M. Abrigo, PhD, Research Fellow,Philippine Institute for Developmental Studies14. Oscar D. Tinio, MD, Committee Chair, Legislation,Philippine Medical Association15. Rogelio V. Dazo, Jr., MD, FPCOM, Legislation,Philippine Medical Association16. Ligaya V. Catadman, MM, Officer-in-charge, HealthPolicy Development and Planning Bureau, Department of Health17. Maria Fatima Garcia-Lorenzo, President, PhilippineAlliance of Patients Organization18. Tomasito P. Javate, Jr, Supervising Economic DevelopmentSpecialist, Health Nutrition and Population Division,National Economic and Development Authority19. Josefina Isidro-Lapena, MD, National Board ofDirector, Philippine Academy of Family Physicians20. Maria Eliza Ruiz-Aguila, MPhty, PhD, Dean, Collegeof Allied Medical Professions, University of thePhilippines Manila21. Ana Melissa F. Hilvano-Cabungcal, MD, AssistantAssociate Dean for Planning & Development, College ofMedicine, University of the Philippines Manila22. Maria Paz P. Corrales, MD, MHA, MPA, Director III,Department of Health-National Capital Region23. Karin Estepa Garcia, MD, Executive Secretary, PhilippineAcademy of Family Physicians24. Adeline A. Mesina, MD, Medical Specialist III,Philippine Health Insurance Corporation25. Glorey Ann P. Alde, RN, MPH, Research Fellow,Department of HealthRTD: Moving towards provincelevel integration throughUniversal Health Care Act1. Hilton Y. Lam, MHA, PhD, Chair, University of thePhilippines Manila Health Policy Development Hub;Director, Institute of Health Policy and DevelopmentStudies, University of the Philippines Manila2. Ma. Esmeralda C. Silva, MPAf, MSPPM, PhD,Faculty, College of Public Health, University of thePhilippines Manila3. Leonardo R. Estacio, Jr., MCD, MPH, PhD, Dean,College of Arts and Sciences, University of thePhilippines Manila4. Michael Antonio F. Mendoza, DDM, MM, Faculty,College of Dentistry, University of the PhilippinesManila5. Mario C. Villaverde, Undersecretary of Health, HealthPolicy and Development Systems and DevelopmentTeam, Department of Health6. Ferdinand A. Pecson, Undersecretary and ExecutiveDirector, Public Private Partnership Center7. Rosanna M. Buccahan, MD, Provincial Health Officer,Bataan Provincial Office8. Lester M. Tan, MD, Division Chief, Bureau of LocalHealth System Development, Department of Health9. Ernesto O. Domingo, MD, FPCP, FPSF, FormerChancellor, University of the Philippines Manila10. Albert Francis E. Domingo, MD, Consultant, HealthSystem strengthening through Public Policy andRegulation, World Health Organization11. Leslie Ann L. Luces, MD, Provincial Health Officer,Aklan12. Rene C. Catan, MD, Provincial Health Officer, Cebu13. Anthony Rosendo G. Faraon, MD, Vice President,Zuellig Family Foundation14. Jose Rafael A. Marfori, MD, Special Assistant to theDirector, Philippine General Hospital15. Jesus Randy O. Cañal, MD, FPSO-HNS, Consultant,Asian Hospital and Medical Center16. Ramon Paterno, MD, Member, Universal Health CareStudy Group, University of the Philippines Manila17. Mayor Eunice U. Babalcon, Mayor, Paranas, Samar18. Zorayda E. Leopando, MD, Former President,Philippine Academy of Family Physicians19. Madeleine de Rosas-Valera, MD, MScIH, SeniorTechnical Consultant, World Bank20. Arlene C. Sebastian, MD, Municipal Health Officer,Sta. Monica, Siargao Island, Mindanao21. Rizza Majella L. Herrera, MD, Acting Senior Manager,Accreditation Department, Philippine Health InsuranceCorporation22. Alvin B. Caballes, MD, MPE, MPP, Faculty, Collegeof Medicine, University of the Philippines Manila23. Pres. Policarpio B. Joves, MD, MPH, MOH, FPAFP,President, Philippine Academy of Family Physicians24. Leilanie A. Nicodemus, MD, Board of Director,Philippine Academy of Family Physicians25. Maria Paz P. Corrales, MD, MHA, MPA, Director III,National Capital Region Office, Department of Health26. Dir. Irma L. Asuncion, MD, MHA, CESO III, DirectorIV, Bureau of Local Health Systems Development,Department of Health27. Bernard B. Argamosa, MD, Mental Health Representative, National Center for Mental Health28. Flerida Chan, Chief, Poverty Reduction Section, JapanInternational Cooperation Agency29. Raul R. Alamis, Chief Health Program Officer, ServiceDelivery Network, Department of Health30. Mary Anne Milliscent B. Castro, Supervising HealthProgram Officer, Department of Health 31. Marikris Florenz N. Garcia, Project Manager, PublicPrivate Partnership Center32. Mary Grace G. Darunday, Supervising Budget andManagement Specialist, Budget and Management Bureaufor the Human Development Sector, Department ofBudget and Management33. Belinda Cater, Senior Budget and Management Specialist,Department of Budget and Management34. Sheryl N. Macalipay, LGU Officer IV, Bureau of LocalGovernment and Development, Department of Interiorand Local Government35. Kristel Faye M. Roderos, OTRP, Representative,College of Allied Medical Professions, University ofthe Philippines Manila36. Jeffrey I. Manalo, Director III, Policy Formulation,Project Evaluation and Monitoring Service, PublicPrivate Partnership Center37. Atty. Phebean Belle A. Ramos-Lacuna, Division Chief,Policy Formulation Division, Public Private PartnershipCenter38. Ricardo Benjamin D. Osorio, Planning Officer, PolicyFormulation, Project Evaluation and MonitoringService, Public Private Partnership Center39. Gladys Rabacal, Program Officer, Japan InternationalCooperation Agency40. Michael Angelo Baluyot, Nurse, Bataan Provincial Office41. Jonna Jane Javier Austria, Nurse, Bataan Provincial Office42. Heidee Buenaventura, MD, Associate Director, ZuelligFamily Foundation43. Dominique L. Monido, Policy Associate, Zuellig FamilyFoundation44. Rosa Nene De Lima-Estellana, RN, MD, Medical OfficerIII, Department of Interior and Local Government45. Ma Lourdes Sangalang-Yap, MD, FPCR, Medical OfficerIV, Department of Interior and Local Government46. Ana Melissa F. Hilvano-Cabungcal, MD, AssistantAssociate Dean for Planning & Development, College ofMedicine, University of the Philippines Manila47. Colleen T. Francisco, Representative, Department ofBudget and Management48. Kristine Galamgam, Representative, Department ofHealth49. Fides S. Basco, Officer-in-charge, Chief Budget andManagement Specialist, Development of Budget andManagementRTD: Health financing: Co-paymentsand Personnel1. Hilton Y. Lam, MHA, PhD, Chair, University of thePhilippines Manila Health Policy Development Hub;Director, Institute of Health Policy and DevelopmentStudies, University of the Philippines Manila2. Ma. Esmeralda C. Silva, MPAf, MSPPM, PhD,Faculty, College of Public Health, University of thePhilippines Manila3. Leonardo R. Estacio, Jr., MCD, MPH, PhD, Dean,College of Arts and Sciences, University of thePhilippines Manila4. Michael Antonio F. Mendoza, DDM, MM, Faculty,College of Dentistry, University of the Philippines Manila5. Ernesto O. Domingo, MD, Professor Emeritus,University of the Philippines Manila6. Irma L. Asuncion, MHA, CESO III, Director IV,Bureau of Local Health Systems Development,Department of Health7. Lester M. Tan, MD, MPH, Division Chief, Bureau ofLocal Health System Development, Department ofHealth8. Marvin C. Galvez, MD, OIC Division Chief, BenefitsDevelopment and Research Department, PhilippineHealth Insurance Corporation9. Adeline A. Mesina, MD, Medical Specialist III, BenefitsDepartment and Research Department, PhilippineHealth Insurance Corporation10. Carlos D. Da Silva, Executive Director, Association ofHealth Maintenance Organization of the Philippines,Inc.11. Ma. Margarita Lat-Luna, MD, Deputy Director, FiscalServices, Philippine General Hospital12. Waldemar V. Galindo, MD, Chief of Clinics, Ospital ngMaynila13. Albert Francis E. Domingo, MD, Consultant, HealthSystem strengthening through Public Policy andRegulation, World Health Organization14. Rogelio V. Dazo, Jr., MD, Member, Commission onLegislation, Philippine Medical Association15. Aileen R. Espina, MD, Board Member, PhilippineAcademy of Family Physicians16. Anthony R. Faraon, MD, Vice President, Zuellig FamilyFoundation17. Jesus Randy O. Cañal, Associate Director, Medical andRegulatory Affairs, Asian Hospital and Medical Center18. Jared Martin Clarianes, Technical Officer, Union of LocalAuthorities of the Philippines19. Leslie Ann L. Luces, MD, Provincial Health Officer,Aklan20. Rosa Nene De Lima-Estellana, MD, Medical OfficerIII, Department of the Interior and Local Government21. Ma. Lourdes Sangalang-Yap, MD, Medical Officer V,Department of the Interior and Local Government 22. Dominique L. Monido, Policy Associate, Zuellig FamilyFoundation23. Krisch Trine D. Ramos, MD, Medical Officer, PhilippineCharity Sweepstakes Office24. Larry R. Cedro, MD, Assistant General Manager, CharitySector, Philippine Charity Sweepstakes Office25. Margarita V. Hing, Officer in Charge, ManagementDivision, Financial Management Service Sector,Department of Health26. Dr. Carlo Irwin Panelo, Associate Professor, College ofMedicine, University of the Philippines Manila27. Dr. Angelita V. Larin, Faculty, College of Public Health,University of the Philippines Manila28. Dr. Abdel Jeffri A. Abdulla, Chair, RegionalizationProgram, University of the Philippines Manila29. Christopher S. Muñoz, Member, Philippine Alliance ofPatients Organization30. Gemma R. Macatangay, LGOO V, Department ofInterior and Local Government – Bureau of LocalGovernment Development31. Dr. Narisa Portia J. Sugay, Acting Vice President, QualityAssurance Group, Philippine Health InsuranceCorporation32. Maria Eliza R. Aguila, Dean, College of Allied MedicalProfessions, University of the Philippines Manila33. Angeli A. Comia, Manager, Zuellig Family Foundation34. Leo Alcantara, Union of Local Authorities of thePhilippines35. Dr. Zorayda E. Leopando, Former President, PhilippineAcademy of Family Physicians36. Dr. Emerito Jose Faraon, Faculty, College of PublicHealth, University of the Philippines Manila37. Dr. Carmelita C. Canila, Faculty, College of PublicHealth, University of the Philippines ManilaRTD: Moving towards third partyaccreditation for health facilities1. Hilton Y. Lam, MHA, PhD, Chair, University of thePhilippines Manila Health Policy Development Hub;Director, Institute of Health Policy and DevelopmentStudies, University of the Philippines Manila2. Ma. Esmeralda C. Silva, MPAf, MSPPM, PhD,Faculty, College of Public Health, University of thePhilippines Manila3. Leonardo R. Estacio, Jr., MCD, MPH, PhD, Dean,College of Arts and Sciences, University of thePhilippines Manila4. Michael Antonio F. Mendoza, DDM, MM, Faculty,College of Dentistry, University of the PhilippinesManila5. Rizza Majella L. Herrera, MD, Acting SeniorManager, Accreditation Department, Philippine HealthInsurance Corporation6. Bernadette C. Hogar-Manlapat, MD, FPBA, FPSA,FPSQua, MMPA, President and Board of Trustee,Philippine Society for Quality in Healthcare, Inc.7. Waldemar V. Galindo, MD, Chief of Clinics, Ospital ngMaynila8. Amor. F. Lahoz, Division Chief, Promotion andDocumentation Division, Department of Trade andIndustry – Philippine Accreditation Bureau9. Jenebert P. Opinion, Development Specialist, Department of Trade and Industry – Philippine AccreditationBureau10. Maria Linda G. Buhat, President, Association ofNursing Service Administrators of the Philippines, Inc.11. Bernardino A. Vicente, MD, FPPA, MHA, CESOIV, President, Philippine Tripartite Accreditation forHealth Facilities, Inc.12. Atty. Bu C. Castro, MD, Board Member, PhilippineHospital Association13. Cristina Lagao-Caalim, RN, MAN, MHA, ImmediatePast President and Board of Trustee, Philippine Societyfor Quality in Healthcare, Inc.14. Manuel E. Villegas Jr., MD, Vice Treasurer and Board ofTrustee, Philippine Society for Quality in Healthcare,Inc.15. Michelle A. Arban, Treasurer and Board of Trustee,Philippine Society for Quality in Healthcare, Inc.16. Joselito R. Chavez, MD, FPCP, FPCCP, FACCP,CESE, Deputy Executive Director, Medical Services,National Kidney and Transplant Institute17. Blesilda A. Gutierrez, CPA, MBA, Deputy ExecutiveDirector, Administrative Services, National Kidney andTransplant Institute18. Eulalia C. Magpusao, MD, Associate Director, Qualityand Patient Safety, St. Luke’s Medical Centre GlobalCity19. Clemencia D. Bondoc, MD, Auditor, Association ofMunicipal Health Officers of the Philippines20. Jesus Randy O. Cañal, MD, FPSO-HNS, AssociateDirector, Medical and Regulatory Affairs, Asian Hospitaland Medical Center21. Maria Fatima Garcia-Lorenzo, President, PhilippineAlliance of Patient Organizations22. Leilanie A. Nicodemus, MD, Board of Directors,Philippine Academy of Family Physicians23. Policarpio B. Joves Jr., MD, President, PhilippineAcademy of Family Physicians24. Kristel Faye Roderos, Faculty, College of Allied MedicalProfessions, University of the Philippines Manila25. Ana Melissa Hilvano-Cabungcal, MD, AssistantAssociate Dean, College of Medicine, University of thePhilippines Manila26. Christopher Malorre Calaquian, MD, Faculty, Collegeof Medicine, University of the Philippines Manila27. Emerito Jose C. Faraon, MD, Faculty, College ofPublic Health, University of the Philippines Manila 28. Carmelita Canila, Faculty, College of Public Health,University of the Philippines Manila29. Oscar D. Tinio, MD, Representative, Philippine MedicalAssociation30. Farrah Rocamora, Member, Philippine Society forQuality in Healthcare, IncRTD: RA 11036 (Mental Health Act):Addressing Mental Health Needs ofOverseas Filipino Workers1. Hilton Y. Lam, MHA, PhD, Chair, University of thePhilippines Manila Health Policy Development Hub;Director, Institute of Health Policy and DevelopmentStudies, University of the Philippines Manila2. Leonardo R. Estacio, Jr., MCD, MPH, PhD, UPManila Health Policy Development Hub; College ofArts and Sciences, UP Manila3. Ma. Esmeralda C. Silva, MPAf, MSPPM, PhD, UPManila Health Policy Development Hub; College ofPublic Health, UP Manila4. Michael Antonio F. Mendoza, DDM, UP ManilaHealth Policy Development Hub; College of Dentistry,UP Manila5. Frances Prescilla L. Cuevas, RN, MAN, Director,Essential Non-Communicable Diseases Division,Department of Health6. Maria Teresa D. De los Santos, Workers Education andMonitoring Division, Philippine Overseas EmploymentAdministration7. Andrelyn R. Gregorio, Policy Program and Development Office,Overseas Workers Welfare Administration8. Sally D. Bongalonta, MA, Institute of Family Life &Children Studies, Philippine Women’s University9. Consul Ferdinand P. Flores, Department of ForeignAffairs10. Jerome Alcantara, BLAS OPLE Policy Center andTraining Institute11. Andrea Luisa C. Anolin, Commission on FilipinoOverseas12. Bernard B. Argamosa, MD, DSBPP, National Centerfor Mental Health13. Agnes Joy L. Casino, MD, DSBPP, National Centerfor Mental Health14. Ryan Roberto E. Delos Reyes, Employment Promotionand Workers Welfare Division, Department of Laborand Employment15. Sheralee Bondad, Legal and International AffairsCluster, Department of Labor and Employment16. Rhodora A. Abano, Center for Migrant Advocacy17. Nina Evita Q. Guzman, Ugnayan at Tulong para saMaralitang Pamilya (UGAT) Foundation, Inc.18. Katrina S. Ching, Ugnayan at Tulong para sa MaralitangPamilya (UGAT) Foundation, Inc.RTD: (Bitter) Sweet Smile of Filipinos1. Dr. Hilton Y. Lam, Institute of Health Policy andDevelopment Studies, NIH2. Dr. Leonardo R. Estacio, Jr., College of Arts andSciences, UP Manila3. Dr. Ma. Esmeralda C. Silva, College of Public Health,UP Manila4. Dr. Michael Antonio F. Mendoza, College of Dentistry,UP Manila5. Dr. Ma. Susan T. Yanga-Mabunga, Department ofHealth Policy & Administration, UP Manila6. Dr. Danilo L. Magtanong, College of Dentistry, UPManila7. Dr. Alvin Munoz Laxamana, Philippine DentalAssociation8. Dr. Fina Lopez, Philippine Pediatric Dental Society, Inc9. Dr. Artemio Licos, Jr.,Department of Health NationalAssociation of Dentists10. Dr. Maria Jona D. Godoy, Professional RegulationCommission11. Ms. Anna Liza De Leon, Philippine Health InsuranceCorporation12. Ms. Nicole Sigmuend, GIZ Fit for School13. Ms. Lita Orbillo, Disease Prevention and Control Bureau14. Mr. Raymond Oxcena Akap sa Bata Philippines15. Dr. Jessica Rebueno-Santos, Department of CommunityDentistry, UP Manila16. Ms. Maria Olivine M. Contreras, Bureau of LocalGovernment Supervision, DILG17. Ms. Janel Christine Mendoza, Philippine DentalStudents Association18. Mr. Eric Raymund Yu, UP College of DentistryStudent Council19. Dr. Joy Memorando, Philippine Pediatric Society20. Dr. Sharon Alvarez, Philippine Association of DentalColleges

Advances in pediatric type 1 diabetes (T1D) management in the last 10 years have led to improvements in glycemic control. Our objective was to compare T1D treatment regimen and glycemic outcomes over a 10-year period, from 8 diabetes registries and the SWEET initiative. Registries included ADDN, ČENDA, DanDiabKids, DPV, NCDR, NPDA, Swediabkids, T1DX-QI and SWEET. Investigators compared data from 2013 to 2022. Children aged &lt;u&gt;&lt;&lt;/u&gt;18 years with T1D duration ≥ 3 months were included. For each registry, demographics, HbA1c data, insulin regimen, diabetes ketoacidosis (DKA) and severe hypoglycemia rates were collected. Join point regression analysis was used to study significant breakpoints in temporal trends. Data were available for 109,494 children from the national registries and 35,590 from SWEET. Mean age between registries was similar and stable over time. Mean HbA1c decreased on average from 66.4 mmol/mol in 2013 to 59.3 mmol/mol in 2022, improving in all registries (Fig. 1). Insulin pump use varied widely but increased in all registries (on average 42.9% 2013 to 62.2% in 2022) (Fig. 1). A decreasing trend of DKA and severe hypoglycemia was observed in most registries over time. Glycemic control improved in children with T1D in all registries over the last 10 years. Use of technology has increased dramatically over this time although with significant differences between registries. Disclosure A. Zimmermann: None. S. Lanzinger: None. T. Skrivarhaug: None. J. Svensson: Speaker's Bureau; Novo Nordisk A/S. Stock/Shareholder; Novo Nordisk. Consultant; Medtronic. Research Support; Medtronic. Speaker's Bureau; Sanofi, Rubin Medical. M.E. Craig: None. S. Rompicherla: None. D.M. Maahs: Advisory Panel; Medtronic. Consultant; Abbott, LifeScan Diabetes Institute, Sanofi, Provention Bio, Inc., Bayer Inc., Kriya Therapeutics, BioSpex. O. Ebekozien: Advisory Panel; Sanofi, Medtronic. Research Support; Vertex Pharmaceuticals Incorporated. Speaker's Bureau; Vertex Pharmaceuticals Incorporated. Research Support; Medtronic, Lilly Diabetes, Abbott, Dexcom, Inc. V. Neuman: None. O. Cinek: None. A.G. Ranjan: None. R.W. Holl: None. H. Robinson: None. J. Warner: None. K. Akesson: Speaker's Bureau; Novo Nordisk. M. Witsch: None. N.A. Lund-Blix: None. H. Bratke: Speaker's Bureau; Novo Nordisk. Z. Sumnik: None. S. Kummernes: None. S.R. Johnson: None. M. Madsen: Other Relationship; Novo Nordisk A/S. K. Eeg-Olofsson: Other Relationship; Abbott, Eli Lilly and Company, Novo Nordisk, Sanofi. S. Pons Perez: None. G.T. Alonso: Advisory Panel; MannKind Corporation. A. Thorén: None.

Despite its well-established benefits, exercise can cause blood glucose levels to drop precipitously. Factors such as pre-exercise glucose, exercise type and insulin on board (IOB) all appear to influence the magnitude of drop in glucose during exercise, but it is currently unclear if insulin delivery modality (i.e., MDI vs. standard pump vs. closed loop pump) has a clinically significant effect. Data from the Type 1 Diabetes Exercise Initiative Pediatric (T1DEXIP) study allowed us to examine if insulin delivery modality influences the change in glucose during exercise in youth with T1D. Youth (N=248) with T1D ([mean ± SD] age= 14±2 years; T1D duration= 5.4±3.9 years; HbA1c= 7.1±1.3%; BMI percentile= 62±27%; 58% male) wore a continuous glucose monitor (Dexcom G6) and a Garmin, Vivosmart 4 activity monitor while logging meals and activity with the bant smartphone app over a 10-day period. Drop in glucose level during exercise was associated with pre-exercise glucose and IOB (mean change in glucose of 5.7 mg/dL, -15.7 mg/dL, and -26.5 mg/dL for IOB of 0 U/kg, &gt;0 to &lt;0.1 U/kg, and ≥0.1 U/kg, respectively; p&lt;0.001), but did not differ significantly by insulin delivery modality (Figure). Pre-exercise glucose and IOB, but not insulin delivery method, are associated with changes in glucose during exercise in youth with T1D. Disclosure M.Riddell: Advisory Panel; Zealand Pharma A/S, Zucara Therapeutics, Indigo Diabetes, Consultant; Lilly Diabetes, Eli Lilly and Company, Jaeb Center for Health Research, Speaker's Bureau; Dexcom, Inc., Novo Nordisk, Sanofi, Stock/Shareholder; Supersapiens, Zucara Therapeutics. S.Bergford: None. R.L.Gal: None. S.R.Patton: None. M.A.Clements: Consultant; Glooko, Inc., Research Support; Dexcom, Inc., Abbott Diabetes. P.Calhoun: None. J.Sherr: Advisory Panel; Bigfoot Biomedical, Inc., Insulet Corporation, Medtronic, Vertex Pharmaceuticals Incorporated, Cecelia Health, StartUp Health T1D Moonshot, Consultant; Bigfoot Biomedical, Inc., Insulet Corporation, Medtronic, Lilly, Research Support; Insulet Corporation, Medtronic, NIH - National Institutes of Health, Juvenile Diabetes Research Foundation (JDRF), Speaker's Bureau; Insulet Corporation, Zealand Pharma A/S, Lilly, Medtronic. T1dexip study group: n/a. Funding The Leona M. and Harry B. Helmsley Charitable Trust; Dexcom, Inc.

Abstract For over 75 years, the National Oceanic and Atmospheric Administration’s Air Resources Laboratory (NOAA ARL) has been at the forefront of federal meteorological and climate research. As the Special Projects Section (SPS) of the U. S. Weather Bureau (USWB), the laboratory pioneered the development of atmospheric trajectory modeling, initially used in studies related to nuclear weapons following World War II. Model development was guided by observations following weapons tests, assisted by later experiments using a wide variety of atmospheric tracers. Today’s familiar Gaussian plume dispersion model, previously in nascent form, was developed and promoted with ARL research, as was the much later and widely-used HYSPLIT model. Much of ARL’s early research was focused on the challenges presented by the complex terrain surrounding nuclear installations, often addressed with high spatial resolution meteorological measurements, atmospheric tracers, and site-specific models. ARL has since extended boundary layer research to increasingly complex landscapes, such as forests, agricultural lands, and urban areas, and has expanded its research scope to air quality, weather, and climate applications based on the knowledge and experience developed throughout its long history. Examples of these research endeavors include the establishment of the US Climate Reference Network, fundamental contributions to the development of the National Air Quality Forecast Capability, and foundational participation in the National Atmospheric Deposition Program. ARL looks forward to continuing to refine scientific understanding from field experiments, including coupling ground-based experimentation with modeling, and sustained observations, in order to facilitate the transfer of knowledge into practical applications of societal relevance.

Background: Reduced-energy diets improve clinical outcomes in type 2 diabetes but are untested in gestational diabetes. Methods: In a randomized, controlled, double-blind, whole-diet replacement trial (ISRCTN; 37866), women with gestational diabetes and BMI &lt;u&gt;&gt;&lt;/u&gt;25 kg/m2 were assigned (1:1) to receive a standard-energy (2000 kcal/day) (control) or a reduced-energy diet (1200 kcal/day) (intervention) until delivery, provided as weekly dietboxes containing 40% carbohydrate, 35% fat and 25% protein. Diagnosis used the National Institute of Health and Care Excellence (NICE) and interim UK Covid-19 criteria. Primary outcomes were maternal weight change (enrolment to 36wks) and offspring standardized birthweight. Secondary outcomes included maternal glycemia, treatment requirements and neonatal outcomes. Results: 423 women were randomized at 29wks gestation; (n=211 control; n=212 intervention). Outcome data were available for 386 (91.3%) participants at 36wks and 358 (84.6%) at delivery. Intervention and control groups had similar maternal weight change to 36wks (mean 0.41(SD 4.25) vs 0.50(4.15) kg; baseline-adjusted difference intervention vs control -0.148 (95%CI -0.95 to 0.68); p=0.741). The intervention reduced requirements for short-acting (odds ratio 0.37 (0.14 to 0.97); p=0.044) and long-acting (0.38 (0.19 to 0.75); p=0.006) insulin therapy at 36wks. Offspring had similar standardized birthweight (0.44(1.03) vs 0.44(0.85) SDS; 0.004(-0.20 to 0.19) p=0.967) and comparable rates of large-for-gestational-age and neonatal intensive care admission. Serious adverse events and withdrawals were similar between groups. Weight loss in late pregnancy appeared safe. Conclusions: The protocol did not result in differences in weight gain or primary outcomes between groups but the provision of a reduced energy diet was associated with a reduced requirement for insulin therapy. Disclosure L.C. Kusinski: None. D. Jones: None. N. Atta: None. E. Turner: None. L.M. Oude Griep: None. K.L. Rennie: None. E. De Lucia Rolfe: None. S. Sharp: Consultant; Shionogi & Co., Ltd. H.R. Murphy: Advisory Panel; Medtronic. Research Support; Abbott, Dexcom, Inc. Speaker's Bureau; Ypsomed AG, Eli Lilly and Company, Dexcom, Inc. R. Taylor: Advisory Panel; Fast800. C.L. Meek: Research Support; Dexcom, Inc. Funding Diabetes UK 17/0005712EFSD - NNF NNF19SA058974

Roux-en-Y gastric bypass surgery (RYGB) alters postprandial glucose metabolism due to changes in gastrointestinal tract anatomy and large weight loss. Here, we propose a model quantifying postprandial hepatic and peripheral glucose fluxes in post-RYGB patients at steady weight loss and healthy controls (HC). Ten RYGB (2M, age=39.2±3.1 y, BMI=28±1 kg/m2 - mean±SE) and 10 HC (5M, age=36.4±3.2 y, BMI=26±1 kg/m2) underwent Deuterium Metabolic Imaging (DMI) at a 7 Tesla MR scanner before and after ingesting 60g of [6,6-2H2]-glucose (D-Glc). Venous blood was sampled to measure plasma insulin (I) and D-Glc (GP). Hepatic DMI was used to track liver D-Glc levels (GL) over 150min. Data was used to develop a model describing postprandial hepatic and peripheral glucose appearance (RaL and RaP) and disposal (RdL and RdP) as well as first-pass hepatic glucose extraction (ISE). Incremental Area Under the Curve (iAUC) of GL was greater in RYGB compared to HC (iAUC(GL)0-150min = 620±39 vs 467±41 mM·min, p=0.010), as was iAUC(I)0-150min (49.8±4.9 vs 29.2±3.4 nM·min, p=0.003), while iAUC(GP)0-150min was not significantly different (628±69 vs 520±26 mM·min). iAUCs of RaL and RaP normalized to 60g were higher in the first 60min in RYGB vs HC (63.0±3.0 vs 27.8±2.7 %; 60.5±3.1 vs 26.0±2.6 %, p&lt;0.001), as were iAUCs of RdL and RdP after 150 min (24.6±1.1 vs 18.0±1.7 %, p=0.005; 53.6±2.9 vs 32.1±4.1 %, p&lt;0.001). Conversely, model-derived ISE was similar (8.6±0.3 vs 8.8±0.7 %) in the two groups.&lt;u&gt;&lt;/u&gt; A model using stable isotope and liver DMI data was developed to quantify peripheral and organ-level glucose turnover without portal vein catheterization. Results showed that the difference in glucose time course in RYGB vs HC is explained by the faster rate of appearance in RYGB, while disposal, at both liver and periphery, appears to be intact. The model also suggests that no saturation arises in the first-pass extraction, despite the high glucose levels. Disclosure A. Brunasso: None. C. Dalla Man: None. S. Poli: None. D. Herzig: Speaker's Bureau; Ypsomed AG. R. Kreis: None. L. Bally: None. M. Schiavon: None. Funding PNRR Next Generation EU (ex DM 118/23)-Swiss National Science Foundation (PCEGP3_186978)

We did a randomized crossover non-inferiority trial to compare 3 weeks of automated insulin delivery with (i) carbohydrate counting and (ii) qualitative meal-size estimation (low, medium, high, or very high carbohydrate (CHO)) in 30 adults with T1D (20/30 females, age 44±17 yrs, A1c 7.4±0.7%) . Low, medium, high, and very high CHO meals were defined as &lt;30 g CHO, 30-60 g CHO, 60-90 g CHO, and &gt;90 g CHO, respectively, and their prandial insulin boluses were calculated as the individualized insulin-to-CHO ratios x 15, 35, 65, and 95, respectively. Closed-loop algorithms were otherwise identical in the two arms. The time in range 3.9-10.0 mmol/L (primary outcome) was 74% (SD 10%) with carbohydrate counting and 71% (11%) with qualitative meal-size estimation; difference -3.6% (95% CI, -0.6% to -6.5%) which crossed the pre-specified non-inferiority margin of 4%. Times &lt;3.9 mmol/L and &lt;3.0 mmol/L were low in both two arms. Automated basal insulin delivery was higher in the qualitative meal-size estimation arm (34.6 vs. 32.6 u/day, p=0.003) . We conclude that non-inferiority of the qualitative meal-size estimation was not confirmed, though this method achieved a high time in range and low time in hypoglycemia. The qualitative meal-size estimation method may benefit from larger prandial boluses and more responsive post-meal automatic basal delivery. Disclosure A.Haidar: Consultant; Eli Lilly and Company, Research Support; ADOCIA, Dexcom, Inc., Eli Lilly and Company, Tandem Diabetes Care, Inc. L.Legault: Advisory Panel; Abbott Diabetes, Insulet Corporation, Novo Nordisk A/S, Other Relationship; Eli Lilly and Company, Research Support; AstraZeneca, Merck & Co., Inc. M.Raffray: None. N.Gouchie-provencher: None. A.Jafar: None. M.Devaux: None. M.Ghanbari: None. R.Rabasa-lhoret: Consultant; HLS Therapeutics Inc., Pfizer Inc., Other Relationship; Abbott Diabetes, AstraZeneca, Boehringer Ingelheim International GmbH, Dexcom, Inc., Eli Lilly and Company, Insulet Corporation, Janssen Pharmaceuticals, Inc., Medtronic, Merck & Co., Inc., Novo Nordisk Canada Inc., Sanofi, Vertex Pharmaceuticals Incorporated, Research Support; Canadian Institutes of Health Research, Cystic Fibrosis Canada, Diabetes Canada, Fondation Francophone pour la Recherche en Diabète (FFRD) , JDRF, National Institutes of Health, Société Francophone du Diabète (SFD) , Speaker's Bureau; Canadian Medical & Surgical Knowledge Translation Research Group (CMS) , CPD Network, Tandem Diabetes Care, Inc. Funding National Institutes of Health (1DP3DK106930-01)

Therapies that preserve β-cell function and enhance glycemic control in type 2 diabetes are of great value. We examined β-cell function in GRADE participants after one year of intervention with insulin glargine U-100, glimepiride, liraglutide or sitagliptin. Participants who remained on originally assigned medication and had complete OGTT data at baseline and Year 1 were analyzed (n=3342 of 5047 initially randomized) . OGTT derived β-cell responses were measured as the ratio of the increment of C-peptide to glucose in the first 30 minutes (CPI) and over 120 minutes (CP/G AUC) . At baseline, age (57.7±9.7 y) , sex (63.5% male) , race (66.8% White) , BMI (34.2±6.7 kg/m2) , fasting C-peptide (1.3±0.5 nmol/L) , HOMA-B (87±35.2 %) , CPI (0.08±0.nmol/mg) and CP/G AUC (1.1±0.6 nmol/mg) did not differ by treatment group. At Year 1, measures of β-cell function were different by treatment groups (Table) . After pairwise analysis, glargine had the lowest fasting C-peptide while CP/G AUC was highest in the liraglutide group. When tested for treatment heterogeneity across subgroups, participants with longer duration of diabetes had smaller increases in CPI and CP/G AUC. Decreased fasting C-peptide by glargine is likely due to lower endogenous insulin secretion in the setting of exogenous insulin. Improved β-cell responses with liraglutide may indicate better β-cell function during the first year of treatment. Disclosure N. Rasouli: Advisory Panel; Eli Lilly and Company, Novo Nordisk, Sanofi. Research Support; Allergan, Eli Lilly and Company, Novo Nordisk. J. Albu: None. R.M. Cohen: Research Support; Dexcom, Inc. R.A. DeFronzo: Advisory Panel; AstraZeneca, Boehringer Ingelheim International GmbH, Intarcia Therapeutics, Inc., Novo Nordisk. Research Support; AstraZeneca, Boehringer Ingelheim International GmbH, Merck & Co., Inc. Speaker’s Bureau; AstraZeneca. E. Diaz: None. A. Ghosh: None. J.A. Luchsinger: None. J.B. McGill: Advisory Panel; Gilead Sciences, Inc., Lilly Diabetes, MannKind Corporation, Novo Nordisk A/S, Provention Bio, Inc., Salix Pharmaceuticals. Consultant; Bayer AG, Boehringer Ingelheim International GmbH. Research Support; Dexcom, Inc., Novo Nordisk. L. Sayyed Kassem: None. W.V. Tamborlane: Consultant; AstraZeneca, Boehringer Ingelheim International GmbH, Medtronic, Novo Nordisk, Sanofi, Takeda Pharmaceutical Company Limited. K. Utzschneider: Consultant; Nevro Corp. N. Younes: None. S.E. Kahn: Advisory Panel; Bayer AG, Boehringer Ingelheim International GmbH, Eli Lilly and Company, Intarcia Therapeutics, Inc., Merck & Co., Inc., Novo Nordisk, Pfizer Inc. Funding National Institute of Diabetes and Digestive and Kidney Diseases (U01DK098246, U34-DK-088043)

Insulin exposure and action are known to differ on each of 3 days of infusion set wear during CSII. We extend these observations to 1 week in a pilot phase study comparing conventional Teflon angled infusion sets to a prototype extended wear set using Capillary Biomedical SteadiFlow™ technology. Participants with T1DM for &gt;12 months, A1C &lt;8.5%, c-peptide &lt;0.6 nmol/L, and ≥6 months use of Medtronic model 530G or higher were enrolled in a 2-period crossover euglycemic clamp study; clamps were performed after fasting overnight stabilization with IV insulin. Five men and 2 women, mean duration of diabetes 22.5 (16.6 SD) years and mean BMI 27.6 (3.8 SD) kg/m2 were enrolled; 4 completed all 8 clamps, 2 completed 7 clamps and 1 completed 1 clamp. We present the pharmacokinetic profiles of insulin lispro, 0.15 U/kg delivered by bolus infusion on Days 0, 3, 5 and 7 of infusion set wear. The Figure shows aggregate results from Control and Investigational infusion sets for insulin concentration (mean±SEM) vs. time by day of set wear. Statistically significant decreases from Day 0 to Day 7 were seen for tmax (p≤0.001) , t50% (early) (p&lt;0.002) , t50% (late) (p&lt;0.001) , and Mean Residence Time (p&lt;0.001) . AUC0-300 declined by approximately 20% from Day 0 to Day 7 (p&lt;0.11) . These results confirm and extend previous observations showing significant progressive acceleration of insulin exposure as a function of duration of infusion set wear time. Disclosure T.S.Bailey: Advisory Panel; Abbott Diabetes, CeQur SA, MannKind Corporation, Medtronic, Novo Nordisk, Consultant; LifeScan, Sanofi, Research Support; Abbott Diabetes, Abbott Diagnostics, Biolinq, Capillary Biomedical, Inc., Dexcom, Inc., Eli Lilly and Company, Kowa Research Institute, Inc., Livongo, MannKind Corporation, Medtronic, Novo Nordisk, REMD Biotherapeutics, Sanofi, Sanvita Medical, Senseonics, ViaCyte, Inc., vTv Therapeutics, Zealand Pharma A/S, Speaker's Bureau; Becton, Dickinson and Company, Medtronic, Sanofi. J.R.Kastner: Consultant; Capillary Biomedical, Inc. P.Strange: Other Relationship; Capillary Biomedical, Inc., Stock/Shareholder; Capillary Biomedical, Inc. L.Shi: None. K.A.Oberg: Consultant; Beta Bionics, Inc., Companion Medical, Tandem Diabetes Care, Inc. J.I.Joseph: Advisory Panel; Capillary Biomedical, Inc., Stock/Shareholder; Capillary Biomedical, Inc. P.J.Strasma: Board Member; Capillary Biomedical, Inc., Employee; Capillary Biomedical, Inc., Stock/Shareholder; Capillary Biomedical, Inc. D.B.Muchmore: Consultant; Capillary Biomedical, Inc., Diasome, Zucara Therapeutics, Stock/Shareholder; Capillary Biomedical, Inc., Diasome. Funding National Institutes of Health (2R44DK110969-02)

Type 2 diabetes (T2D) is progressive, often requiring additional medications to maintain glycemic control. We assessed baseline β-cell function and insulin sensitivity as predictors of worsening glycemia (HbA1c) in the GRADE Study. Adults with T2D &lt;y and HbA1c 6.8-8.5% were randomized to glimepiride, sitagliptin, insulin glargine 100 U/mL or liraglutide added to metformin monotherapy. Complete baseline OGTT data were available for 4586 of 5047 participants (Mean±SD: Age 57±y, 64% male, 5.0±1.3 y f/up) . Insulin sensitivity (HOMA2S) and early (C-peptide index (CPI) : ΔCP/ΔG 0-30 min) and total (incAUC-CP/G 0-120 min) C-peptide responses were used in Cox proportional hazard models to predict time to 1° (HbA1c ≥7%) and 2° (HbA1c &gt;7.5%) glycemic outcomes and tested for treatment interaction. Given the inverse relationship with insulin sensitivity, C-peptide responses were adjusted for HOMA2S. Values determined at baseline (mean±SD) were: CPI 0.8±.nmol/g, incAUC CP/G 1.0±0.6 nmol/mg, HOMA2S 35±68 %, fasting glucose 152±31 mg/dl. Higher C-peptide responses predicted lower risk of 1° (CPI: HR±SE per 1 unit change =0.74±0.03, p&lt;0.001; incAUC-CP/G: HR=0.68±0.02, p&lt;0.001) and 2° glycemic outcomes (CPI: HR=0.71±0.03, p&lt;0.001; incAUC-CP/G: HR=0.60±0.03, p&lt;0.001) . Risks did not differ by treatment. There was interaction for HOMA2S and treatment; a 5 unit change in HOMA2S predicted lower risk of 1° and 2° outcomes with glimepiride and sitagliptin (HR=0.97±0.for both 1° outcomes; HR=0.96±0.for 2° outcome with glimepiride, HR=0.95±0.for 2° outcome with sitagliptin; all p&lt;0.05) . A mg/dL change in fasting glucose predicted greater risk of 1° outcomes for all treatments, lowest for insulin glargine (HR=1.05±0.01) and highest for sitagliptin (HR=1.11±0.01) . Conclusions: Impaired β-cell function based on an OGTT predicted higher risk of T2D progression regardless of assigned treatment. This approach may identify cases that may benefit from earlier more aggressive therapy. Disclosure K.Utzschneider: Consultant; Nevro Corp. T.A.Elasy: None. W.Valencia: None. C.Ma: None. N.Rasouli: Advisory Panel; Eli Lilly and Company, Novo Nordisk, Sanofi, Research Support; Allergan, Eli Lilly and Company, Novo Nordisk. S.E.Kahn: Advisory Panel; Bayer AG, Boehringer Ingelheim International GmbH, Eli Lilly and Company, Intarcia Therapeutics, Inc., Merck & Co., Inc., Novo Nordisk, Pfizer Inc. W.Sivitz: n/a. Grade research group: n/a. N.Younes: None. N.M.Butera: None. A.Balasubramanyam: None. C.Desouza: Advisory Panel; AstraZeneca, Bayer AG, Novo Nordisk A/S, Consultant; Asahi Kasei Corporation. J.Krakoff: None. J.I.Barzilay: None. R.A.Defronzo: Advisory Panel; AstraZeneca, Boehringer Ingelheim International GmbH, Intarcia Therapeutics, Inc., Novo Nordisk, Research Support; AstraZeneca, Boehringer Ingelheim International GmbH, Merck & Co., Inc., Speaker’s Bureau; AstraZeneca. R.M.Bergenstal: Advisory Panel; Hygieia, Medtronic, Roche Diabetes Care, Zealand Pharma A/S, Consultant; Abbott Diabetes, Ascensia Diabetes Care, Bigfoot Biomedical, Inc., CeQur SA, Dexcom, Inc., Eli Lilly and Company, Novo Nordisk, Onduo LLC, Sanofi, United HealthCare Services, Inc., Research Support; Abbott Diabetes, Dexcom, Inc., Eli Lilly and Company, Insulet Corporation, Medtronic, Novo Nordisk, Sanofi. Funding National Institute of Diabetes and Digestive and Kidney Diseases (U01DK098246, U34-DK-088043)

Introduction: Our current obsession with the lives of others “Biography—that is to say, our creative and non-fictional output devoted to recording and interpreting real lives—has enjoyed an extraordinary renaissance in recent years,” writes Nigel Hamilton in Biography: A Brief History (1). Ian Donaldson agrees that biography is back in fashion: “Once neglected within the academy and relegated to the dustier recesses of public bookstores, biography has made a notable return over recent years, emerging, somewhat surprisingly, as a new cultural phenomenon, and a new academic adventure” (23). For over a decade now, commentators having been making similar observations about our obsession with the intimacies of individual people’s lives. In a lecture in 1994, Justin Kaplan asserted the West was “a culture of biography” (qtd. in Salwak 1) and more recent research findings by John Feather and Hazel Woodbridge affirm that “the undiminished human curiosity about other peoples lives is clearly reflected in the popularity of autobiographies and biographies” (218). At least in relation to television, this assertion seems valid. In Australia, as in the USA and the UK, reality and other biographically based television shows have taken over from drama in both the numbers of shows produced and the viewers these shows attract, and these forms are also popular in Canada (see, for instance, Morreale on The Osbournes). In 2007, the program Biography celebrated its twentieth anniversary season to become one of the longest running documentary series on American television; so successful that in 1999 it was spun off into its own eponymous channel (Rak; Dempsey). Premiered in May 1996, Australian Story—which aims to utilise a “personal approach” to biographical storytelling—has won a significant viewership, critical acclaim and professional recognition (ABC). It can also be posited that the real home movies viewers submit to such programs as Australia’s Favourite Home Videos, and “chat” or “confessional” television are further reflections of a general mania for biographical detail (see Douglas), no matter how fragmented, sensationalized, or even inane and cruel. A recent example of the latter, the USA-produced The Moment of Truth, has contestants answering personal questions under polygraph examination and then again in front of an audience including close relatives and friends—the more “truthful” their answers (and often, the more humiliated and/or distressed contestants are willing to be), the more money they can win. Away from television, but offering further evidence of this interest are the growing readerships for personally oriented weblogs and networking sites such as MySpace and Facebook (Grossman), individual profiles and interviews in periodical publications, and the recently widely revived newspaper obituary column (Starck). Adult and community education organisations run short courses on researching and writing auto/biographical forms and, across Western countries, the family history/genealogy sections of many local, state, and national libraries have been upgraded to meet the increasing demand for these services. Academically, journals and e-mail discussion lists have been established on the topics of biography and autobiography, and North American, British, and Australian universities offer undergraduate and postgraduate courses in life writing. The commonly aired wisdom is that published life writing in its many text-based forms (biography, autobiography, memoir, diaries, and collections of personal letters) is enjoying unprecedented popularity. It is our purpose to examine this proposition. Methodological problems There are a number of problems involved in investigating genre popularity, growth, and decline in publishing. Firstly, it is not easy to gain access to detailed statistics, which are usually only available within the industry. Secondly, it is difficult to ascertain how publishing statistics are gathered and what they report (Eliot). There is the question of whether bestselling booklists reflect actual book sales or are manipulated marketing tools (Miller), although the move from surveys of booksellers to electronic reporting at point of sale in new publishing lists such as BookScan will hopefully obviate this problem. Thirdly, some publishing lists categorise by subject and form, some by subject only, and some do not categorise at all. This means that in any analysis of these statistics, a decision has to be made whether to use the publishing list’s system or impose a different mode. If the publishing list is taken at face value, the question arises of whether to use categorisation by form or by subject. Fourthly, there is the bedeviling issue of terminology. Traditionally, there reigned a simple dualism in the terminology applied to forms of telling the true story of an actual life: biography and autobiography. Publishing lists that categorise their books, such as BookScan, have retained it. But with postmodern recognition of the presence of the biographer in a biography and of the presence of other subjects in an autobiography, the dichotomy proves false. There is the further problem of how to categorise memoirs, diaries, and letters. In the academic arena, the term “life writing” has emerged to describe the field as a whole. Within the genre of life writing, there are, however, still recognised sub-genres. Academic definitions vary, but generally a biography is understood to be a scholarly study of a subject who is not the writer; an autobiography is the story of a entire life written by its subject; while a memoir is a segment or particular focus of that life told, again, by its own subject. These terms are, however, often used interchangeably even by significant institutions such the USA Library of Congress, which utilises the term “biography” for all. Different commentators also use differing definitions. Hamilton uses the term “biography” to include all forms of life writing. Donaldson discusses how the term has been co-opted to include biographies of place such as Peter Ackroyd’s London: The Biography (2000) and of things such as Lizzie Collingham’s Curry: A Biography (2005). This reflects, of course, a writing/publishing world in which non-fiction stories of places, creatures, and even foodstuffs are called biographies, presumably in the belief that this will make them more saleable. The situation is further complicated by the emergence of hybrid publishing forms such as, for instance, the “memoir-with-recipes” or “food memoir” (Brien, Rutherford and Williamson). Are such books to be classified as autobiography or put in the “cookery/food & drink” category? We mention in passing the further confusion caused by novels with a subtitle of The Biography such as Virginia Woolf’s Orlando. The fifth methodological problem that needs to be mentioned is the increasing globalisation of the publishing industry, which raises questions about the validity of the majority of studies available (including those cited herein) which are nationally based. Whether book sales reflect what is actually read (and by whom), raises of course another set of questions altogether. Methodology In our exploration, we were fundamentally concerned with two questions. Is life writing as popular as claimed? And, if it is, is this a new phenomenon? To answer these questions, we examined a range of available sources. We began with the non-fiction bestseller lists in Publishers Weekly (a respected American trade magazine aimed at publishers, librarians, booksellers, and literary agents that claims to be international in scope) from their inception in 1912 to the present time. We hoped that this data could provide a longitudinal perspective. The term bestseller was coined by Publishers Weekly when it began publishing its lists in 1912; although the first list of popular American books actually appeared in The Bookman (New York) in 1895, based itself on lists appearing in London’s The Bookman since 1891 (Bassett and Walter 206). The Publishers Weekly lists are the best source of longitudinal information as the currently widely cited New York Times listings did not appear till 1942, with the Wall Street Journal a late entry into the field in 1994. We then examined a number of sources of more recent statistics. We looked at the bestseller lists from the USA-based Amazon.com online bookseller; recent research on bestsellers in Britain; and lists from Nielsen BookScan Australia, which claims to tally some 85% or more of books sold in Australia, wherever they are published. In addition to the reservations expressed above, caveats must be aired in relation to these sources. While Publishers Weekly claims to be an international publication, it largely reflects the North American publishing scene and especially that of the USA. Although available internationally, Amazon.com also has its own national sites—such as Amazon.co.uk—not considered here. It also caters to a “specific computer-literate, credit-able clientele” (Gutjahr: 219) and has an unashamedly commercial focus, within which all the information generated must be considered. In our analysis of the material studied, we will use “life writing” as a genre term. When it comes to analysis of the lists, we have broken down the genre of life writing into biography and autobiography, incorporating memoir, letters, and diaries under autobiography. This is consistent with the use of the terminology in BookScan. Although we have broken down the genre in this way, it is the overall picture with regard to life writing that is our concern. It is beyond the scope of this paper to offer a detailed analysis of whether, within life writing, further distinctions should be drawn. Publishers Weekly: 1912 to 2006 1912 saw the first list of the 10 bestselling non-fiction titles in Publishers Weekly. It featured two life writing texts, being headed by an autobiography, The Promised Land by Russian Jewish immigrant Mary Antin, and concluding with Albert Bigelow Paine’s six-volume biography, Mark Twain. The Publishers Weekly lists do not categorise non-fiction titles by either form or subject, so the classifications below are our own with memoir classified as autobiography. In a decade-by-decade tally of these listings, there were 3 biographies and 20 autobiographies in the lists between 1912 and 1919; 24 biographies and 21 autobiographies in the 1920s; 13 biographies and 40 autobiographies in the 1930s; 8 biographies and 46 biographies in the 1940s; 4 biographies and 14 autobiographies in the 1950s; 11 biographies and 13 autobiographies in the 1960s; 6 biographies and 11 autobiographies in the 1970s; 3 biographies and 19 autobiographies in the 1980s; 5 biographies and 17 autobiographies in the 1990s; and 2 biographies and 7 autobiographies from 2000 up until the end of 2006. See Appendix 1 for the relevant titles and authors. Breaking down the most recent figures for 1990–2006, we find a not radically different range of figures and trends across years in the contemporary environment. The validity of looking only at the top ten books sold in any year is, of course, questionable, as are all the issues regarding sources discussed above. But one thing is certain in terms of our inquiry. There is no upwards curve obvious here. If anything, the decade break-down suggests that sales are trending downwards. This is in keeping with the findings of Michael Korda, in his history of twentieth-century bestsellers. He suggests a consistent longitudinal picture across all genres: In every decade, from 1900 to the end of the twentieth century, people have been reliably attracted to the same kind of books […] Certain kinds of popular fiction always do well, as do diet books […] self-help books, celebrity memoirs, sensationalist scientific or religious speculation, stories about pets, medical advice (particularly on the subjects of sex, longevity, and child rearing), folksy wisdom and/or humour, and the American Civil War (xvii). Amazon.com since 2000 The USA-based Amazon.com online bookselling site provides listings of its own top 50 bestsellers since 2000, although only the top 14 bestsellers are recorded for 2001. As fiction and non-fiction are not separated out on these lists and no genre categories are specified, we have again made our own decisions about what books fall into the category of life writing. Generally, we erred on the side of inclusion. (See Appendix 2.) However, when it came to books dealing with political events, we excluded books dealing with specific aspects of political practice/policy. This meant excluding books on, for instance, George Bush’s so-called ‘war on terror,’ of which there were a number of bestsellers listed. In summary, these listings reveal that of the top 364 books sold by Amazon from 2000 to 2007, 46 (or some 12.6%) were, according to our judgment, either biographical or autobiographical texts. This is not far from the 10% of the 1912 Publishers Weekly listing, although, as above, the proportion of bestsellers that can be classified as life writing varied dramatically from year to year, with no discernible pattern of peaks and troughs. This proportion tallied to 4% auto/biographies in 2000, 14% in 2001, 10% in 2002, 18% in 2003 and 2004, 4% in 2005, 14% in 2006 and 20% in 2007. This could suggest a rising trend, although it does not offer any consistent trend data to suggest sales figures may either continue to grow, or fall again, in 2008 or afterwards. Looking at the particular texts in these lists (see Appendix 2) also suggests that there is no general trend in the popularity of life writing in relation to other genres. For instance, in these listings in Amazon.com, life writing texts only rarely figure in the top 10 books sold in any year. So rarely indeed, that from 2001 there were only five in this category. In 2001, John Adams by David McCullough was the best selling book of the year; in 2003, Hillary Clinton’s autobiographical Living History was 7th; in 2004, My Life by Bill Clinton reached number 1; in 2006, Nora Ephron’s I Feel Bad About My Neck: and Other Thoughts on Being a Woman was 9th; and in 2007, Ishmael Beah’s discredited A Long Way Gone: Memoirs of a Boy Soldier came in at 8th. Apart from McCulloch’s biography of Adams, all the above are autobiographical texts, while the focus on leading political figures is notable. Britain: Feather and Woodbridge With regard to the British situation, we did not have actual lists and relied on recent analysis. John Feather and Hazel Woodbridge find considerably higher levels for life writing in Britain than above with, from 1998 to 2005, 28% of British published non-fiction comprising autobiography, while 8% of hardback and 5% of paperback non-fiction was biography (2007). Furthermore, although Feather and Woodbridge agree with commentators that life writing is currently popular, they do not agree that this is a growth state, finding the popularity of life writing “essentially unchanged” since their previous study, which covered 1979 to the early 1990s (Feather and Reid). Australia: Nielsen BookScan 2006 and 2007 In the Australian publishing industry, where producing books remains an ‘expensive, risky endeavour which is increasingly market driven’ (Galligan 36) and ‘an inherently complex activity’ (Carter and Galligan 4), the most recent Australian Bureau of Statistics figures reveal that the total numbers of books sold in Australia has remained relatively static over the past decade (130.6 million in the financial year 1995–96 and 128.8 million in 2003–04) (ABS). During this time, however, sales volumes of non-fiction publications have grown markedly, with a trend towards “non-fiction, mass market and predictable” books (Corporall 41) resulting in general non-fiction sales in 2003–2004 outselling general fiction by factors as high as ten depending on the format—hard- or paperback, and trade or mass market paperback (ABS 2005). However, while non-fiction has increased in popularity in Australia, the same does not seem to hold true for life writing. Here, in utilising data for the top 5,000 selling non-fiction books in both 2006 and 2007, we are relying on Nielsen BookScan’s categorisation of texts as either biography or autobiography. In 2006, no works of life writing made the top 10 books sold in Australia. In looking at the top 100 books sold for 2006, in some cases the subjects of these works vary markedly from those extracted from the Amazon.com listings. In Australia in 2006, life writing makes its first appearance at number 14 with convicted drug smuggler Schapelle Corby’s My Story. This is followed by another My Story at 25, this time by retired Australian army chief, Peter Cosgrove. Jonestown: The Power and Myth of Alan Jones comes in at 34 for the Australian broadcaster’s biographer Chris Masters; the biography, The Innocent Man by John Grisham at 38 and Li Cunxin’s autobiographical Mao’s Last Dancer at 45. Australian Susan Duncan’s memoir of coping with personal loss, Salvation Creek: An Unexpected Life makes 50; bestselling USA travel writer Bill Bryson’s autobiographical memoir of his childhood The Life and Times of the Thunderbolt Kid 69; Mandela: The Authorised Portrait by Rosalind Coward, 79; and Joanne Lees’s memoir of dealing with her kidnapping, the murder of her partner and the justice system in Australia’s Northern Territory, No Turning Back, 89. These books reveal a market preference for autobiographical writing, and an almost even split between Australian and overseas subjects in 2006. 2007 similarly saw no life writing in the top 10. The books in the top 100 sales reveal a downward trend, with fewer titles making this band overall. In 2007, Terri Irwin’s memoir of life with her famous husband, wildlife warrior Steve Irwin, My Steve, came in at number 26; musician Andrew Johns’s memoir of mental illness, The Two of Me, at 37; Ayaan Hirst Ali’s autobiography Infidel at 39; John Grogan’s biography/memoir, Marley and Me: Life and Love with the World’s Worst Dog, at 42; Sally Collings’s biography of the inspirational young survivor Sophie Delezio, Sophie’s Journey, at 51; and Elizabeth Gilbert’s hybrid food, self-help and travel memoir, Eat, Pray, Love: One Woman’s Search for Everything at 82. Mao’s Last Dancer, published the year before, remained in the top 100 in 2007 at 87. When moving to a consideration of the top 5,000 books sold in Australia in 2006, BookScan reveals only 62 books categorised as life writing in the top 1,000, and only 222 in the top 5,000 (with 34 titles between 1,000 and 1,999, 45 between 2,000 and 2,999, 48 between 3,000 and 3,999, and 33 between 4,000 and 5,000). 2007 shows a similar total of 235 life writing texts in the top 5,000 bestselling books (75 titles in the first 1,000, 27 between 1,000 and 1,999, 51 between 2,000 and 2,999, 39 between 3,000 and 3,999, and 43 between 4,000 and 5,000). In both years, 2006 and 2007, life writing thus not only constituted only some 4% of the bestselling 5,000 titles in Australia, it also showed only minimal change between these years and, therefore, no significant growth. Conclusions Our investigation using various instruments that claim to reflect levels of book sales reveals that Western readers’ willingness to purchase published life writing has not changed significantly over the past century. We find no evidence of either a short, or longer, term growth or boom in sales in such books. Instead, it appears that what has been widely heralded as a new golden age of life writing may well be more the result of an expanded understanding of what is included in the genre than an increased interest in it by either book readers or publishers. What recent years do appear to have seen, however, is a significantly increased interest by public commentators, critics, and academics in this genre of writing. We have also discovered that the issue of our current obsession with the lives of others tends to be discussed in academic as well as popular fora as if what applies to one sub-genre or production form applies to another: if biography is popular, then autobiography will also be, and vice versa. If reality television programming is attracting viewers, then readers will be flocking to life writing as well. Our investigation reveals that such propositions are questionable, and that there is significant research to be completed in mapping such audiences against each other. This work has also highlighted the difficulty of separating out the categories of written texts in publishing studies, firstly in terms of determining what falls within the category of life writing as distinct from other forms of non-fiction (the hybrid problem) and, secondly, in terms of separating out the categories within life writing. Although we have continued to use the terms biography and autobiography as sub-genres, we are aware that they are less useful as descriptors than they are often assumed to be. In order to obtain a more complete and accurate picture, publishing categories may need to be agreed upon, redefined and utilised across the publishing industry and within academia. This is of particular importance in the light of the suggestions (from total sales volumes) that the audiences for books are limited, and therefore the rise of one sub-genre may be directly responsible for the fall of another. Bair argues, for example, that in the 1980s and 1990s, the popularity of what she categorises as memoir had direct repercussions on the numbers of birth-to-death biographies that were commissioned, contracted, and published as “sales and marketing staffs conclude[d] that readers don’t want a full-scale life any more” (17). Finally, although we have highlighted the difficulty of using publishing statistics when there is no common understanding as to what such data is reporting, we hope this study shows that the utilisation of such material does add a depth to such enquiries, especially in interrogating the anecdotal evidence that is often quoted as data in publishing and other studies. Appendix 1 Publishers Weekly listings 1990–1999 1990 included two autobiographies, Bo Knows Bo by professional athlete Bo Jackson (with Dick Schaap) and Ronald Reagan’s An America Life: An Autobiography. In 1991, there were further examples of life writing with unimaginative titles, Me: Stories of My Life by Katherine Hepburn, Nancy Reagan: The Unauthorized Biography by Kitty Kelley, and Under Fire: An American Story by Oliver North with William Novak; as indeed there were again in 1992 with It Doesn’t Take a Hero: The Autobiography of Norman Schwarzkopf, Sam Walton: Made in America, the autobiography of the founder of Wal-Mart, Diana: Her True Story by Andrew Morton, Every Living Thing, yet another veterinary outpouring from James Herriot, and Truman by David McCullough. In 1993, radio shock-jock Howard Stern was successful with the autobiographical Private Parts, as was Betty Eadie with her detailed recounting of her alleged near-death experience, Embraced by the Light. Eadie’s book remained on the list in 1994 next to Don’t Stand too Close to a Naked Man, comedian Tim Allen’s autobiography. Flag-waving titles continue in 1995 with Colin Powell’s My American Journey, and Miss America, Howard Stern’s follow-up to Private Parts. 1996 saw two autobiographical works, basketball superstar Dennis Rodman’s Bad as I Wanna Be and figure-skater, Ekaterina Gordeeva’s (with EM Swift) My Sergei: A Love Story. In 1997, Diana: Her True Story returns to the top 10, joining Frank McCourt’s Angela’s Ashes and prolific biographer Kitty Kelly’s The Royals, while in 1998, there is only the part-autobiography, part travel-writing A Pirate Looks at Fifty, by musician Jimmy Buffet. There is no biography or autobiography included in either the 1999 or 2000 top 10 lists in Publishers Weekly, nor in that for 2005. In 2001, David McCullough’s biography John Adams and Jack Welch’s business memoir Jack: Straight from the Gut featured. In 2002, Let’s Roll! Lisa Beamer’s tribute to her husband, one of the heroes of 9/11, written with Ken Abraham, joined Rudolph Giuliani’s autobiography, Leadership. 2003 saw Hillary Clinton’s autobiography Living History and Paul Burrell’s memoir of his time as Princess Diana’s butler, A Royal Duty, on the list. In 2004, it was Bill Clinton’s turn with My Life. In 2006, we find John Grisham’s true crime (arguably a biography), The Innocent Man, at the top, Grogan’s Marley and Me at number three, and the autobiographical The Audacity of Hope by Barack Obama in fourth place. Appendix 2 Amazon.com listings since 2000 In 2000, there were only two auto/biographies in the top Amazon 50 bestsellers with Lance Armstrong’s It’s Not about the Bike: My Journey Back to Life about his battle with cancer at 20, and Dave Eggers’s self-consciously fictionalised memoir, A Heartbreaking Work of Staggering Genius at 32. In 2001, only the top 14 bestsellers were recorded. At number 1 is John Adams by David McCullough and, at 11, Jack: Straight from the Gut by USA golfer Jack Welch. In 2002, Leadership by Rudolph Giuliani was at 12; Master of the Senate: The Years of Lyndon Johnson by Robert Caro at 29; Portrait of a Killer: Jack the Ripper by Patricia Cornwell at 42; Blinded by the Right: The Conscience of an Ex-Conservative by David Brock at 48; and Louis Gerstner’s autobiographical Who Says Elephants Can’t Dance: Inside IBM’s Historic Turnaround at 50. In 2003, Living History by Hillary Clinton was 7th; Benjamin Franklin: An American Life by Walter Isaacson 14th; Dereliction of Duty: The Eyewitness Account of How President Bill Clinton Endangered America’s Long-Term National Security by Robert Patterson 20th; Under the Banner of Heaven: A Story of Violent Faith by Jon Krakauer 32nd; Leap of Faith: Memoirs of an Unexpected Life by Queen Noor of Jordan 33rd; Kate Remembered, Scott Berg’s biography of Katharine Hepburn, 37th; Who’s your Caddy?: Looping for the Great, Near Great and Reprobates of Golf by Rick Reilly 39th; The Teammates: A Portrait of a Friendship about a winning baseball team by David Halberstam 42nd; and Every Second Counts by Lance Armstrong 49th. In 2004, My Life by Bill Clinton was the best selling book of the year; American Soldier by General Tommy Franks was 16th; Kevin Phillips’s American Dynasty: Aristocracy, Fortune and the Politics of Deceit in the House of Bush 18th; Timothy Russert’s Big Russ and Me: Father and Son. Lessons of Life 20th; Tony Hendra’s Father Joe: The Man who Saved my Soul 23rd; Ron Chernow’s Alexander Hamilton 27th; Cokie Roberts’s Founding Mothers: The Women Who Raised our Nation 31st; Kitty Kelley’s The Family: The Real Story of the Bush Dynasty 42nd; and Chronicles, Volume 1 by Bob Dylan was 43rd. In 2005, auto/biographical texts were well down the list with only The Year of Magical Thinking by Joan Didion at 45 and The Glass Castle: A Memoir by Jeanette Walls at 49. In 2006, there was a resurgence of life writing with Nora Ephron’s I Feel Bad About My Neck: and Other Thoughts on Being a Woman at 9; Grisham’s The Innocent Man at 12; Bill Buford’s food memoir Heat: an Amateur’s Adventures as Kitchen Slave, Line Cook, Pasta-Maker, and Apprentice to a Dante-Quoting Butcher in Tuscany at 23; more food writing with Julia Child’s My Life in France at 29; Immaculée Ilibagiza’s Left to Tell: Discovering God amidst the Rwandan Holocaust at 30; CNN anchor Anderson Cooper’s Dispatches from the Edge: A Memoir of War, Disasters and Survival at 43; and Isabella Hatkoff’s Owen & Mzee: The True Story of a Remarkable Friendship (between a baby hippo and a giant tortoise) at 44. In 2007, Ishmael Beah’s discredited A Long Way Gone: Memoirs of a Boy Soldier came in at 8; Walter Isaacson’s Einstein: His Life and Universe 13; Ayaan Hirst Ali’s autobiography of her life in Muslim society, Infidel, 18; The Reagan Diaries 25; Jesus of Nazareth by Pope Benedict XVI 29; Mother Teresa: Come be my Light 36; Clapton: The Autobiography 40; Tina Brown’s The Diana Chronicles 45; Tony Dungy’s Quiet Strength: The Principles, Practices & Priorities of a Winning Life 47; and Daniel Tammet’s Born on a Blue Day: Inside the Extraordinary Mind of an Autistic Savant at 49. Acknowledgements A sincere thank you to Michael Webster at RMIT for assistance with access to Nielsen BookScan statistics, and to the reviewers of this article for their insightful comments. Any errors are, of course, our own. References Australian Broadcasting Commission (ABC). “About Us.” Australian Story 2008. 1 June 2008. ‹http://www.abc.net.au/austory/aboutus.htm>. Australian Bureau of Statistics. “1363.0 Book Publishers, Australia, 2003–04.” 2005. 1 June 2008 ‹http://www.abs.gov.au/ausstats/abs@.nsf/mf/1363.0>. Bair, Deirdre “Too Much S & M.” Sydney Morning Herald 10–11 Sept. 2005: 17. Basset, Troy J., and Christina M. Walter. “Booksellers and Bestsellers: British Book Sales as Documented by The Bookman, 1891–1906.” Book History 4 (2001): 205–36. Brien, Donna Lee, Leonie Rutherford, and Rosemary Williamson. “Hearth and Hotmail: The Domestic Sphere as Commodity and Community in Cyberspace.” M/C Journal 10.4 (2007). 1 June 2008 ‹http://journal.media-culture.org.au/0708/10-brien.php>. Carter, David, and Anne Galligan. “Introduction.” Making Books: Contemporary Australian Publishing. St Lucia: U of Queensland P, 2007. 1–14. Corporall, Glenda. Project Octopus: Report Commissioned by the Australian Society of Authors. Sydney: Australian Society of Authors, 1990. Dempsey, John “Biography Rewrite: A&E’s Signature Series Heads to Sib Net.” Variety 4 Jun. 2006. 1 June 2008 ‹http://www.variety.com/article/VR1117944601.html?categoryid=1238&cs=1>. Donaldson, Ian. “Matters of Life and Death: The Return of Biography.” Australian Book Review 286 (Nov. 2006): 23–29. Douglas, Kate. “‘Blurbing’ Biographical: Authorship and Autobiography.” Biography 24.4 (2001): 806–26. Eliot, Simon. “Very Necessary but not Sufficient: A Personal View of Quantitative Analysis in Book History.” Book History 5 (2002): 283–93. Feather, John, and Hazel Woodbridge. “Bestsellers in the British Book Industry.” Publishing Research Quarterly 23.3 (Sept. 2007): 210–23. Feather, JP, and M Reid. “Bestsellers and the British Book Industry.” Publishing Research Quarterly 11.1 (1995): 57–72. Galligan, Anne. “Living in the Marketplace: Publishing in the 1990s.” Publishing Studies 7 (1999): 36–44. Grossman, Lev. “Time’s Person of the Year: You.” Time 13 Dec. 2006. Online edition. 1 June 2008 ‹http://www.time.com/time/magazine/article/0%2C9171%2C1569514%2C00.html>. Gutjahr, Paul C. “No Longer Left Behind: Amazon.com, Reader Response, and the Changing Fortunes of the Christian Novel in America.” Book History 5 (2002): 209–36. Hamilton, Nigel. Biography: A Brief History. Cambridge, MA: Harvard UP, 2007. Kaplan, Justin. “A Culture of Biography.” The Literary Biography: Problems and Solutions. Ed. Dale Salwak. Basingstoke: Macmillan, 1996. 1–11. Korda, Michael. Making the List: A Cultural History of the American Bestseller 1900–1999. New York: Barnes & Noble, 2001. Miller, Laura J. “The Bestseller List as Marketing Tool and Historical Fiction.” Book History 3 (2000): 286–304. Morreale, Joanne. “Revisiting The Osbournes: The Hybrid Reality-Sitcom.” Journal of Film and Video 55.1 (Spring 2003): 3–15. Rak, Julie. “Bio-Power: CBC Television’s Life & Times and A&E Network’s Biography on A&E.” LifeWriting 1.2 (2005): 1–18. Starck, Nigel. “Capturing Life—Not Death: A Case For Burying The Posthumous Parallax.” Text: The Journal of the Australian Association of Writing Programs 5.2 (2001). 1 June 2008 ‹http://www.textjournal.com.au/oct01/starck.htm>.

Image 1: “Oklahoma State Highway Re-imagined.” CC BY-SA 4.0 2015 by author, using Wikimedia image by Ks0stm (CC BY-SA 3 2013). Introduction This article is divided in three major parts. First a scenario, second its context, and third, an analysis. The text draws on ethnographic research on security practices in the United States among police and parts of the intelligence community from 2006 through to the beginning of 2014. Real names are used when the material is drawn from archival sources, while individuals who were interviewed during fieldwork are referred to by their position rank or title. For matters of fact not otherwise referenced, see the sources compiled on “The Complete 911 Timeline” at History Commons. First, a scenario. Oklahoma, 2001 It is 1 April 2001, in far western Oklahoma, warm beneath the late afternoon sun. Highway Patrol Trooper C.L. Parkins is about 80 kilometres from the border of Texas, watching trucks and cars speed along Interstate 40. The speed limit is around 110 kilometres per hour, and just then, his radar clocks a blue Toyota Corolla going 135 kph. The driver is not wearing a seatbelt. Trooper Parkins swung in behind the vehicle, and after a while signalled that the car should pull over. The driver was dark-haired and short; in Parkins’s memory, he spoke English without any problem. He asked the man to come sit in the patrol car while he did a series of routine checks—to see if the vehicle was stolen, if there were warrants out for his arrest, if his license was valid. Parkins said, “I visited with him a little bit but I just barely remember even having him in my car. You stop so many people that if […] you don't arrest them or anything […] you don't remember too much after a couple months” (Clay and Ellis). Nawaf Al Hazmi had a valid California driver’s license, with an address in San Diego, and the car’s registration had been legally transferred to him by his former roommate. Parkins’s inquiries to the National Crime Information Center returned no warnings, nor did anything seem odd in their interaction. So the officer wrote Al Hazmi two tickets totalling $138, one for speeding and one for failure to use a seat belt, and told him to be on his way. Al Hazmi, for his part, was crossing the country to a new apartment in a Virginia suburb of Washington, DC, and upon arrival he mailed the payment for his tickets to the county court clerk in Oklahoma. Over the next five months, he lived several places on the East Coast: going to the gym, making routine purchases, and taking a few trips that included Las Vegas and Florida. He had a couple more encounters with local law enforcement and these too were unremarkable. On 1 May 2001 he was mugged, and promptly notified the police, who documented the incident with his name and local address (Federal Bureau of Investigation, 139). At the end of June, having moved to New Jersey, he was involved in a minor traffic accident on the George Washington Bridge, and officers again recorded his real name and details of the incident. In July, Khalid Al Mihdhar, the previous owner of the car, returned from abroad, and joined Al Hazmi in New Jersey. The two were boyhood friends, and they went together to a library several times to look up travel information, and then, with Al Hazmi’s younger brother Selem, to book their final flight. On 11 September, the three boarded American Airlines flight 77 as part of the Al Qaeda team that flew the mid-sized jet into the west façade of the Pentagon. They died along with the piloting hijacker, all the passengers, and 125 people on the ground. Theirs was one of four airplanes hijacked that day, one of which was crashed by passengers, the others into significant sites of American power, by men who had been living for varying lengths of time all but unnoticed in the United States. No one thought that Trooper Parkins, or the other officers with whom the 9/11 hijackers crossed paths, should have acted differently. The Commissioner of the Oklahoma Department of Public Safety himself commented that the trooper “did the right thing” at that April traffic stop. And yet, interviewed by a local newspaper in January of 2002, Parkins mused to the reporter “it's difficult sometimes to think back and go: 'What if you had known something else?'" (Clay and Ellis). Missed Opportunities Image 2: “Hijackers Timeline (Redacted).” CC BY-SA 4.0 2015 by author, using the Federal Bureau of Investigation (FBI)’s “Working Draft Chronology of Events for Hijackers and Associates”. In fact, several of the men who would become the 9/11 hijackers were stopped for minor traffic violations. Mohamed Atta, usually pointed to as the ringleader, was given a citation in Florida that spring of 2001 for driving without a license. When he missed his court date, a bench warrant was issued (Wall Street Journal). Perhaps the warrant was not flagged properly, however, since nothing happened when he was pulled over again, for speeding. In the government inquiries that followed attack, and in the press, these brushes with the law were “missed opportunities” to thwart the 9/11 plot (Kean and Hamilton, Report 353). Among a certain set of career law enforcement personnel, particularly those active in management and police associations, these missed opportunities were fraught with a sense of personal failure. Yet, in short order, they were to become a source of professional revelation. The scenarios—Trooper Parkins and Al Hazmi, other encounters in other states, the general fact that there had been chance meetings between police officers and the hijackers—were re-imagined in the aftermath of 9/11. Those moments were returned to and reversed, so that multiple potentialities could be seen, beyond or in addition to what had taken place. The deputy director of an intelligence fusion centre told me in an interview, “it is always a local cop who saw something” and he replayed how the incidents of contact had unfolded with the men. These scenarios offered a way to recapture the past. In the uncertainty of every encounter, whether a traffic stop or questioning someone taking photos of a landmark (and potential terrorist target), was also potential. Through a process of re-imagining, police encounters with the public became part of the government’s “national intelligence” strategy. Previously a division had been marked between foreign and domestic intelligence. While the phrase “national intelligence” had long been used, notably in National Intelligence Estimates, after 9/11 it became more significant. The overall director of the US intelligence community became the Director National Intelligence, for instance, and the cohesive term marked the way that increasingly diverse institutional components, types of data and forms of action were evolving to address the collection of data and intelligence production (McConnell). In a series of working groups mobilised by members of major police professional organisations, and funded by the US Department of Justice, career officers and representatives from federal agencies produced detailed recommendations and plans for involving police in the new Information Sharing Environment. Among the plans drawn up during this period was what would eventually come to be the Nationwide Suspicious Activity Reporting Initiative, built principally around the idea of encounters such as the one between Parkins and Al Hazmi. Map 1: Map of pilot sites in the Nationwide Suspicious Activity Reporting Evaluation Environment in 2010 (courtesy of the author; no longer available online). Map 2: Map of participating sites in the Nationwide Suspicious Activity Reporting Initiative, as of 2014. In an interview, a fusion centre director who participated in this planning as well as its implementation, told me that his thought had been, “if we train state and local cops to understand pre-terrorism indicators, if we train them to be more curious, and to question more what they see,” this could feed into “a system where they could actually get that information to somebody where it matters.” In devising the reporting initiative, the working groups counter-actualised the scenarios of those encounters, and the kinds of larger plots to which they were understood to belong, in order to extract a set of concepts: categories of suspicious “activities” or “patterns of behaviour” corresponding to the phases of a terrorism event in the process of becoming (Deleuze, Negotiations). This conceptualisation of terrorism was standardised, so that it could be taught, and applied, in discerning and documenting the incidents comprising an event’s phases. In police officer training, the various suspicious behaviours were called “terrorism precursor activities” and were divided between criminal and non-criminal. “Functional Standards,” developed by the Los Angeles Police Department and then tested by the Department of Homeland Security (DHS), served to code the observed behaviours for sharing (via compatible communication protocols) up the federal hierarchy and also horizontally between states and regions. In the popular parlance of videos made for the public by local police departments and DHS, which would come to populate the internet within a few years, these categories were “signs of terrorism,” more specifically: surveillance, eliciting information, testing security, and so on. Image 3: “The Seven Signs of Terrorism (sometimes eight).” CC BY-SA 4.0 2015 by author, using materials in the public domain. If the problem of 9/11 had been that the men who would become hijackers had gone unnoticed, the basic idea of the Suspicious Activity Reporting Initiative was to create a mechanism through which the eyes and ears of everyone could contribute to their detection. In this vein, “If You See Something, Say Something™” was a campaign that originated with the New York City Metropolitan Transportation Authority, and was then licensed for use to DHS. The tips and leads such campaigns generated, together with the reports from officers on suspicious incidents that might have to do with terrorism, were coordinated in the Information Sharing Environment. Drawing on reports thus generated, the Federal Government would, in theory, communicate timely information on security threats to law enforcement so that they would be better able to discern the incidents to be reported. The cycle aimed to catch events in emergence, in a distinctively anticipatory strategy of counterterrorism (Stalcup). Re-imagination A curious fact emerges from this history, and it is key to understanding how this initiative developed. That is, there was nothing suspicious in the encounters. The soon-to-be terrorists’ licenses were up-to-date, the cars were legal, they were not nervous. Even Mohamed Atta’s warrant would have resulted in nothing more than a fine. It is not self-evident, given these facts, how a governmental technology came to be designed from these scenarios. How––if nothing seemed of immediate concern, if there had been nothing suspicious to discern––did an intelligence strategy come to be assembled around such encounters? Evidently, strident demands were made after the events of 9/11 to know, “what went wrong?” Policies were crafted and implemented according to the answers given: it was too easy to obtain identification, or to enter and stay in the country, or to buy airplane tickets and fly. But the trooper’s question, the reader will recall, was somewhat different. He had said, “It’s difficult sometimes to think back and go: ‘What if you had known something else?’” To ask “what if you had known something else?” is also to ask what else might have been. Janet Roitman shows that identifying a crisis tends to implicate precisely the question of what went wrong. Crisis, and its critique, take up history as a series of right and wrong turns, bad choices made between existing dichotomies (90): liberty-security, security-privacy, ordinary-suspicious. It is to say, what were the possibilities and how could we have selected the correct one? Such questions seek to retrospectively uncover latencies—systemic or structural, human error or a moral lapse (71)—but they ask of those latencies what false understanding of the enemy, of threat, of priorities, allowed a terrible thing to happen. “What if…?” instead turns to the virtuality hidden in history, through which missed opportunities can be re-imagined. Image 4: “The Cholmondeley Sisters and Their Swaddled Babies.” Anonymous, c. 1600-1610 (British School, 17th century); Deleuze and Parnet (150). CC BY-SA 4.0 2015 by author, using materials in the public domain. Gilles Deleuze, speaking with Claire Parnet, says, “memory is not an actual image which forms after the object has been perceived, but a virtual image coexisting with the actual perception of the object” (150). Re-imagined scenarios take up the potential of memory, so that as the trooper’s traffic stop was revisited, it also became a way of imagining what else might have been. As Immanuel Kant, among others, points out, “the productive power of imagination is […] not exactly creative, for it is not capable of producing a sense representation that was never given to our faculty of sense; one can always furnish evidence of the material of its ideas” (61). The “memory” of these encounters provided the material for re-imagining them, and thereby re-virtualising history. This was different than other governmental responses, such as examining past events in order to assess the probable risk of their repetition, or drawing on past events to imagine future scenarios, for use in exercises that identify vulnerabilities and remedy deficiencies (Anderson). Re-imagining scenarios of police-hijacker encounters through the question of “what if?” evoked what Erin Manning calls “a certain array of recognizable elastic points” (39), through which options for other movements were invented. The Suspicious Activity Reporting Initiative’s architects instrumentalised such moments as they designed new governmental entities and programs to anticipate terrorism. For each element of the encounter, an aspect of the initiative was developed: training, functional standards, a way to (hypothetically) get real-time information about threats. Suspicion was identified as a key affect, one which, if cultivated, could offer a way to effectively deal not with binary right or wrong possibilities, but with the potential which lies nestled in uncertainty. The “signs of terrorism” (that is, categories of “terrorism precursor activities”) served to maximise receptivity to encounters. Indeed, it can apparently create an oversensitivity, manifested, for example, in police surveillance of innocent people exercising their right to assemble (Madigan), or the confiscation of photographers’s equipment (Simon). “What went wrong?” and “what if?” were different interrogations of the same pre-9/11 incidents. The questions are of course intimately related. Moments where something went wrong are when one is likely to ask, what else might have been known? Moreover, what else might have been? The answers to each question informed and shaped the other, as re-imagined scenarios became the means of extracting categories of suspicious activities and patterns of behaviour that comprise the phases of an event in becoming. Conclusion The 9/11 Commission, after two years of investigation into the causes of the disastrous day, reported that “the most important failure was one of imagination” (Kean and Hamilton, Summary). The iconic images of 9/11––such as airplanes being flown into symbols of American power––already existed, in guises ranging from fictive thrillers to the infamous FBI field memo sent to headquarters on Arab men learning to fly, but not land. In 1974 there had already been an actual (failed) attempt to steal a plane and kill the president by crashing it into the White House (Kean and Hamilton, Report Ch11 n21). The threats had been imagined, as Pat O’Malley and Philip Bougen put it, but not how to govern them, and because the ways to address those threats had been not imagined, they were discounted as matters for intervention (29). O’Malley and Bougen argue that one effect of 9/11, and the general rise of incalculable insecurities, was to make it necessary for the “merely imaginable” to become governable. Images of threats from the mundane to the extreme had to be conjured, and then imagination applied again, to devise ways to render them amenable to calculation, minimisation or elimination. In the words of the 9/11 Commission, the Government must bureaucratise imagination. There is a sense in which this led to more of the same. Re-imagining the early encounters reinforced expectations for officers to do what they already do, that is, to be on the lookout for suspicious behaviours. Yet, the images of threat brought forth, in their mixing of memory and an elastic “almost,” generated their own momentum and distinctive demands. Existing capacities, such as suspicion, were re-shaped and elaborated into specific forms of security governance. The question of “what if?” and the scenarios of police-hijacker encounter were particularly potent equipment for this re-imagining of history and its re-virtualisation. References Anderson, Ben. “Preemption, Precaution, Preparedness: Anticipatory Action and Future Geographies.” Progress in Human Geography 34.6 (2010): 777-98. Clay, Nolan, and Randy Ellis. “Terrorist Ticketed Last Year on I-40.” NewsOK, 20 Jan. 2002. 25 Nov. 2014 ‹http://newsok.com/article/2779124›. Deleuze, Gilles. Negotiations. New York: Columbia UP, 1995. Deleuze, Gilles, and Claire Parnet. Dialogues II. New York: Columbia UP 2007 [1977]. Federal Bureau of Investigation. “Hijackers Timeline (Redacted) Part 01 of 02.” Working Draft Chronology of Events for Hijackers and Associates. 2003. 18 Apr. 2014 ‹https://vault.fbi.gov/9-11%20Commission%20Report/9-11-chronology-part-01-of-02›. Kant, Immanuel. Anthropology from a Pragmatic Point of View. Trans. Robert B. Louden. Cambridge: Cambridge UP, 2006. Kean, Thomas H., and Lee Hamilton. Executive Summary of the 9/11 Commission Report: Final Report of the National Commission on Terrorist Attacks upon the United States. 25 Oct. 2015 ‹http://www.9-11commission.gov/report/911Report_Exec.htm›. Kean, Thomas H., and Lee Hamilton. The 9/11 Commission Report: Final Report of the National Commission on Terrorist Attacks upon the United States. New York: W.W. Norton, 2004. McConnell, Mike. “Overhauling Intelligence.” Foreign Affairs, July/Aug. 2007. Madigan, Nick. “Spying Uncovered.” Baltimore Sun 18 Jul. 2008. 25 Oct. 2015 ‹http://www.baltimoresun.com/news/maryland/bal-te.md.spy18jul18-story.html›. Manning, Erin. Relationscapes: Movement, Art, Philosophy. Cambridge, MA: MIT P, 2009. O’Malley, P., and P. Bougen. “Imaginable Insecurities: Imagination, Routinisation and the Government of Uncertainty post 9/11.” Imaginary Penalities. Ed. Pat Carlen. Cullompton, UK: Willan, 2008.Roitman, Janet. Anti-Crisis. Durham, NC: Duke UP, 2013. Simon, Stephanie. “Suspicious Encounters: Ordinary Preemption and the Securitization of Photography.” Security Dialogue 43.2 (2012): 157-73. Stalcup, Meg. “Policing Uncertainty: On Suspicious Activity Reporting.” Modes of Uncertainty: Anthropological Cases. Eds. Limor Saminian-Darash and Paul Rabinow. Chicago: U of Chicago P, 2015. 69-87. Wall Street Journal. “A Careful Sequence of Mundane Dealings Sows a Day of Bloody Terror for Hijackers.” 16 Oct. 2001.

Photo by 193001056 © Yee Xin Tan on Dreamstime.com ABSTRACT Suicide and overdose, associated with perinatal mental health conditions, are the leading causes of maternal mortality in the United States. Experts in the field of perinatal mental health are using perinatal mood and anxiety disorders (PMAD) as an umbrella term that includes many mental health conditions and bring to light the lack of screening and treatment for perinatal mental health in the United States. There is a growing need to equip Obstetricians and Gynecologist (OB-GYN) providers with better tools to screen, triage, and refer to mental health services that are equitable and immediately accessible to their patients. Integrating a tech-enabled perinatal collaborative care model with peer-to-peer coaching as the driver of behavior change is a novel approach to addressing the maternal mental health crisis by improving outcomes, reducing disparities, and lowering costs. INTRODUCTION Over the past two decades, maternal mortality and other maternal health outcomes have worsened in the United States disproportionately to those in other developed countries.[1] In 2021, 1,205 pregnant women died in the US, representing a 40 percent increase in maternal death from 2020 and the highest rise in rates since the 1960s.[2] Suicide and overdose associated with perinatal mental health conditions are the leading causes of maternal mortality.[3] Mental health-related deaths are most likely to occur after six weeks postpartum.[4] Despite the postpartum period representing a higher risk for mental health conditions, historically, only a single postpartum visit is performed between 4 and 6 weeks after delivery. 40 percent of women do not attend a postpartum visit.[5] Recent data from Maternal Mortality Review Committees reveal that 80 percent of maternal deaths are preventable. The maternal mental health crisis represents a unique ethical dilemma. For perinatal women, the current healthcare system is unjust. There is a growing need to equip obstetricians and gynecologists (OB-GYNs) with the tools to screen, triage, and refer patients to mental health services that are equitable and immediately accessible to their patients. This paper will analyze the current state of perinatal mental healthcare in America. It will introduce the Psychiatric Collaborative Care Model and demonstrate its effectiveness. I highlight research performed using the Psychiatric Collaborative Care Model in obstetrics as well as barriers to real-world implementation. Lastly, this paper will argue that the integration of a tech-enabled perinatal collaborative care model with peer-to-peer coaching as the driver of behavior change would improve outcomes, reduce disparities, and lower costs. I. Scope of the Problem Prior to the COVID-19 pandemic, the prevalence of postpartum depression ranged from 13.2 percent, to as high as 23.5 percent, of births in the US.[6] The COVID-19 pandemic has exacerbated this issue, with studies revealing up to 1 in 3 postpartum women experiencing postpartum depression.[7] Although postpartum depression has been the focus of perinatal mental health conditions, it is just the tip of the iceberg. Experts in the field of perinatal mental health are now using perinatal mood and anxiety disorders as an umbrella term that includes perinatal depression, anxiety, obsessive-compulsive disorder, post-traumatic stress disorder, bipolar disorder, and psychosis from the prenatal period through the first year postpartum. Socio-economically disadvantaged women are at increased risk of experiencing perinatal mood and anxiety disorders and face greater barriers to high-quality mental health care.[8] The American College of Obstetricians and Gynecologists (ACOG) recommends that physicians perform postpartum depression screenings during pregnancy. The Health Resources and Services Administration provides Healthy Start Initiative Grants to communities with high rates of adverse perinatal outcomes. Yet, the Healthcare Effectiveness Data and Information Set (HEDIS) reveals that screening in both pregnancy and the postpartum period occurs in fewer than 20 percent of patients.[9] Furthermore, in the US, if screening does occur, only 22 percent of women who are deemed positive in their screening receive mental health care.[10] The United States is currently experiencing a shortage of mental health providers that is expected to worsen in the upcoming years.[11] Nearly half of all Americans currently live in a mental health professional desert.[12] Waitlists for therapists and psychiatrists average 48 days, and individuals report not seeking mental health care due to cost or lack of insurance coverage.[13] Given the significant mental health provider shortage, obstetric providers have a unique opportunity to care for the “whole patient” during and after pregnancy by addressing not only their physical health but also their mental health. Approximately one-third of women consider their OB-GYN their primary care provider during and after pregnancy, and over 50 percent of OB-GYNs perceive themselves as primary care providers for women, supporting primary, specialty, and preventive care.[14] Medicaid covers 42 percent of all births in the US, and more than half of all births in some states, thus OB-GYNs provide a disproportionate amount of care for poor and minority women as compared to other specialties.[15] Yet, OB-GYN providers commonly feel hesitant to screen for depression due to the shortage of therapists and psychiatrists to address the mental health needs of their patients, particularly in the Medicaid population.[16] As a result, fewer than 10 percent of pregnant women with mental health conditions receive adequate treatment.[17] A recent study of 288 obstetrics fellows revealed that 84 percent prescribed SSRIs to their patients; obstetricians are filling the mental health provider gap and taking ownership over their patients’ mental health.[18] Despite ACOG’s recommendations that obstetrics providers screen for and treat mental health conditions in the perinatal period, OB-GYNs do not receive formal mental health training during residency or fellowship and do not typically use validated tools such as the Diagnostic and Statistical Manual of Mental Disorders-Forth Edition (DSM-IV) for diagnosis of depression or prior to prescribing antidepressants. Their lack of a standard reference can lead to misdiagnoses.[19] In fact, 22 percent of women screened and found to have postpartum depression are later diagnosed with bipolar disorder.[20] Screening and treatment for perinatal mood and anxiety disorders are further impacted by patients’ lack of trust in healthcare providers. Distrust between patients, particularly those receiving Medicaid, and their OB-GYNs in the US is high and strongly associated with worse self-reported health outcomes.[21] Notably, women with Medicaid coverage reported being treated unfairly and with disrespect by providers because of their race and insurance status. They reported a loss of decision-making autonomy during labor and delivery and less postpartum emotional and practical support at home.[22] Many women do not feel comfortable discussing mental disorders with a healthcare provider.[23] Connecting perinatal women to a person with shared lived experiences, known as peer-to-peer engagement or coaching, may be a simple solution. II. Collaborative Care Model The Psychiatric Collaborative Care Model (collaborative care), developed by the University of Washington in 2002, is an integrated behavioral health approach designed to treat common mental health conditions such as depression and anxiety that require measurement-based follow-up due to their chronic nature.[24] Centers for Medicare and Medicaid Services issued billing codes for the Psychiatric Collaborative Care Model in 2016. Medicare adopted them in 2017, and they were widely operationalized in the primary care field.[25] As of 2022, the collaborative care billing codes have been adopted by 19 state Medicaid plans.[26] The collaborative care model facilitates the integration of a behavioral health care manager, typically a licensed therapist or care worker, in the primary care setting. The behavioral health care manager can provide in-person or virtual care and facilitate mental health screenings, symptom monitoring, psychiatric consultations, and care coordination.[27] A psychiatric consultant, typically a board-certified psychiatrist or psychiatric nurse practitioner, is an integrated behavioral health provider on the collaborative care team. Psychiatric consultants do not see patients one on one. Rather, they review complex or treatment-resistant cases and provide psychiatric management recommendations to the primary provider. Thus, the primary care team is expanded by two members who provide behavioral health expertise to the primary care provider, who is ultimately the prescribing provider if any psychoactive medications are indicated.[28] This model has been tested in over 90 randomized clinical trials evaluating efficacy for the treatment of depression and anxiety across multiple medical specialties.[29] Data from the primary care setting indicate that this integrated behavioral health approach is both successful and more cost-effective than usual care for patients with behavioral health conditions.[30] Studies show that the collaborative care model improves clinical outcomes and lowers costs, returning $6.50 for every dollar spent on treatment of depression. Furthermore, the model is effective across diverse patient populations.[31] III. Evidence for Collaborative Care in Obstetrics The success of the collaborative care model for identifying anxiety and depression in the primary care setting and its potential for cost savings suggest that implementation of perinatal collaborative care for perinatal mood and anxiety disorders is a feasible approach.[32] Randomized clinical trials showed significant improvement in quality care, depression severity, and remission rates from before birth to 18 months postbaseline for socioeconomically disadvantaged women.[33] In addition, collaborative care is associated with mitigating racial disparities in antenatal depression care; it may be an equity-promoting intervention for maternal health.[34] The trials faced limitations, including the inability to establish causality, and the researchers recommended further research. Although further research is warranted, the collaborative care model in obstetrics programs has indicated improved depression outcomes. IV. Barriers to Adoption of a Collaborative Care Model in Obstetrics Despite promising results, implementation is limited, and collaborative care is billable under Medicaid in only 19 states.[35] Large health systems have difficulty operationalizing a collaborative care model in obstetrics due to implementation costs, mental health provider shortages, and administrative burdens. More evidence of financial benefits to obstetrics clinics, hospitals, and health systems is needed. Additionally, obstetric practices must adapt to updated care plans, and obstetricians must be motivated to become involved in behavioral health issues and potentially broaden their scope of practice.[36] As this is a major ask from practices and providers, robust evidence is lacking to show that a perinatal collaborative care model can be applied without the resources and infrastructure of a randomized trial. V. Peer-to-Peer Engagement Peer support in healthcare is growing. Peer support is defined as help and support that people with lived experiences can give one another.[37] Effective examples of peer support or engagement are found in addiction, mental health services, and the workforce. Regarding addiction recovery support, a systematic review concluded that peer support interventions have a beneficial effect on participants and positively contribute to substance use outcomes.[38] Peer support is highly used in medicine and other professions when attending physicians or skilled professionals train new colleagues. The nursing profession uses peer support to help deliver quality care and reduce symptoms of burnout.[39] Peer support has been well described in literature, and programs differ in their methodology and delivery. The feasibility and maintenance of peer support programs are possible through collaboration with all healthcare stakeholders.[40] Understanding that shared experiences establish a foundation of trust may help obstetricians see peers as a way to bridge the gap. A peer coach may be valuable in the collaborative care model. VI. Integrating Peer-to-Peer into the Collaborative Care Model for Obstetrics Currently, a start-up based in Boston and Philadelphia, FamilyWell, has piloted tech-enabled peer-to-peer engagement into a collaborative care model for obstetric patients. The company strives to solve the perinatal mental health crisis and close the health equity gap in the US by applying a text messaging platform to connect expecting and newly postpartum mothers with peer coaches. Peer coaches are trained to support perinatal mothers, defined as third-trimester pregnancy through 12 months postpartum, by providing quality support based on the latest research. Coaches have their own unique birth and postpartum stories, making them relatable and equipped to support mothers through the ups and downs of parenthood.[41] Increased education, screening, and treatment for perinatal mood and anxiety disorders co-occur as connections are being made through texting and virtual visits with coaches. On demand texting with coaches ensures no mother feels alone and that mothers have a safe space to ask questions and process emotions. If needed, enrolled moms can request longer virtual coaching sessions of 50 minutes with certified perinatal mental health coaches, who focus on current issues and how to move forward and feel better, accomplished through cognitive behavioral coaching techniques.[42] The platform schedules automated text messages containing educational content. Individual care plans are developed in collaboration with an individual’s OB and include monthly mental health screenings during and post-pregnancy. Notably, at three-week postpartum, participants are sent the Edinburg postnatal depression scale 3 (EPDS-3) questions via text messages.[43] This screening is three weeks prior to the national six-weeks postpartum screening recommendation and focuses on antepartum anxiety, which represents a risk factor for depression.[44] If an individual needs more mental health support compared to coaching, virtual therapy sessions are available through the platform, giving access to licensed therapist, specializing in perinatal mental health without extensive waitlist. Therapists can diagnosis and provide medication management if needed. FamilyWell CEO and founder, Jessica Gaulton, revealed that preliminary data collected during the first two months of the company’s launch, limited to the Philadelphia, PA region and three clinics, indicated that 24 postpartum mothers consented to the program. A total of 3,000 texts were exchanged, and 44.2 percent of those texts came from participants to peer coaches.[45] The platform expediates appropriate referrals, creates individualized maternal wellness treatment plans, and serves as a resource for navigating the medical system. VII. Providing Justice in the Maternal Healthcare System The well-being of mothers is a bellwether for the well-being of society; every injustice in our society shows up in maternal health.[46] Earlier, broader, and more frequent screening combined with direct mental health access is essential to address perinatal mood and anxiety disorders and ultimately the maternal mortality rate. Integrating collaborative care with peer-to-peer coaching provides new mothers with direct support and follow-up care. This simple yet novel integration begins to close the gap by providing equitable care. The tech-based platform’s research and success highlight that a broader focus on screening is critical. Limiting mental illness to depression fails to serve women adequately. Expanding criteria to screen for indicators of future depression, such as anxiety, is a simple, proactive step. A relatable peer may be a critical factor in helping perinatal women feel comfortable openly discussing problems they are facing and beginning conversations not otherwise occurring in a perinatal or postpartum visit. Companies like FamilyWell can contribute to making collaborative care feasible in the OB-GYN setting. Having an outside organization with peer-coaches building a foundation of trust and championing the collaborative care model reduces the burden for overworked obstetricians. Furthermore, the tech-based platform can organize and facilitate interprofessional communications, which rarely take place in the current system.[47] The texting and telehealth approach brings compassion, care, and more frequent contact directly to the patient, which is critical for socioeconomically disadvantaged women as they are the demographic not properly accessing care now. As the coaches and behavior care coordinator make the referrals for mental health services that align with a mother’s insurance coverage, they reduce stress for new mothers who might not know where to begin when navigating the mental health care system. Additionally, obstetricians may feel more comfortable performing mental health screenings knowing their patients can access mental health care. CONCLUSION The perinatal mental health crisis is significant. Women are currently experiencing injustice in the healthcare system due to a lack of trust, screening, and effective, accessible care. The psychiatric collaborative care model has been proven effective in the primary care setting, and randomized clinical trials conclude it is also effective in obstetrics, but barriers exist. Integrating peer-to-peer coaching through a tech-enabled platform into obstetrics collaborative care may eliminate barriers and build trust between patients and the healthcare system. More research is needed to show the efficacy of a tech-enabled model, and more research is critical to demonstrate that this model can be financially sustainable and revenue-generating for hospitals and obstetrics departments. However, this simple novel step may begin to generate equitable care for women and potentially save lives. - [1] Collier, A. R. Y., & Molina, R. L. (2019). Maternal mortality in the United States: updates on trends, causes, and solutions. Neoreviews, 20(10), e561-e574. [2] Hoyert, D. L. (2023). Maternal Mortality Rates in the United States, 2021.Health E-Stats. National Center for Health Statistics. Centers for Disease Control. https://dx.doi.org/10.15620/cdc:124678 [3] Miller, E. S., Grobman, W. A., Ciolino, J. D., Zumpf, K., Sakowicz, A., Gollan, J., & Wisner, K. L. (2021). Increased depression screening and treatment recommendations after implementation of a perinatal collaborative care program. Psychiatric Services, 72(11), 1268-1275. [4] Trost, S. L., Beauregard, J. L., Smoots, A. N., Ko, J. Y., Haight, S. C., Moore Simas, T. A., ... & Goodman, D. (2021). Preventing Pregnancy-Related Mental Health Deaths: Insights From 14 US Maternal Mortality Review Committees, 2008–17: Study examines maternal mortality and mental health. Health Affairs, 40(10), 1551-1559. [5] Blenning, C. E., & Paladine, H. L. (2005). An approach to the postpartum office visit. American Family Physician, 72(12), 2491-2496; ACOG Committee Opinion No. 736: Optimizing Postpartum Care. Obstetrics and gynecology, 132(3), 784–785. https://doi.org/10.1097/AOG.0000000000002849 [6]Bauman, B. L., Ko, J. Y., Cox, S., D'Angelo Mph, D. V., Warner, L., Folger, S., Tevendale, H. D., Coy, K. C., Harrison, L., & Barfield, W. D. (2020). Vital Signs: Postpartum Depressive Symptoms and Provider Discussions About Perinatal Depression - United States, 2018. MMWR. Morbidity and mortality weekly report, 69(19), 575–581. https://doi.org/10.15585/mmwr.mm6919a2 [7] Shuman, C.J., Peahl, A.F., Pareddy, N. (2022) Postpartum depression and associated risk factors during the COVID-19 pandemic. BMC Res Notes 15, 102. https://doi.org/10.1186/s13104-022-05991-8 [8] Grote, N. K., Katon, W. J., Russo, J. E., Lohr, M. J., Curran, M., Galvin, E., & Carson, K. (2015). Collaborative care for perinatal depression in socioeconomically disadvantaged women: a randomized trial. Depression and Anxiety, 32(11), 821-834. [9] HESI Annual Report. HESI. (2022, November). Retrieved April 30, 2023, from Special-Report-Nov-2022-Results-for-Measures-Leveraging-Electronic-Clinical-Data-for-HEDIS.pdf (ncqa.org) [10] Byatt, N., Levin, L. L., Ziedonis, D., Moore Simas, T. A., & Allison, J. (2015). Enhancing Participation in Depression Care in Outpatient Perinatal Care Settings: A Systematic Review. Obstetrics and Gynecology, 126(5), 1048–1058. https://doi.org/10.1097/AOG.0000000000001067 [11] Satiani, A., Niedermier, J., Satiani, B., & Svendsen, D. P. (2018). Projected Workforce of Psychiatrists in the United States: A Population Analysis. Psychiatric Services (Washington, D.C.), 69(6), 710–713. https://doi.org/10.1176/appi.ps.201700344 [12] Bureau of Health Workforce Health Resources and Services Administration (HRSA) U.S. Department of Health & Human Services. (April 27, 2023) Designated Health Professional Shortage Areas Statistics, Second Quarter of Fiscal Year 2023 Designated HPSA Quarterly Summary. https://data.hrsa.gov/Default/GenerateHPSAQuarterlyReport [13] Coward, K. (2021). New data shows CCBHCs improve behavioral health access, reduce wait times. Behavioral Health Business. https://bhbusiness.com/2021/05/25/new-data-shows-ccbhcs-improve-behavioral-health-access-reduce-wait-times; The United States Government. (2022, June 17). Reducing the economic burden of unmet mental health needs - CEA. The White House. Retrieved April 30, 2023, from https://www.whitehouse.gov/cea/written-materials/2022/05/31/reducing-the-economic-burden-of-unmet-mental-health-needs/ [14] LaRocco-Cockburn, A., Reed, S. D., Melville, J., Croicu, C., Russo, J. E., Inspektor, M., ... & Katon, W. (2013). Improving depression treatment for women: integrating a collaborative care depression intervention into OB-GYN care. Contemporary clinical trials, 36(2), 362-370. [15] Raney, L. (2020). Cracking the codes: State Medicaid approaches to reimbursing psychiatric collaborative care. Oakland, California Health Care Foundation. [16] Hansen, M. E. D., Tobón, A. L., Haider, U. K., Simas, T. A. M., Newsome, M., Finelli, J., ... & Byatt, N. (2023). The role of perinatal psychiatry access programs in advancing mental health equity. General Hospital Psychiatry. [17] Cox, E. Q., Sowa, N. A., Meltzer-Brody, S. E., & Gaynes, B. N. (2016). The perinatal depression treatment cascade: baby steps toward improving outcomes. The Journal of clinical psychiatry, 77(9), 20901. [18] Taouk, L. H., Matteson, K. A., Stark, L. M., & Schulkin, J. (2018). Prenatal depression screening and antidepressant prescription: obstetrician-gynecologists' practices, opinions, and interpretation of evidence. Archives of women's mental health, 21(1), 85–91. https://doi.org/10.1007/s00737-017-0760-7 [19] Garbarino, A. H., Kohn, J. R., Coverdale, J. H., & Kilpatrick, C. C. (2019). Current Trends in Psychiatric Education Among Obstetrics and Gynecology Residency Programs. Academic psychiatry: the journal of the American Association of Directors of Psychiatric Residency Training and the Association for Academic Psychiatry, 43(3), 294–299. https://doi.org/10.1007/s40596-019-01018-w ; [20] Wisner, K. L., Sit, D. K., McShea, M. C., Rizzo, D. M., Zoretich, R. A., Hughes, C. L.,& Hanusa, B. H. (2013). Onset timing, thoughts of self-harm, and diagnoses in postpartum women with screen-positive depression findings. JAMA psychiatry, 70(5), 490-498 [21] Armstrong, K., Rose, A., Peters, N., Long, J. A., McMurphy, S., & Shea, J. A. (2006). Distrust of the health care system and self-reported health in the United States. Journal of general internal medicine, 21(4), 292–297. https://doi.org/10.1111/j.1525-1497.2006.00396.x [22] Declercq, E., & Zephyrin, L. (2020). Maternal mortality in the United States: A Primer. Commonwealth Fund. https://www.commonwealthfund.org/publications/issue-brief-report/2020/dec/maternal-mortality-united-states-primer [23] Scholle, S. H., & Kelleher, K. (2003). Preferences for depression advice among low-income women. Maternal and child health journal, 7(2), 95–102. https://doi.org/10.1023/a:1023864810207https://doi.org/10.1023/a:1023864810207 [24] AIMS Center. (n.d.). Collaborative care. https://aims.uw.edu/collaborative-care [25] Press, M. J., Howe, R., Schoenbaum, M., Cavanaugh, S., Marshall, A., Baldwin, L., & Conway, P. H. (2017). Medicare payment for behavioral health integration. n Engl j Med, 376(5), 405-407. [26] Chang, D., Morrison, D. J., Bowen, D. J., Harris, H. M., Dusic, E. J., Velasquez, M. B., & Ratzliff, A. D. H. (2023). Making It to Sustainability: Evaluating Billing Strategies for Collaborative Care. Psychiatric services (Washington, D.C.), appips20220596. Advance online publication. https://doi.org/10.1176/appi.ps.20220596 [27] Miller, E. S., Jensen, R., Hoffman, M. C., Osborne, L. M., McEvoy, K., Grote, N., & Moses-Kolko, E. L. (2020). Implementation of perinatal collaborative care: a health services approach to perinatal depression care. Primary health care research & development, 21, e30. [28] Raney, L. (2020). Cracking the codes: State Medicaid approaches to reimbursing psychiatric collaborative care. Oakland, California Health Care Foundation. [29] Unützer, J., Katon, W., Callahan, C. M., Williams, J. W., Jr, Hunkeler, E., Harpole, L., Hoffing, M., Della Penna, R. D., Noël, P. H., Lin, E. H., Areán, P. A., Hegel, M. T., Tang, L., Belin, T. R., Oishi, S., Langston, C., & IMPACT Investigators. Improving Mood-Promoting Access to Collaborative Treatment (2002). Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA, 288(22), 2836–2845. https://doi.org/10.1001/jama.288.22.2836 [30] Raney, L. (2020). [31] Unützer, J., Harbin, H., Schoenbaum, M., & Druss, B. (2013). The collaborative care model: An approach for integrating physical and mental health care in Medicaid health homes. Health Home Information Resource Center, 1-13. [32] Raney, L. (2020). Cracking the codes: State Medicaid approaches to reimbursing psychiatric collaborative care. Oakland, California Health Care Foundation. [33] Grote, N. K., Katon, W. J., Russo, J. E., Lohr, M. J., Curran, M., Galvin, E., & Carson, K. (2015). Collaborative care for perinatal depression in socioeconomically disadvantaged women: a randomized trial. Depression and anxiety, 32(11), 821-834 [34] Miller, E. S., Grobman, W. A., Ciolino, J. D., Zumpf, K., Sakowicz, A., Gollan, J., & Wisner, K. L. (2021). Increased depression screening and treatment recommendations after implementation of a perinatal collaborative care program. Psychiatric Services, 72(11), 1268-1275; Snowber, K., Ciolino, J. D., Clark, C. T., Grobman, W. A., & Miller, E. S. (2022). Associations Between Implementation of the Collaborative Care Model and Disparities in Perinatal Depression Care. Obstetrics & Gynecology, 140(2), 204-211. [35] Percent of People Covered By Medicaid/CHIP, 2022. (2022). Medicaid State Fact Sheets. KFF. Retrieved May 1, 2023, from https://www.kff.org/interactive/medicaid-state-fact-sheets/ [36] Miller, E. S., Grobman, W. A., Ciolino, J. D., Zumpf, K., Sakowicz, A., Gollan, J., & Wisner, K. L. (2021). Increased depression screening and treatment recommendations after implementation of a perinatal collaborative care program. Psychiatric Services, 72(11), 1268-1275. [37] Shalaby, R. A. H., & Agyapong, V. I. (2020). Peer support in mental health: literature review. JMIR mental health, 7(6), e15572. [38] Bassuk, E. L., Hanson, J., Greene, R. N., Richard, M., & Laudet, A. (2016). Peer-delivered recovery support services for addictions in the United States: A systematic review. Journal of substance abuse treatment, 63, 1-9. [39] Eastburg, M. C., Williamson, M., Gorsuch, R., & Ridley, C. (1994). Social support, personality, and burnout in nurses. Journal of Applied Social Psychology, 24(14), 1233-1250. [41] FamilyWell. (2023.). https://familywellhealth.com/ [42] Patients, Family Well (2023). https://familywellhealth.com/patients [43] Providers, Family Well (2023). https://familywellhealth.com/providers [44] Patients, Family Well (2023). https://familywellhealth.com/patients [45] Author interview with Jessica Gaulton, FamilyWell. (2023) [46] Maven (2022). “If moms are unwell, society is unwell.” Recapping our Q&A with Dr. Neel Shah. Maven. https://www.mavenclinic.com/post/if-moms-are-unwell-society-is-unwell-recapping-our-q-a-with-dr-neel-shah#! [47] Klatter, C. K., van Ravesteyn, L. M., & Stekelenburg, J. (2022). Is collaborative care a key component for treating pregnant women with psychiatric symptoms (and additional psychosocial problems)? A systematic review. Archives of Women's Mental Health, 25(6), 1029-1039.

Are male porn stars full-fledged citizens? Recent political developments make this question more than rhetorical. The Bush Justice Department, led by Attorney General John Ashcroft, has targeted the porn industry, beginning with its prosecution of Extreme Associates. More recently, the President requested an increase in the FBI’s 2005 budget for prosecuting obscenity, one of the few budget increases for the Bureau outside of its anti-terrorism program (Schmitt A1). To be sure, the concept of “citizen” is itself vexed. Citizenship, when obtained or granted, ostensibly legitimates a subject and opens up pathways to privilege: social, political, economic, etc. Yet all citizens do not seem to be created equal. “There is, in the operation of state-defined rules and in common practices an assumption of moral worth in which de facto as opposed to de jure rights of citizenship are defined as open to those who are deserving or who are capable of acting responsibly,” asserts feminist critic Linda McDowell. “The less deserving and the less responsible are defined as unworthy of or unfitted for the privileges of full citizenship” (150). Under this rubric, a citizen must measure up to a standard of “moral worth”—an individual is not a full-fledged citizen merely on the basis of birth or geographical placement. As McDowell concludes, “citizenship is not an inclusive but an exclusive concept” (150). Thus, in figuring out how male porn stars stand in regard to the question of citizenship, we must ask who determines “moral worth,” who distinguishes the less from the more deserving, and how people have come to agree on the “common practices” of citizenship. Many critics writing about citizenship, including McDowell, Michael Warner, Lauren Berlant, Russ Castronovo, Robyn Wiegman, Michael Moon, and Cathy Davidson (to name only a few) have located the nexus of “moral worth” in the body. In particular, the ability to make the body abstract, invisible, and non-identifiable has been the most desirable quality for a citizen to possess. White men seem ideally situated for such acts of “decorporealization,” and the white male body has been installed as the norm for citizenship. Conversely, women, people of color, and the ill and disabled, groups that are frequently defined by their very embodiment, find themselves more often subject to regulation. If the white male body is the standard, however, for “moral worth,” the white male porn star would seem to disrupt such calculations. Clearly, the profession demands that these men put their bodies very much in evidence, and the most famous porn stars, like John C. Holmes and Ron Jeremy, derive much of their popularity from their bodily excess. Jeremy’s struggle for “legitimacy,” and the tenuous position of men in the porn industry in general, demonstrate that even white males, when they cannot or will not aspire to abstraction and invisibility, will lose the privileges of citizenship. The right’s attack on pornography can thus be seen as yet another attempt to regulate and restrict citizenship, an effort that forces Jeremy and the industry that made him famous struggle for strategies of invisibility that will permit some mainstream acceptance. In American Anatomies, Robyn Wiegman points out that the idea of democratic citizenship rested on a distinct sense of the abstract and non-particular. The more “particular” an individual was, however, the less likely s/he could pass into the realm of citizen. “For those trapped by the discipline of the particular (women, slaves, the poor),” Wiegman writes, “the unmarked and universalized particularity of the white masculine prohibited their entrance into the abstraction of personhood that democratic equality supposedly entailed” (49). The norm of the “white masculine” caused others to signify “an incontrovertible difference” (49), so people who were visibly different (or perceived as visibly different) could be tyrannized over and regulated to ensure the purity of the norm. Like Wiegman, Lauren Berlant has written extensively about the ways in which the nation recognizes only one “official” body: “The white, male body is the relay to legitimation, but even more than that, the power to suppress that body, to cover its tracks and its traces, is the sign of real authority, according to constitutional fashion” (113). Berlant notes that “problem citizens”—most notably women of color—struggle with the problem of “surplus embodiment.” They cannot easily suppress their bodies, so they are subjected to the regulatory power of a law that defines them and consequently opens their bodies up to violation. To escape their “surplus embodiment,” those who can seek abstraction and invisibility because “sometimes a person doesn’t want to seek the dignity of an always-already-violated body, and wants to cast hers off, either for nothingness, or in a trade for some other, better model” (114). The question of “surplus embodiment” certainly has resonance for male porn stars. Peter Lehman has argued that hardcore pornography relies on images of large penises as signifiers of strength and virility. “The genre cannot tolerate a small, unerect penis,” Lehman asserts, “because the sight of the organ must convey the symbolic weight of the phallus” (175). The “power” of male porn stars derives from their visibility, from “meat shots” and “money shots.” Far from being abstract, decorporealized “persons,” male porn stars are fully embodied. In fact, the more “surplus embodiment” they possess, the more famous they become. Yet the very display that makes white male porn stars famous also seemingly disqualifies them from the “legitimacy” afforded the white male body. In the industry itself, male stars are losing authority to the “box-cover girls” who sell the product. One’s “surplus embodiment” might be a necessity for working in the industry, but, as Susan Faludi notes, “by choosing an erection as the proof of male utility, the male performer has hung his usefulness, as porn actor Jonathan Morgan observed, on ‘the one muscle on our body we can’t flex’” (547). When that muscle doesn’t work, a male porn star doesn’t become an abstraction—he becomes “other,” a joke, swept aside and deemed useless. Documentary filmmaker Scott J. Gill recognizes the tenuousness of the “citizenship” of male porn stars in his treatment of Ron Jeremy, “America’s most famous porn star.” The film, Porn Star: The Legend of Ron Jeremy (2001), opens with a clear acknowledgment of Jeremy’s body, as one voiceover explains how his nickname, “the Hedgehog,” derives from the fact that Jeremy is “small, fat, and very hairy.” Then, Gill intercuts the comments of various Jeremy fans: “An idol to an entire generation,” one young man opines; “One of the greatest men this country has ever seen,” suggests another. This opening scene concludes with an image of Jeremy, smirking and dressed in a warm-up suit with a large dollar sign necklace, standing in front of an American flag (an image repeated at the end of the film). This opening few minutes posit the Hedgehog as super-citizen, embraced as few Americans are. “Everyone wants to be Ron Jeremy,” another young fan proclaims. “They want his life.” Gill also juxtaposes “constitutional” forms of legitimacy that seemingly celebrate Jeremy’s bodily excess with the resultant discrimination that body actually engenders. In one clip, Jeremy exposes himself to comedian Rodney Dangerfield, who then sardonically comments, “All men are created equal—what bullshit!” Later, Gill employs a clip of a film in which Jeremy is dressed like Ben Franklin while in a voiceover porn director/historian Bill Margold notes that the Freeman decision “gave a birth certificate to a bastard industry—it legitimized us.” The juxtaposition thus posits Jeremy as a “founding father” of sorts, the most recognizable participant in an industry now going mainstream. Gill, however, emphasizes the double-edged nature of Jeremy’s fame and the price of his display. Immediately after the plaudits of the opening sequence, Gill includes clips from various Jeremy talk show appearances in which he is denounced as “scum” and told “You should go to jail just for all the things that you’ve helped make worse in this country” and “You should be shot.” Gill also shows a clearly dazed Jeremy in close-up confessing, “I hate myself. I want to find a knife and slit my wrists.” Though Jeremy does not seem serious, this comment comes into better focus as the film unfolds. Jeremy’s efforts to go “legit,” to break into mainstream film and leave his porn life behind, keep going off the tracks. In the meantime, Jeremy must fulfill his obligations to his current profession, including getting a monthly HIV test. “There’ll be one good thing about eventually getting out of the porn business,” he confesses as Gill shows scenes of a clearly nervous Jeremy awaiting results in a clinic waiting room, “to be able to stop taking these things every fucking month.” Gill shows that the life so many others would love to have requires an abuse of the body that fans never see. Jeremy is seeking to cast off that life, “either for nothingness, or in a trade for some other, better model.” Behind this “legend” is unseen pain and longing. Gill emphasizes the dichotomy between Jeremy (illegitimate) and “citizens” in his own designations. Adam Rifkin, director of Detroit Rock City, in which Jeremy has a small part, and Troy Duffy, another Jeremy pal, are referred to as “mainstream film directors.” When Jeremy returns to his home in Queens to visit his father, Arnold Hyatt is designated “physicist.” In fact, Jeremy’s father forbids his son from using the family name in his porn career. “I don’t want any confusion between myself and his line of work,” Hyatt confesses, “because I’m retired.” Denied his patronym, Jeremy is truly “illegitimate.” Despite his father’s understanding and support, Jeremy is on his own in the business he has chosen. Jeremy’s reputation also gets in the way of his mainstream dreams. “Sometimes all this fame can hurt you,” Jeremy himself notes. Rifkin admits that “People recognize Ron as a porn actor and immediately will ask me to remove him from the final cut.” Duffy concurs that Jeremy’s porn career has made him a pariah for some mainstream producers: “Stigma attached to him, and that’s all anybody’s ever gonna see.” Jeremy’s visibility, the “stigma” that people have “seen,” namely, his large penis and fat, hairy body, denies him the abstract personhood he needs to go “legitimate.” Thus, whether through the concerted efforts of the Justice Department or the informal, personal angst of a producer fearing a backlash against a film, Jeremy, as a representative of an immoral industry, finds himself subject to regulation. Indeed, as his “legitimate” filmography indicates, Jeremy has been cut out of more than half the films he has appeared in. The issue of “visibility” as the basis for regulation of hardcore pornography has its clearest articulation in Potter Stewart’s famous proclamation “I know it when I see it.” But as Bob Woodward and Scott Armstrong report in The Brethren, Stewart was not the only Justice who used visibility as a standard. Byron White’s personal definition was “no erect penises, no intercourse, no oral or anal sodomy” (193). William Brennan, too, had what his clerks called “the limp dick standard” (194). Erection, what Lehman has identified as the conveyance of the phallus, now became the point of departure for regulation, transferring, once again, the phallus to the “law.” When such governmental regulation failed First Amendment ratification, other forms of societal regulation kicked in. The porn industry has accommodated itself to this regulation, as Faludi observes, in its emphasis on “soft” versions of product for distribution to “legitimate” outlets like cable and hotels. “The version recut for TV would have to be entirely ‘soft,’” Faludi notes, “which meant, among other things, no erect penises and no semen” (547). The work of competent “woodsmen” like Jeremy now had to be made invisible to pass muster. Thus, even the penis could be conveyed to the viewer, a “fantasy penis,” as Katherine Frank has called it, that can be made to correlate to that viewer’s “fantasized identity” of himself (133-4). At the beginning of Porn Star, during the various homages paid to Jeremy, one fan draws a curious comparison: “There’s Elvis, and then there’s Ron.” Elvis’s early career had certainly been plagued by criticism related to his bodily excess. Musicologist Robert Fink has recently compared Presley’s July 2, 1956, recording of “Hound Dog” to music for strip tease, suggesting that Elvis used such subtle variations to challenge the law that was constantly impinging on his performances: “The Gray Lady was sensitive to the presence of quite traditional musical erotics—formal devices that cued the performer and audience to experience their bodies sexually—but not quite hep enough to accept a male performer recycling these musical signifiers of sex back to a female audience” (99). Eventually, though, Elvis stopped rebelling and sought respectability. Writing to President Nixon on December 21, 1970, Presley offered his services to help combat what he perceived to be a growing cultural insurgency. “The drug culture, the hippie elements, the SDS, Black Panthers, etc., do not consider me as their enemy or as they call it, The Establishment,” Presley confided. “I call it America and I love it” (Carroll 266). In short, Elvis wanted to use his icon status to help reinstate law and order, in the process demonstrating his own patriotism, his value and worth as a citizen. At the end of Porn Star, Jeremy, too, craves legitimacy. Whereas Elvis appealed to Nixon, Jeremy concludes by appealing to Steven Spielberg. Elvis received a badge from Nixon designating him as “special assistant” for the Bureau of Narcotics and Dangerous Drugs. Presumably Jeremy invests his legitimacy in a SAG card. Kenny Dollar, a Jeremy friend, unironically summarizes the final step the Hedgehog must take: “It’s time for Ron to go on and reach his full potential. Let him retire his dick.” That Jeremy must do the latter before having a chance for the former illustrates how “surplus embodiment” and “citizenship” remain inextricably entangled and mutually exclusive. References Berlant, Lauren. “National Brands/National Body: Imitation of Life.” Comparative American Identities: Race, Sex and Nationality in the Modern Text. Ed. Hortense Spillers. New York: Routledge, 1991: 110-140. Carroll, Andrew, ed. Letters of a Nation: A Collection of Extraordinary American Letters. New York: Broadway Books, 1999. Castronovo, Russ and Nelson, Dana D., eds. Materializing Democracy: Toward a Revitalized Cultural Politics. Durham: Duke University Press, 2002. Faludi, Susan. Stiffed: The Betrayal of the American Man. New York: William Morrow and Company, Inc., 1999. Fink, Robert. “Elvis Everywhere: Musicology and Popular Music Studies at the Twilight of the Canon.” Rock Over the Edge: Transformations in Popular Music Culture. Eds. Roger Beebe, Denise Fulbrook, and Ben Saunders. Durham: Duke University Press, 2002: 60-109. Frank, Katherine. G-Strings and Sympathy: Strip Club Regulars and Male Desire. Durham: Duke University Press, 2002. Gill, Scott J., dir. Porn Star: The Legend of Ron Jeremy. New Video Group, 2001. Lehman, Peter. Running Scared: Masculinity and the Representation of the Male Body. Philadelphia: Temple University Press, 1993. McDowell, Linda. Gender, Identity and Place: Understanding Feminist Geographies. Minneapolis: University of Minnesota Press, 1999. Moon, Michael and Davidson, Cathy N., eds. Subjects and Citizens: From Oroonoko to Anita Hill. Durham: Duke University Press, 1995. Schmitt, Richard B. “U. S. Plans to Escalate Porn Fight.” The Los Angeles Times 14 February 2004. A1. Wiegman, Robyn. American Anatomies: Theorizing Race and Gender. Durham: Duke University Press, 1995. Woodward, Bob and Armstrong, Scott. The Brethren: Inside the Supreme Court. New York: Simon and Schuster, 1979. MLA Style Russell, David. "The Tumescent Citizen: The Legend of Ron Jeremy." M/C Journal 7.4 (2004). 10 October 2004 <http://www.media-culture.org.au/0410/01_citizen.php>. APA Style Russell, D. (2004 Oct 11). The Tumescent Citizen: The Legend of Ron Jeremy, M/C Journal, 7(4). Retrieved Oct 10 2004 from <http://www.media-culture.org.au/0410/01_citizen.php>

Photo by Nathan Dumlao on Unsplash ABSTRACT The demographic of physicians in the United States has failed to include a proportionate population of Latinos in the United States. In what follows, I shall argue that the medical school admission process places an undue burden on low-income Latino applicants. Hence, the underrepresentation of Latinos in medical schools is an injustice. This injustice relates to the poor community health of the Latino community. Health disparities such as diabetes, HIV infection, and cancer mortality are higher amongst the Latino community. The current representation of Latino medical students is not representative of those in the United States. INTRODUCTION The demographic of physicians in the United States has failed to include a proportionate number of Latinos, meaning people of Latin American origin. Medical schools serve as the gatekeepers to the medical field, and they can alter the profession based on whom they admit. With over 60 million Latinos in the United States, people of Latin American origin comprise the largest minority group in the nation.[1] In 2020-2021, only 6.7 percent of total US medical school enrollees and only 4 percent of medical school leadership identified as Latino.[2] Latino physicians can connect to a historically marginalized community that faces barriers including language, customs, income, socioeconomic status, and health literacy. I argue that the medical school admissions process places an undue burden on low-income Latino applicants. This paper explores the underrepresentation of Latinos in medical schools as an injustice. A further injustice occurs as the barriers to medical education result in fewer Latino doctors to effectively deliver health care and preventive health advice to their communities in a culturally competent way. I. Latino Community Health Data The terms Latino and Hispanic have largely been considered interchangeable. US government departments, such as the US Census Bureau and the Centers for Disease Control and Prevention (CDC), define Hispanic people as those with originating familial ties to native Spanish-speaking countries, most of whom are from Latin America. The term Latino is more inclusive because it refers to all of those with strong originating ties to countries in Latin America, including those coming from countries such as Brazil and Belize who are not native Spanish speakers. Throughout this work, I refer to the term Latino because it is more inclusive, although the data retrieved from US government departments may refer to the population as Hispanic. “Low-income” refers to the qualifying economic criteria for the AAMC’s Fee Assistance Program Poverty Guidelines.[3] The AAMC Fee Assistance Program is designed to help individuals who do not have the financial means to pay the total costs of applying to medical school. For this paper, low-income refers to those who qualify for this program. The US government gathers data about Latino community health and its health risks. The Latino community has a higher poverty rate than the non-Hispanic white community.[4] Latino community health has long trailed that of white people collectively. For example, the Latino community experiences higher levels of preventable diseases, including hypertension, diabetes, and hepatitis, than the non-Hispanic white community does.[5] The CDC collects data about Latino community health and provides statistics to the public. Latinos in the United States trail only non-Hispanic blacks in prevalence of obesity. The Latino adult obesity rates are 45.7 percent for males and 43.7 percent for females.[6] Of the 1.2 million people infected with HIV in the United States, 294,200 are Latino.[7] The infection rate of chlamydia is 392.6 per 100,000 ― 1.9 times the rate in the non-Hispanic white population.[8] The tuberculosis incidence rate is eight times higher than that of non-Hispanic white people at 4.4 per 100,000.[9] Furthermore, Latinos have the third highest death rate for hepatitis C among all races and ethnic groups.[10] The prevalence of total diabetes, diagnosed and undiagnosed, among adults aged 18 and older also remains higher than that of non-Hispanic whites at 14.7 percent compared to 11.9 percent.[11] The high disease rate evidences the poor health of the community. Furthermore, 19 percent of Latinos in the United States remain uninsured.[12] Almost a quarter of the Latino population in the United States lives in poverty.[13] The high incidence of disease, lack of insurance, and high poverty rate create a frail health status for the Latino community in the United States. The medical conditions seen are largely preventable, and the incident rates can be lowered with greater investments in Latino community health. Considering the health disparities between Latino and non-Hispanic White people, there is an ethical imperative to provide better medical care and guidance to the Latino community. II. Ethical and Practical Importance of Increasing the Number of Latino Physicians Minorities respond more positively to patient-physician interactions and are more willing to undergo preventative healthcare when matched with a physician of their racial or ethnic background.[14] Latino medical doctors may lead to an improvement in overall community health through improved communication and trusting relationships. Patient-physician racial concordance leads to greater patient satisfaction with their physicians.[15] Identifying with the ethnicity of a physician may lead to greater confidence in the physician-patient relationship, resulting in more engagement on the patient’s behalf. A randomized study regarding African American men and the race of their attending physician found an increase in requests for preventative care when assigned to a black doctor.[16] Although the subjects were African American men, the study has implications applicable to other minority racial and ethnic groups. The application process is unjust for low-income Latinos. The low matriculation of Latinos in medical schools represents a missed opportunity to alleviate the poor community health of the Latino population in the United States. Medical school also would create an opportunity to address health issues that plague the Latino community. Becoming a physician allows low-income Latinos to climb the social ladder and enter the spaces in health care that have traditionally been closed off to them. Nonwhite physicians significantly serve underserved communities.[17] Increasing the number of Latino doctors can boost their presence, potentially improving care for underserved individuals. Teaching physicians cultural competence is not enough to address the health disparities the Latino community faces. Latino physicians are best equipped to understand the healthcare needs of low-income Latinos. I contend that reforming the application process represents the most straightforward method to augment the number of Latino physicians who wish to work in predominantly Latino or diverse communities, thereby improving healthcare for the Latino community. III. Cultural Tenets Affecting Healthcare Interactions “Poor cultural competence can lead to decreased patient satisfaction, which may cause the patient not to attend future appointments or seek further care.”[18] Latino community health is negatively affected when medical professionals misinterpret cultural beliefs. Cultural tenets like a reservation towards medication, a deep sense of respect for the physician, and an obligation to support the family financially and through advocacy affect how Latinos seek and use the healthcare system.[19] First, the Latino population's negative cultural beliefs about medication add a barrier to patient compliance. It is highlighted that fear of dependence upon medicine leads to trouble with medication regimens.[20] The fear stems from the negative perception of addiction in the Latino community. Taking as little medication as possible avoids the chance of addiction occurring, which is why many take the prescribed medicine only until they feel healthier, regardless of the prescribing regimen. Some would rather not take any medication because of the deep-rooted fear. Physicians must address this concern by communicating the importance of patient compliance to remedy the health issue. Explaining that proper use of the medication as prescribed will ensure the best route to alleviate the condition and minimize the occurrence of dependence. Extra time spent addressing concerns and checking for comprehension may combat the negative perception of medication. Second, the theme of respeto, or respect, seems completely harmless to most people. After all, how can being respectful lead to bad health? This occurs when respect is understood as paternalism. Some patients may relinquish their decision-making to the physician. The physician might not act with beneficence, in this instance, because of the cultural dissonance in the physician-patient relationship that may lead to medical misinterpretation. A well-meaning physician might not realize that the patient is unlikely to speak up about their goals of care and will follow the physician’s recommendations without challenging them. That proves costly because a key aspect of the medical usefulness of a patient’s family history is obtaining it through dialogue. The Latino patient may refrain from relaying health concerns because of the misconceived belief that it’s the doctor’s job to know what to ask. Asking the physician questions may be considered a sign of disrespect, even if it applies to signs, symptoms, feelings, or medical procedures the patient may not understand.[21] Respeto is dangerous because it restricts the patients from playing an active role in their health. Physicians cannot derive what medical information may be relevant to the patient without their cooperation. And physicians without adequate cultural competency may not know they need to ask more specific questions. Cultural competency may help, but a like-minded physician raised similarly would be a more natural fit. “A key component of physician-patient communication is the ability of patients to articulate concerns, reservations, and lack of understanding through questions.”[22] As a patient, engaging with a physician of one’s cultural background fortifies a strong physician-patient relationship. Latino physicians are in the position to explain to the patients that respeto is not lost during a physician-patient dialogue. In turn, the physician can express that out of their value of respeto, and the profession compels them to place the patient’s best interest above all. This entails physicians advocating on behalf of the patients to ask questions and check for comprehension, as is required to obtain informed consent. Latino physicians may not have a cultural barrier and may already organically understand this aspect of their patient’s traditional relationship with physicians. The common ground of respeto can be used to improve the health of the Latino community just as it can serve as a barrier for someone from a different background. Third, in some Latino cultures, there is an expectation to contribute to the family financially or in other ways and, above all, advocate on the family’s behalf. Familial obligations entail more than simply translating or accompanying family members to their appointments. They include actively advocating for just treatment in terms of services. Navigating institutions, such as hospitals, in a foreign landscape proves difficult for underrepresented minorities like Latinos who are new to the United States. These difficulties can sometimes lead to them being taken advantage of, as they might not fully understand their rights, the available resources, or the standard procedures within these institutions. The language barrier and unfamiliar institutional policies may misinterpret patients’ needs or requests. Furthermore, acting outside of said institution’s policy norms may be erroneously interpreted as actions of an uncooperative patient leading to negative interactions between the medical staff and the Latino patient. The expectation of familial contribution is later revisited as it serves as a constraint to the low-income Latino medical school applicant. Time is factored out to meet these expectations, and a moral dilemma to financially contribute to the family dynamic rather than delay the contribution to pursue medical school discourages Latinos from applying. IV. How the Medical School Admission Process is Creating an Undue Burden for Low-Income Latino Applicants Applying a bioethics framework to the application process highlights its flaws. Justice is a central bioethical tenet relevant to the analysis of the MD admissions process. The year-long medical school application process begins with the primary application. The student enters information about the courses taken, completes short answer questions and essays, and uploads information about recommenders. Secondary applications are awarded to some medical students depending on the institutions’ policies. Some schools ask all applicants for secondary applications, while others select which applicants to send secondary requests. Finally, interviews are conducted after a review of both primary and secondary applications. This is the last step before receiving an admissions decision. The medical school application process creates undue restrictions against underserved communities. It is understood that matriculating into medical school and becoming a doctor should be difficult. The responsibilities of a physician are immense, and the consequences of actions or inactions may put the patients’ lives in jeopardy. Medical schools should hold high standards because of the responsibility and expertise required to provide optimal healthcare. However, I argue that the application process places an undue burden on low-income Latino applicants that is not beneficial to optimal health care. The burden placed on low-income Latino applicants through the application process is excessive and not necessary to forge qualified medical students. The financial aspect of the medical school application has made the profession virtually inaccessible to the working class. The medical school application proves costly because of the various expenses, including primary applications, secondary applications, and interview logistics. There is financial aid for applications, but navigating some aid to undertake test prep, the Medical College Admission Test (MCAT), and the travel for interviews proves more difficult. Although not mandatory, prep courses give people a competitive edge.[23] The MCAT is one of the key elements of an application, and many medical schools will not consider applications that do not reach their score threshold. This practically makes the preparatory courses mandatory for a competitive score. The preparatory courses themselves cost in the thousands of dollars. There has been talk about adjusting the standardized test score requirements for applicants from medically underserved backgrounds. I believe the practice of holding strict cutoffs for MCAT scores is detrimental to low-income Latino applicants, especially considering the average MCAT scores for Latinos trail that of white people. The American Association of Medical Colleges’ recent data for the matriculating class of 2021 illustrates the wide gap in MCAT scores: Latino applicants average 500.2, and Latino matriculants average 506.6, compared to white applicants, who average 507.5 and white matriculants, who average 512.7.[24] This discrepancy suggests that considerations beyond scores do play some role in medical school matriculation. However, the MCAT scores remain a predominant factor, and there is room to value other factors more and limit the weight given to scores. The practice of screening out applicants based solely on MCAT scores impedes low-income Latino applicants from matriculating into medical school. Valuing the MCAT above all other admissions criteria limits the opportunities for those from underserved communities, who tend to score lower on the exam. One indicator of a potentially great physician may be overcoming obstacles or engaging in scientific or clinical experiences. There are aspects of the application where the applicant can expand on their experiences, and the personal statement allows them to showcase their passion for medicine. These should hold as much weight as the MCAT. The final indicator of a good candidate should not solely rest on standardized tests. There is a cost per medical school that is sent to the primary application. The average medical school matriculant applies to about 16 universities, which drives up the cost of sending the applications.[25] According to the American Association of Medical Colleges, the application fee for the first school is $170, and each additional school is an additional $42. Sending secondary applications after the initial application is an additional cost that ranges by university. The American Medical College Application Service (AMCAS), the primary application portal for Medical Doctorate schools in the United States and Canada, offers the Fee Assistance Program (FAP) to aid low-income medical school applicants. The program reduces the cost of the MCAT from $325 to $130, includes a complimentary Medical School Admission Requirements (MSAR) subscription, and fee waivers for one AMCAS application covering up to 20 schools.[26] The program is an important aid for low-income Latino students who would otherwise not be able to afford to send multiple applications. Although the aid is a great resource, there are other expenses of the application process that the program cannot cover. For a low-income applicant, the burden of the application cost is felt intensely. A study analyzing the American Medical College Application Service (AMCAS) data for applicants and matriculants from 2014 to 2019 revealed an association between income and acceptance into medical school. They state, “Combining all years, the likelihood of acceptance into an MD program increased stepwise by income. The adjusted rate of acceptance was 24.32 percent for applicants with income less than $50 000, 27.57 percent for $50 000 - $74 999, 29.90 percent for $75 000 - $124 999, 33.27 percent for $125 000 - $199 999, and 36.91 percent for $200,000 or greater.”[27] It becomes a discouraging factor when it is difficult to obtain the necessary funds. The interview process for medical schools may prove costly because of travel, lodging, and time. In-person interviews may require applicants to travel from their residence to other cities or states. The applicant must find their own transportation and housing during the interview process, ranging from a single day to multiple days. Being granted multiple interviews becomes bittersweet for low-income applicants because they are morally distraught, knowing the universities are interested yet understanding the high financial cost of the interviews. The expense of multiple interviews can impede an applicant from progressing in the application process. Medical schools do not typically cover travel expenses for the interview process. Only 4 percent of medical school faculty identify as Latino.[28] The medical school admission board members reviewing the application lack Latino representation.[29] Because of this, it is extremely difficult for a low-income Latino applicant to portray hardships that the board members would understand. Furthermore, the section to discuss any hardships only allows for 200 words. This limited space makes it extremely difficult to explain the nuances of navigating higher education as a low-income Latino. Explaining those difficulties is then restricted to the interview process. However, that comes late in the application process when most applicants have been filtered out of consideration. The lack of diversity among the board members, combined with the minimal space to explain hardships or burdens, impedes a connection to be formed between the Latino applicants and the board members. It is not equitable that this population cannot relate to their admissions reviewers because of cultural barriers. Gatekeeping clinical experience inadvertently favors higher socioeconomic status applicants. Most medical schools require physician shadowing or clinical work, which can be difficult to obtain with no personal connections to the field. Using clinical experience on the application is another way that Latinos are disadvantaged compared to people who have more professional connections or doctors in the family and social circles. The already competitive market for clinical care opportunities is reduced by nepotism, which does not work in favor of Latino applicants. Yet some programs are designed to help low-income students find opportunities, such as Johns Hopkins’ Careers in Science and Medicine Summer Internship Program, which provides clinical experience and health professions mentoring.[30] Without social and professional ties to health care professionals, they are forced to enter a competitive job and volunteer market in clinical care and apply to these tailored programs not offered at all academic institutions. While it is not unique to Latinos, the time commitment of the application process is especially harsh on low-income students because they have financial burdens that can determine their survival. Some students help their families pay for food, rent, and utilities, making devoting time to the application process more problematic. As noted earlier, Latino applicants may also have to set aside time to advocate for their families. Because the applicants tend to be more in tune with the dominant American culture, they are often assigned the family advocate role. They must actively advocate for their family members' well-being. The role of a family advocate, with both its financial and other supportive roles ascribed to low-income Latino applicants, is an added strain that complicates the medical school application. As a member of a historically marginalized community, one must be proactive to ensure that ethical treatment is received. Ordinary tasks such as attending a doctor's appointment or meeting with a bank account manager may require diligent oversight. Applicants must ensure the standard of service is applied uniformly to their family as it is to the rest of the population. This applies to business services and healthcare. It can be discouraging to approach a field that does not have many people from your background. The lack of representation emphasizes the applicant's isolation going through the process. There is not a large group of Latinos in medicine to look to for guidance.[31] The group cohesiveness that many communities experience through a rigorous process is not established among low-income Latino applicants. They may feel like outsiders to the profession. Encountering medical professionals of similar backgrounds gives people the confidence to pursue the medical profession. V. Medical School Admission Data This section will rely on the most recent MD medical school students, the 2020-2021 class. The data includes demographic information such as income and ethnicity. The statistics used in this section were retrieved from scholarly peer-reviewed articles and the Medical School Admission Requirement (MSAR) database. Both sources of data are discussed in more detail throughout the section. The data reveals that only 6.7 percent of medical students for the 2020-2021 school year identify as Latino.[32] The number of Latino students in medical school is not proportional to the Latino community in the United States. While Latinos comprise almost 20 percent of the US population (62.1 million), they comprise only 6.7 percent of the medical student population.[33] Below are three case studies of medical schools in cities with a high Latino population. VI. Medical School Application Process Case Studies a) New York University Grossman School of Medicine is situated in Manhattan, where a diverse population of Latinos reside. The population of the borough of Manhattan is approximately 1,629,153, with 26 percent of the population identifying as Latino.[34] As many medical schools do, Grossman School of Medicine advertises an MD Student Diversity Recruitment program. The program, entitled Prospective MD Student Liaison Program, is aimed such that “students from backgrounds that are underrepresented in medicine are welcomed and supported throughout their academic careers.”[35] The program intervenes with underrepresented students during the interview process of the medical school application. All students invited to interviews can participate in the Prospective MD Student Liaison Program. They just need to ask to be part of it. That entails being matched with a current medical student in either the Black and Latinx Student Association (BALSA) or LGBTQMed who will share their experiences navigating medical school. Apart from the liaison program, NYU participates in the Science Technology Entry Program (STEP), which provides academic guidance to middle and high school students who are underrepresented minorities.[36] With the set programs in place, one would expect to find a significantly larger proportion of Latino medical students in the university. The Medical School Admission Requirement (MSAR) database compiled extensive data about participants in the medical school; the data range from tuition to student body demographics. Of the admitted medical students in 2021, only 16 out of 108 identified as Latino, despite the much larger Latino population of New York.[37] Furthermore, only 4 percent of the admitted students classify themselves as being from a disadvantaged status.[38] The current efforts to increase medical school diversity are not producing adequate results at NYU. Although the Latino representation in this medical school may be higher than that in others, it does not reflect the number of Latinos in Manhattan. The Prospective MD Student Liaison Program intervenes at a late stage of the medical school application process. It would be more beneficial for a program to cover the entire application process. The lack of Latino medical students makes it difficult for prospective students to seek advice from Latino students. Introducing low-income Latino applicants to enrolled Latino medical students would serve as a guiding tool throughout the application process. An early introduction could encourage the applicants to apply and provide a resourceful ally in the application process when, in many circumstances, there would be none. Latino medical students can share their experiences of overcoming cultural and social barriers to enter medical school. b) The Latino population in Philadelphia is over 250,000, constituting about 15 percent of the 1.6 million inhabitants.[39] According to MSAR, the cohort of students starting at Drexel University College of Medicine, located in Philadelphia, in 2021 was only 7.6 percent Latino.[40] 18 percent of matriculated students identify as having disadvantaged status, while 21 percent identify as coming from a medically underserved community.[41] Drexel University College of Medicine claims that “Students who attend racially and ethnically diverse medical schools are better prepared to care for patients in a diverse society.”[42] They promote diversity with various student organizations within the college, including the following: Student National Medical Association (SNMA), Latino Medical Student Association (LMSA), Drexel Black Doctors Network, LGBT Medical Student Group, and Drexel Mentoring and Pipeline Program (DMAPP). The Student Center for Diversity and Inclusion of the College of Medicine offers support groups for underrepresented medical students. The support offered at Drexel occurs at the point of matriculation, not for prospective students. The one program that does seem to be a guide for prospective students is the Drexel Pathway to Medical School program. Drexel Pathway to Medical School is a one-year master’s program with early assurance into the College of Medicine and may serve as a gateway for prospective Latino Students.[43] The graduate program is tailored for students who are considered medically underserved or socioeconomically disadvantaged and have done well in the traditional pre-medical school coursework. It is a competitive program that receives between 500 and 700 applicants for the 65 available seats. The assurance of entry into medical school makes the Drexel Pathway to Medical School a beneficial program in aiding Latino representation in medicine. Drexel sets forth minimum requirements for the program that show the school is willing to consider students without the elite scores and grades required of many schools. MCAT scores must be in the 25th percentile or higher, and the overall or science GPA must be at least 2.9.[44] The appealing factor of this program is its mission to attract medically underserved students. This is a tool to increase diversity in medical school. Prospective low-income Latino students can view this as a graduate program tailored to communities like theirs. However, this one-year program is not tuition-free. It may be tempting to assume that patients prefer doctors with exceptional academic records. There's an argument against admitting individuals with lower test scores into medical schools, rooted in the belief that this approach does not necessarily serve the best interests of health care. The argument asserts that the immense responsibility of practicing medicine should be entrusted to the most qualified candidates. Programs like the Drexel Pathway to Medical School are designed to address the lower academic achievements often seen in underrepresented communities. Their purpose is not to admit underqualified individuals into medical school but to bridge the educational gap, helping these individuals take the necessary steps to become qualified physicians. c) The University of California San Francisco School of Medicine reports that 23 percent of its first-year class identifies as Latino, while 34 percent consider themselves disadvantaged.[45] The Office of Diversity and Outreach is concerned with increasing the number of matriculants from underserved communities. UCSF has instilled moral commitments and conducts pipeline and outreach programs to increase the diversity of its medical school student body. The Differences Matter Initiative that the university has undertaken is a complex years-long restructuring of the medical school aimed at making the medical system equitable, diverse, and inclusive.[46] The five-phase commitment includes restructuring the leadership of the medical school, establishing anti-oppression and anti-racism competencies, and critically analyzing the role race, ethnicity, gender, and sexual orientation play in medicine. UCSF offers a post-baccalaureate program specifically tailored to disadvantaged and underserved students. The program’s curriculum includes MCAT preparation, skills workshops, science courses, and medical school application workshops.[47] The MCAT preparation and medical school application workshops serve as a great tool for prospective Latino applicants. UCSF seems to do better than most medical schools regarding Latino medical students. San Francisco has a population of 873,965, of which 15.2 percent are Latino.[48] The large population of Latino medical students indicates that the school’s efforts to increase diversity are working. The 23 percent Latino matriculating class of 2021 better represents the number of Latinos in the United States, which makes up about a fifth of the population. With this current data, it is important to closely dissect the efforts UCSF has taken to increase diversity in its medical school. Their Differences Matter initiative instills a commitment to diversifying their medical school. As mentioned, the school's leadership has been restructuring to include a diverse administrative body. This allows low-income Latino applicants to relate to the admissions committee reviewing their application. With a hopeful outlook, the high percentage of Latino applicants may reflect comprehension of the application process and the anticipated medical school atmosphere and rigor among Latino applicants and demonstrate that the admissions committee understands the applicants. However, there are still uncertainties about the demographics of the Latino student population in the medical school. Although it is a relatively high percentage, it is necessary to decipher which proportion of those students are low-income Latino Americans. UCSF School of Medicine can serve as a model to uplift the Latino community in a historically unattainable profession. VII. Proposed Reform for Current Medical School Application One reform would be toward the reviewing admissions committee, which has the power to change the class composition. By increasing the diversity of the admissions committee itself, schools can give minority applicants a greater opportunity to connect to someone with a similar background through their application. It would address low-income Latino applicants feeling they cannot “get personal” in their application. These actions are necessary because it is not just to have a representative administration for only a portion of the public. Of the three medical schools examined, the University of California San Francisco has the highest percentage of Latino applicants in their entering class. They express an initiative to increase diversity within their medical school leadership via the Differences Matter initiative. This active role in increasing diversity within the medical school leadership may play a role in UCSF’s high percentage of Latino matriculants. That serves as an important step in creating an equitable application process for Latino applicants. An important consideration is whether the medical school administration at UCSF mirrors the Latino population in the United States. The importance of whether the medical school administration at UCSF mirrors the Latino population in the United States lies in its potential to foster diversity, inclusivity, and cultural competence in medical education, as well as to positively impact the healthcare outcomes and experiences of the Latino community. A diverse administration can serve as role models for students and aspiring professionals from underrepresented backgrounds. It can inspire individuals who might otherwise feel excluded or underrepresented in their career pursuits, including aspiring Latino medical students. Furthermore, a diverse leadership can help develop curricula, policies, and practices that are culturally sensitive and relevant, which is essential for addressing health disparities and providing equitable healthcare. It is also important to have transparency so the public knows the number of low-income Latino individuals in medical school. The Latino statistics from the medical school generally include international students. That speaks to diversity but misses the important aspect of uplifting the low-income Latino population of the United States. Passing off wealthy international students from Latin America to claim a culturally diverse class is misleading as it does not reflect income diversity. Doing so gives the incorrect perception that the medical school is accurately representing the Latino population of the United States. There must be a change in how the application process introduces interviews. It needs to be introduced earlier so the admissions committee can form early, well-rounded inferences about an applicant. The interview allows for personal connections with committee members that otherwise would not be established through the primary application. The current framework has the interviews as one of the last aspects of the application process before admissions decisions are reached. At this point in the application process, many low-income Latinos may have been screened out. I understand this is not an easy feat to accomplish. This will lead to an increase in interviews to be managed by the admissions committee. The burden can be strategically minimized by first conducting video interviews with applicants the admission committee is interested in moving forward and those that they are unsure about because of a weakness in a certain area of the application. The video interview provides a more formal connection between the applicants and admission committee reviewers. It allows the applicant to provide a narrative through spoken words and can come off as a more intimate window into their characteristics. It would also allow for an opportunity to explain hardships and what is unique. From this larger pool of video-interviewed applicants, the admission committee can narrow down to traditional in-person interviews. A form of these video interviews may be already in place in some medical school application process. I believe making this practice widespread throughout medical schools will provide an opportunity to increase the diversity of medical school students. There must be an increase in the number of programs dedicated to serving as a gateway to clinical experience for low-income Latino applicants. These programs provide the necessary networking environment needed to get clinical experience. It is important to consider that networking with clinical professionals is an admissions factor that detrimentally affects the low-income Latino population. One of the organizations that aids underserved communities, not limited to Latinos, in clinical exposure is the Summer Clinical Oncology Research Experience (SCORE) program.[49] The SCORE program, conducted by Memorial Sloan Kettering Cancer Center, provides its participants with mentorship opportunities in medicine and science. In doing so, strong connections are made in clinical environments. Low-income Latinos seek these opportunities as they have limited exposure to such an environment. I argue that it is in the medical school’s best interest to develop programs of this nature to construct a more diverse applicant pool. These programs are in the best interest of medical schools because they are culturing a well-prepared applicant pool. It should not be left to the goodwill of a handful of organizations to cultivate clinically experienced individuals from minority communities. Medical schools have an ethical obligation to produce well-suited physicians from all backgrounds. Justice is not upheld when low-income Latinos are disproportionally represented in medical schools. Programs tailored for low-income Latinos supplement the networking this population lacks, which is fundamental to obtaining clinical experience. These programs help alleviate the burden of an applicant’s low socioeconomic status in attaining clinical exposure. VIII. Additional Considerations Affecting the Medical School Application Process and Latino Community Health A commitment to practicing medicine in low-income Latino communities can be established to improve Latino community health.[50] Programs, such as the National Health Service Corps, encourage clinicians to practice in underserved areas by forgiving academic loans for years of work.[51] Increasing the number of clinicians in underserved communities can lead to a positive correlation with better health. It would be ideal to have programs for low-income Latino medical students that incentivize practicing in areas with a high population of underserved Latinos. This would provide the Latino community with physicians of a similar cultural background to attend to them, creating a deeper physician-patient relationship that has been missing in this community. Outreach for prospective Latino applicants by Latino medical students and physicians could encourage an increased applicant turnout. This effort can guide low-income Latinos who do not see much representation in the medical field. It would serve as a motivating factor and an opportunity to network within the medical field. Since there are few Latino physicians and medical students, a large effort must be made to make their presence known. IX. Further Investigation Required It is important to investigate the causes of medical school rejections of low-income Latinos. Understanding this piece of information would provide insight into the specific difficulties this population has with the medical school application. From there, the requirements can be subjected to bioethical analysis to determine whether those unfulfilled requirements serve as undue restrictions. The aspect of legacy students, children of former alumni, proves to be a difficult subject to find data on and merits further research. Legacy students are often given preferred admission into universities.[52] It is necessary to understand how this affects the medical school admissions process and whether it comes at a cost to students that are not legacy. It does not seem like these preferences are something universities are willing to disclose. The aspect of legacy preferences in admissions decisions could be detrimental to low-income Latino applicants if their parents are not college-educated in the United States, which often is the case. It would be beneficial to note how many Latinos in medical school are low-income. The MSAR report denotes the number of Latino-identified students per medical school class at an institution and the number of students who identify as coming from low resources. They do not specify which of the Latino students come from low-income families. This information would be useful to decipher how many people from the low-income Latino community are matriculating into medical schools. CONCLUSION It is an injustice that low-income Latinos are grossly underrepresented in medical school. It would remain an injustice even if the health of the Latino community in the United States were good. The current operation of medical school admission is based on a guild-like mentality, which perpetuates through barriers to admissions. It remains an exclusive club with processes that favor the wealthy over those who cannot devote money and time to the prerequisites such as test preparation courses and clinical internships. This has come at the expense of the Latino community in the United States in the form of both fewer Latino doctors and fewer current medical students. It is reasonable to hope that addressing the injustice of the underrepresentation of low-income Latinos in the medical field would improve Latino community health. With such a large demographic, the lack of representation in the medical field is astonishing. The Latino population faces cultural barriers when seeking healthcare, and the best way to combat that is with a familiar face. An increase in Latino medical students would lead to more physicians that not only can culturally relate to the Latino community, but that are a part of it. This opens the door for a comprehensive understanding between the patient and physician. As described in my thesis, Latino physicians can bridge cultural gaps that have proven detrimental to that patient population. That may help patients make informed decisions, exercising their full autonomy. The lack of representation of low-income Latinos in medicine is a long-known issue. Here, I have connected how the physician-patient relationship can be positively improved with an increase in low-income Latino physicians through various reforms in the admissions process. My hope is to have analyzed the problem of under-representation in a way that points toward further research and thoughtful reforms that can truly contribute to the process of remedying this issue. - [1] Passel, J. S., Lopez, M. H., & Cohn, D. (2022, February 3). U.S. Hispanic population continued its geographic spread in the 2010s. Pew Research Center. https://www.pewresearch.org/fact-tank/2022/02/03/u-s-hispanic-population-continued-its-geographic-spread-in-the-2010s/ [2] Ramirez, A. G., Lepe, R., & Cigarroa, F. (2021). Uplifting the Latino Population From Obscurity to the Forefront of Health Care, Public Health Intervention, and Societal Presence. JAMA, 326(7), 597–598. https://doi.org/10.1001/jama.2021.11997 [3] Association of American Medical Colleges. (2023). Who is eligible to participate in the fee assistance program? https://students-residents.aamc.org/fee-assistance-program/who-eligble-participate-fee-assistance-mprogram [4] U.S. Department of Health and Human Services Office of Minority Health. (2021). Profile: Hispanic/Latino Americans. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=64 [5] Prevalence of Obesity and Severe Obesity Among Adults: United States, 2017–2018. (2020). Center for Disease Control and Prevention. https://www.cdc.gov/nchs/products/databriefs/db360.htm; Center for Disease Control and Prevention. (2019). National Diabetes Statistic Report. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf; Hispanics / Latinos | Health Disparities | CDC. (2020, September 14). Health Disparities in HIV, Viral Hepatitis, STDs, and TB. https://www.cdc.gov/nchhstp/healthdisparities/hispanics.html [6] Prevalence of Obesity and Severe Obesity Among Adults: United States, 2017–2018. (2020). Center for Disease Control and Prevention. https://www.cdc.gov/nchs/products/databriefs/db360.htm [7] Center for Disease Control and Prevention. (2021, October). Estimated HIV incidence and prevalence in the United States 2015–2019. https://www.cdc.gov/hiv/pdf/group/racialethnic/hispanic-latino/cdc-hiv-group-hispanic-latino-factsheet.pdf [8] Hispanics / Latinos | Health Disparities | CDC. (2020, September 14). Health Disparities in HIV, Viral Hepatitis, STDs, and TB. https://www.cdc.gov/nchhstp/healthdisparities/hispanics.html [9] CDC. (2020). [10] CDC. (2020). [11] Center for Disease Control and Prevention. (2019). National Diabetes Statistic Report. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf [12] Office of the Assistant Secretary for Planning and Evaluation. (2021, October). Issue Brief No. HP-2021-2. Health Insurance Coverage and Access to Care Among Latinos: Recent Trends and Key Challenges. U.S. Department of Health and Human Services. https://aspe.hhs.gov/reports/health-insurance-coverage-access-care-among-latinos [13] U.S. Department of Health and Human Services Office of Minority Health. (2021). Profile: Hispanic/Latino Americans. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=64 [14] Alsan, M., Garrick, O., & Graziani, G. (2019). Does Diversity Matter for Health? Experimental Evidence from Oakland. American Economic Review, 109(12), 4071–4111. https://doi.org/10.1257/aer.20181446 [15] Takeshita, J., Wang, S., Loren, A. W., Mitra, N., Shults, J., Shin, D. B., & Sawinski, D. L. (2020). Association of Racial/Ethnic and Gender Concordance Between Patients and Physicians With Patient Experience Ratings. JAMA Network Open, 3(11). https://doi.org/10.1001/jamanetworkopen.2020.24583 [16] Alsan, et. al. (2019). [17] Marrast, L., Zallman, L., Woolhandler, S., Bor, D. H., & McCormick, D. (2014). Minority physicians’ role in the care of underserved patients. JAMA Internal Medicine, 174(2), 289. https://doi.org/10.1001/jamainternmed.2013.12756 (“Nonwhite physicians cared for 53.5% of minority and 70.4% of non-English speaking patients.” Increasing the number of Latino doctors could lead to more nonwhite physicians to care for the underserved populations as they serve those populations at disproportionate rates. This may lead to better care for the patients.) [18] Cersosimo, E., & Musi, N. (2011). Improving Treatment in Hispanic/Latino Patients. The American Journal of Medicine, 124(10), S16–S21. https://doi.org/10.1016/j.amjmed.2011.07.019 [19] Flores, G. (2000). Culture and the patient-physician relationship: Achieving cultural competency in health care. The Journal of Pediatrics, 136(1), 14–23. https://doi.org/10.1016/s0022-3476(00)90043-x [20] Cersosimo & Musi. (2011). [21] Flores. (2000). [22] Torres, D. (2019). Knowing How to Ask Good Questions: Comparing Latinos and Non-Latino Whites Enrolled in a Cardiovascular Disease Prevention Study. The Permanente Journal. https://doi.org/10.7812/tpp/18-258 [23] The Princeton Review. (n.d.). Score 513+ on the MCAT, Guaranteed! | The Princeton Review. [24] 2021 FACTS: Applicants and Matriculants Data. (2022). AAMC. https://www.aamc.org/data-reports/students-residents/interactive-data/2021-facts-applicants-and-matriculants-data [25] The Princeton Review. (n.d.). How Many Med Schools Should You Apply To? https://www.princetonreview.com/med-school-advice/how-many-med-schools-should-you-apply-to [26] Association of American Medical Colleges. (n.d.). Fee Assistance Program (FAP). AAMC. https://students-residents.aamc.org/fee-assistance-program/fee-assistance-program-fap [27] Nguyen, M., Desai, M. M., Fancher, T. L., Chaudhry, S. I., Mason, H. R. C., & Boatright, D. (2023). Temporal trends in childhood household income among applicants and matriculants to medical school and the likelihood of acceptance by income, 2014-2019. JAMA. https://doi.org/10.1001/jama.2023.5654 [28] Ramirez, et al. (2021). [29] Ko, M. J., Henderson, M. C., Fancher, T. L., London, M., Simon, M., & Hardeman, R. R. (2023). US medical school admissions leaders’ experiences with barriers to and advancements in diversity, equity, and inclusion. JAMA Network Open, 6(2), e2254928. https://doi.org/10.1001/jamanetworkopen.2022.54928 [30] Johns Hopkins University School of Medicine. (n.d.). JHU CSM SIP. Johns Hopkins Initiative for Careers in Science and Medicine - the Summer Internship Program. https://csmsip.cellbio.jhmi.edu/ [31] Figure 18. Percentage of all active physicians by race/ethnicity, 2018 | AAMC. (2018). AAMC. https://www.aamc.org/data-reports/workforce/data/figure-18-percentage-all-active-physicians-race/ethnicity-2018 [32] Ramirez, et al. (2021). [33] Passel, et al. (2022). [34] Census Reporter. (n.d.). Census profile: Manhattan borough, New York County, NY. https://censusreporter.org/profiles/06000US3606144919-manhattan-borough-new-york-county-ny/ [35] MD Student Diversity Recruitment. (2022). NYU Langone Health. https://med.nyu.edu/our-community/why-nyu-grossman-school-medicine/diversity-inclusion/recruiting-diversity/md-student-diversity-recruitment [36] NYU. (n.d.). STEP Pre-College Program. New York University. https://www.nyu.edu/admissions/undergraduate-admissions/how-to-apply/all-freshmen-applicants/opportunity-programs/pre-college-programs.html [37] Association of American Medical Colleges. (2022). NYU Grossman School of Medicine. Medical School Admission Requirements (MSAR). https://mec.aamc.org/msar-ui/#/medSchoolDetails/152 [38] Association of American Medical Colleges. (2022). [39] U.S. Census Bureau. (2021). U.S. Census Bureau QuickFacts: Philadelphia County, Pennsylvania. Census Bureau QuickFacts. https://www.census.gov/quickfacts/philadelphiacountypennsylvania [40] Association of American Medical Colleges. (2022). Drexel University College of Medicine. Medical School Admission Requirements. https://mec.aamc.org/msar-ui/#/medSchoolDetails/833 [41] Association of American Medical Colleges. (2022). [42] Drexel University College of Medicine. (n.d.). Diversity, Equity & Inclusion For Students. https://drexel.edu/medicine/about/diversity/diversity-for-students/ [43] Drexel University College of Medicine. (n.d.-b). Drexel Pathway to Medical School. https://drexel.edu/medicine/academics/graduate-school/drexel-pathway-to-medical-school/ [44] Drexel University College of Medicine. Drexel Pathway to Medical School. [45] Association of American Medical Colleges. (2022). University of California, San Francisco, School of Medicine. Medical School Admission Requirements. https://mec.aamc.org/msar-ui/#/medSchoolDetails/108 [46] The Regents of the University of California. (n.d.). Differences Matter. UCSF School of Medicine. https://medschool.ucsf.edu/differences-matter [47] The Regents of the University of California. (n.d.-b). Post Baccalaureate Program | UCSF Medical Education. UCSF Medical Education. https://meded.ucsf.edu/post-baccalaureate-program [48] United States Census Bureau. (2021). U.S. Census Bureau QuickFacts: San Francisco County, California. Census Bureau QuickFacts. https://www.census.gov/quickfacts/sanfranciscocountycalifornia [49] Memorial Sloan Kettering Cancer Center. (n.d.). Student Programs. https://www.mskcc.org/about/leadership/office-faculty-development/student-programs [50] Alsan, et al. (2021). [51] National Health Service Corps. (2021, November 2). Mission, Work, and Impact | NHSC. https://nhsc.hrsa.gov/about-us [52] Elam, C. L., & Wagoner, N. E. (2012). Legacy Admissions in Medical School. AMA Journal of Ethics, 14(12), 946–949. https://doi.org/10.1001/virtualmentor.2012.14.12.ecas3-1212

The term “coffee palace” was primarily used in Australia to describe the temperance hotels that were built in the last decades of the 19th century, although there are references to the term also being used to a lesser extent in the United Kingdom (Denby 174). Built in response to the worldwide temperance movement, which reached its pinnacle in the 1880s in Australia, coffee palaces were hotels that did not serve alcohol. This was a unique time in Australia’s architectural development as the economic boom fuelled by the gold rush in the 1850s, and the demand for ostentatious display that gathered momentum during the following years, afforded the use of richly ornamental High Victorian architecture and resulted in very majestic structures; hence the term “palace” (Freeland 121). The often multi-storied coffee palaces were found in every capital city as well as regional areas such as Geelong and Broken Hill, and locales as remote as Maria Island on the east coast of Tasmania. Presented as upholding family values and discouraging drunkenness, the coffee palaces were most popular in seaside resorts such as Barwon Heads in Victoria, where they catered to families. Coffee palaces were also constructed on a grand scale to provide accommodation for international and interstate visitors attending the international exhibitions held in Sydney (1879) and Melbourne (1880 and 1888). While the temperance movement lasted well over 100 years, the life of coffee palaces was relatively short-lived. Nevertheless, coffee palaces were very much part of Australia’s cultural landscape. In this article, I examine the rise and demise of coffee palaces associated with the temperance movement and argue that coffee palaces established in the name of abstinence were modelled on the coffee houses that spread throughout Europe and North America in the 17th and 18th centuries during the Enlightenment—a time when the human mind could be said to have been liberated from inebriation and the dogmatic state of ignorance. The Temperance Movement At a time when newspapers are full of lurid stories about binge-drinking and the alleged ill-effects of the liberalisation of licensing laws, as well as concerns over the growing trend of marketing easy-to-drink products (such as the so-called “alcopops”) to teenagers, it is difficult to think of a period when the total suppression of the alcohol trade was seriously debated in Australia. The cause of temperance has almost completely vanished from view, yet for well over a century—from 1830 to the outbreak of the Second World War—the control or even total abolition of the liquor trade was a major political issue—one that split the country, brought thousands onto the streets in demonstrations, and influenced the outcome of elections. Between 1911 and 1925 referenda to either limit or prohibit the sale of alcohol were held in most States. While moves to bring about abolition failed, Fitzgerald notes that almost one in three Australian voters expressed their support for prohibition of alcohol in their State (145). Today, the temperance movement’s platform has largely been forgotten, killed off by the practical example of the United States, where prohibition of the legal sale of alcohol served only to hand control of the liquor traffic to organised crime. Coffee Houses and the Enlightenment Although tea has long been considered the beverage of sobriety, it was coffee that came to be regarded as the very antithesis of alcohol. When the first coffee house opened in London in the early 1650s, customers were bewildered by this strange new drink from the Middle East—hot, bitter, and black as soot. But those who tried coffee were, reports Ellis, soon won over, and coffee houses were opened across London, Oxford, and Cambridge and, in the following decades, Europe and North America. Tea, equally exotic, entered the English market slightly later than coffee (in 1664), but was more expensive and remained a rarity long after coffee had become ubiquitous in London (Ellis 123-24). The impact of the introduction of coffee into Europe during the seventeenth century was particularly noticeable since the most common beverages of the time, even at breakfast, were weak “small beer” and wine. Both were safer to drink than water, which was liable to be contaminated. Coffee, like beer, was made using boiled water and, therefore, provided a new and safe alternative to alcoholic drinks. There was also the added benefit that those who drank coffee instead of alcohol began the day alert rather than mildly inebriated (Standage 135). It was also thought that coffee had a stimulating effect upon the “nervous system,” so much so that the French called coffee une boisson intellectuelle (an intellectual beverage), because of its stimulating effect on the brain (Muskett 71). In Oxford, the British called their coffee houses “penny universities,” a penny then being the price of a cup of coffee (Standage 158). Coffee houses were, moreover, more than places that sold coffee. Unlike other institutions of the period, rank and birth had no place (Ellis 59). The coffee house became the centre of urban life, creating a distinctive social culture by treating all customers as equals. Egalitarianism, however, did not extend to women—at least not in London. Around its egalitarian (but male) tables, merchants discussed and conducted business, writers and poets held discussions, scientists demonstrated experiments, and philosophers deliberated ideas and reforms. For the price of a cup (or “dish” as it was then known) of coffee, a man could read the latest pamphlets and newsletters, chat with other patrons, strike business deals, keep up with the latest political gossip, find out what other people thought of a new book, or take part in literary or philosophical discussions. Like today’s Internet, Twitter, and Facebook, Europe’s coffee houses functioned as an information network where ideas circulated and spread from coffee house to coffee house. In this way, drinking coffee in the coffee house became a metaphor for people getting together to share ideas in a sober environment, a concept that remains today. According to Standage, this information network fuelled the Enlightenment (133), prompting an explosion of creativity. Coffee houses provided an entirely new environment for political, financial, scientific, and literary change, as people gathered, discussed, and debated issues within their walls. Entrepreneurs and scientists teamed up to form companies to exploit new inventions and discoveries in manufacturing and mining, paving the way for the Industrial Revolution (Standage 163). The stock market and insurance companies also had their birth in the coffee house. As a result, coffee was seen to be the epitome of modernity and progress and, as such, was the ideal beverage for the Age of Reason. By the 19th century, however, the era of coffee houses had passed. Most of them had evolved into exclusive men’s clubs, each geared towards a certain segment of society. Tea was now more affordable and fashionable, and teahouses, which drew clientele from both sexes, began to grow in popularity. Tea, however, had always been Australia’s most popular non-alcoholic drink. Tea (and coffee) along with other alien plants had been part of the cargo unloaded onto Australian shores with the First Fleet in 1788. Coffee, mainly from Brazil and Jamaica, remained a constant import but was taxed more heavily than tea and was, therefore, more expensive. Furthermore, tea was much easier to make than coffee. To brew tea, all that is needed is to add boiling water, coffee, in contrast, required roasting, grinding and brewing. According to Symons, until the 1930s, Australians were the largest consumers of tea in the world (19). In spite of this, and as coffee, since its introduction into Europe, was regarded as the antidote to alcohol, the temperance movement established coffee palaces. In the early 1870s in Britain, the temperance movement had revived the coffee house to provide an alternative to the gin taverns that were so attractive to the working classes of the Industrial Age (Clarke 5). Unlike the earlier coffee house, this revived incarnation provided accommodation and was open to men, women and children. “Cheap and wholesome food,” was available as well as reading rooms supplied with newspapers and periodicals, and games and smoking rooms (Clarke 20). In Australia, coffee palaces did not seek the working classes, as clientele: at least in the cities they were largely for the nouveau riche. Coffee Palaces The discovery of gold in 1851 changed the direction of the Australian economy. An investment boom followed, with an influx of foreign funds and English banks lending freely to colonial speculators. By the 1880s, the manufacturing and construction sectors of the economy boomed and land prices were highly inflated. Governments shared in the wealth and ploughed money into urban infrastructure, particularly railways. Spurred on by these positive economic conditions and the newly extended inter-colonial rail network, international exhibitions were held in both Sydney and Melbourne. To celebrate modern technology and design in an industrial age, international exhibitions were phenomena that had spread throughout Europe and much of the world from the mid-19th century. According to Davison, exhibitions were “integral to the culture of nineteenth century industrialising societies” (158). In particular, these exhibitions provided the colonies with an opportunity to demonstrate to the world their economic power and achievements in the sciences, the arts and education, as well as to promote their commerce and industry. Massive purpose-built buildings were constructed to house the exhibition halls. In Sydney, the Garden Palace was erected in the Botanic Gardens for the 1879 Exhibition (it burnt down in 1882). In Melbourne, the Royal Exhibition Building, now a World Heritage site, was built in the Carlton Gardens for the 1880 Exhibition and extended for the 1888 Centennial Exhibition. Accommodation was required for the some one million interstate and international visitors who were to pass through the gates of the Garden Palace in Sydney. To meet this need, the temperance movement, keen to provide alternative accommodation to licensed hotels, backed the establishment of Sydney’s coffee palaces. The Sydney Coffee Palace Hotel Company was formed in 1878 to operate and manage a number of coffee palaces constructed during the 1870s. These were designed to compete with hotels by “offering all the ordinary advantages of those establishments without the allurements of the drink” (Murdoch). Coffee palaces were much more than ordinary hotels—they were often multi-purpose or mixed-use buildings that included a large number of rooms for accommodation as well as ballrooms and other leisure facilities to attract people away from pubs. As the Australian Town and Country Journal reveals, their services included the supply of affordable, wholesome food, either in the form of regular meals or occasional refreshments, cooked in kitchens fitted with the latest in culinary accoutrements. These “culinary temples” also provided smoking rooms, chess and billiard rooms, and rooms where people could read books, periodicals and all the local and national papers for free (121). Similar to the coffee houses of the Enlightenment, the coffee palaces brought businessmen, artists, writers, engineers, and scientists attending the exhibitions together to eat and drink (non-alcoholic), socialise and conduct business. The Johnson’s Temperance Coffee Palace located in York Street in Sydney produced a practical guide for potential investors and businessmen titled International Exhibition Visitors Pocket Guide to Sydney. It included information on the location of government departments, educational institutions, hospitals, charitable organisations, and embassies, as well as a list of the tariffs on goods from food to opium (1–17). Women, particularly the Woman’s Christian Temperance Union (WCTU) were a formidable force in the temperance movement (intemperance was generally regarded as a male problem and, more specifically, a husband problem). Murdoch argues, however, that much of the success of the push to establish coffee palaces was due to male politicians with business interests, such as the one-time Victorian premiere James Munro. Considered a stern, moral church-going leader, Munro expanded the temperance movement into a fanatical force with extraordinary power, which is perhaps why the temperance movement had its greatest following in Victoria (Murdoch). Several prestigious hotels were constructed to provide accommodation for visitors to the international exhibitions in Melbourne. Munro was responsible for building many of the city’s coffee palaces, including the Victoria (1880) and the Federal Coffee Palace (1888) in Collins Street. After establishing the Grand Coffee Palace Company, Munro took over the Grand Hotel (now the Windsor) in 1886. Munro expanded the hotel to accommodate some of the two million visitors who were to attend the Centenary Exhibition, renamed it the Grand Coffee Palace, and ceremoniously burnt its liquor licence at the official opening (Murdoch). By 1888 there were more than 50 coffee palaces in the city of Melbourne alone and Munro held thousands of shares in coffee palaces, including those in Geelong and Broken Hill. With its opening planned to commemorate the centenary of the founding of Australia and the 1888 International Exhibition, the construction of the Federal Coffee Palace, one of the largest hotels in Australia, was perhaps the greatest monument to the temperance movement. Designed in the French Renaissance style, the façade was embellished with statues, griffins and Venus in a chariot drawn by four seahorses. The building was crowned with an iron-framed domed tower. New passenger elevators—first demonstrated at the Sydney Exhibition—allowed the building to soar to seven storeys. According to the Federal Coffee Palace Visitor’s Guide, which was presented to every visitor, there were three lifts for passengers and others for luggage. Bedrooms were located on the top five floors, while the stately ground and first floors contained majestic dining, lounge, sitting, smoking, writing, and billiard rooms. There were electric service bells, gaslights, and kitchens “fitted with the most approved inventions for aiding proficients [sic] in the culinary arts,” while the luxury brand Pears soap was used in the lavatories and bathrooms (16–17). In 1891, a spectacular financial crash brought the economic boom to an abrupt end. The British economy was in crisis and to meet the predicament, English banks withdrew their funds in Australia. There was a wholesale collapse of building companies, mortgage banks and other financial institutions during 1891 and 1892 and much of the banking system was halted during 1893 (Attard). Meanwhile, however, while the eastern States were in the economic doldrums, gold was discovered in 1892 at Coolgardie and Kalgoorlie in Western Australia and, within two years, the west of the continent was transformed. As gold poured back to the capital city of Perth, the long dormant settlement hurriedly caught up and began to emulate the rest of Australia, including the construction of ornately detailed coffee palaces (Freeman 130). By 1904, Perth had 20 coffee palaces. When the No. 2 Coffee Palace opened in Pitt Street, Sydney, in 1880, the Australian Town and Country Journal reported that coffee palaces were “not only fashionable, but appear to have acquired a permanent footing in Sydney” (121). The coffee palace era, however, was relatively short-lived. Driven more by reformist and economic zeal than by good business sense, many were in financial trouble when the 1890’s Depression hit. Leading figures in the temperance movement were also involved in land speculation and building societies and when these schemes collapsed, many, including Munro, were financially ruined. Many of the palaces closed or were forced to apply for liquor licences in order to stay afloat. Others developed another life after the temperance movement’s influence waned and the coffee palace fad faded, and many were later demolished to make way for more modern buildings. The Federal was licensed in 1923 and traded as the Federal Hotel until its demolition in 1973. The Victoria, however, did not succumb to a liquor licence until 1967. The Sydney Coffee Palace in Woolloomooloo became the Sydney Eye Hospital and, more recently, smart apartments. Some fine examples still survive as reminders of Australia’s social and cultural heritage. The Windsor in Melbourne’s Spring Street and the Broken Hill Hotel, a massive three-story iconic pub in the outback now called simply “The Palace,” are some examples. Tea remained the beverage of choice in Australia until the 1950s when the lifting of government controls on the importation of coffee and the influence of American foodways coincided with the arrival of espresso-loving immigrants. As Australians were introduced to the espresso machine, the short black, the cappuccino, and the café latte and (reminiscent of the Enlightenment), the post-war malaise was shed in favour of the energy and vigour of modernist thought and creativity, fuelled in at least a small part by caffeine and the emergent café culture (Teffer). Although the temperance movement’s attempt to provide an alternative to the ubiquitous pubs failed, coffee has now outstripped the consumption of tea and today’s café culture ensures that wherever coffee is consumed, there is the possibility of a continuation of the Enlightenment’s lively discussions, exchange of news, and dissemination of ideas and information in a sober environment. References Attard, Bernard. “The Economic History of Australia from 1788: An Introduction.” EH.net Encyclopedia. 5 Feb. (2012) ‹http://eh.net/encyclopedia/article/attard.australia›. Blainey, Anna. “The Prohibition and Total Abstinence Movement in Australia 1880–1910.” Food, Power and Community: Essays in the History of Food and Drink. Ed. Robert Dare. Adelaide: Wakefield Press, 1999. 142–52. Boyce, Francis Bertie. “Shall I Vote for No License?” An address delivered at the Convention of the Parramatta Branch of New South Wales Alliance, 3 September 1906. 3rd ed. Parramatta: New South Wales Alliance, 1907. Clarke, James Freeman. Coffee Houses and Coffee Palaces in England. Boston: George H. Ellis, 1882. “Coffee Palace, No. 2.” Australian Town and Country Journal. 17 Jul. 1880: 121. Davison, Graeme. “Festivals of Nationhood: The International Exhibitions.” Australian Cultural History. Eds. S. L. Goldberg and F. B. Smith. Cambridge: Cambridge UP, 1989. 158–77. Denby, Elaine. Grand Hotels: Reality and Illusion. London: Reaktion Books, 2002. Ellis, Markman. The Coffee House: A Cultural History. London: Weidenfeld & Nicolson, 2004. Federal Coffee Palace. The Federal Coffee Palace Visitors’ Guide to Melbourne, Its Suburbs, and Other Parts of the Colony of Victoria: Views of the Principal Public and Commercial Buildings in Melbourne, With a Bird’s Eye View of the City; and History of the Melbourne International Exhibition of 1880, etc. Melbourne: Federal Coffee House Company, 1888. Fitzgerald, Ross, and Trevor Jordan. Under the Influence: A History of Alcohol in Australia. Sydney: Harper Collins, 2009. Freeland, John. The Australian Pub. Melbourne: Sun Books, 1977. Johnson’s Temperance Coffee Palace. International Exhibition Visitors Pocket Guide to Sydney, Restaurant and Temperance Hotel. Sydney: Johnson’s Temperance Coffee Palace, 1879. Mitchell, Ann M. “Munro, James (1832–1908).” Australian Dictionary of Biography. Canberra: National Centre of Biography, Australian National U, 2006-12. 5 Feb. 2012 ‹http://adb.anu.edu.au/biography/munro-james-4271/text6905›. Murdoch, Sally. “Coffee Palaces.” Encyclopaedia of Melbourne. Eds. Andrew Brown-May and Shurlee Swain. 5 Feb. 2012 ‹http://www.emelbourne.net.au/biogs/EM00371b.htm›. Muskett, Philip E. The Art of Living in Australia. New South Wales: Kangaroo Press, 1987. Standage, Tom. A History of the World in 6 Glasses. New York: Walker & Company, 2005. Sydney Coffee Palace Hotel Company Limited. Memorandum of Association of the Sydney Coffee Palace Hotel Company, Ltd. Sydney: Samuel Edward Lees, 1879. Symons, Michael. One Continuous Picnic: A Gastronomic History of Australia. Melbourne: Melbourne UP, 2007. Teffer, Nicola. Coffee Customs. Exhibition Catalogue. Sydney: Customs House, 2005.

Introduction The highly contagious COVID-19 virus has presented particularly difficult public policy challenges. The relatively late emergence of an effective treatments and vaccines, the structural stresses on health care systems, the lockdowns and the economic dislocations, the evident structural inequalities in effected societies, as well as the difficulty of prevention have tested social and political cohesion. Moreover, the intrusive nature of many prophylactic measures have led to individual liberty and human rights concerns. As noted by the Victorian (Australia) Ombudsman Report on the COVID-19 lockdown in Melbourne, we may be tempted, during a crisis, to view human rights as expendable in the pursuit of saving human lives. This thinking can lead to dangerous territory. It is not unlawful to curtail fundamental rights and freedoms when there are compelling reasons for doing so; human rights are inherently and inseparably a consideration of human lives. (5) These difficulties have raised issues about the importance of social or community capital in fighting the pandemic. This article discusses the impacts of social and community capital and other factors on the governmental efforts to combat the spread of infectious disease through the maintenance of social distancing and household ‘bubbles’. It argues that the beneficial effects of social and community capital towards fighting the pandemic, such as mutual respect and empathy, which underpins such public health measures as social distancing, the use of personal protective equipment, and lockdowns in the USA, have been undermined as preventive measures because they have been transmogrified to become a salient aspect of the “culture wars” (Peters). In contrast, states that have relatively lower social capital such a China have been able to more effectively arrest transmission of the disease because the government was been able to generate and personify a nationalist response to the virus and thus generate a more robust social consensus regarding the efforts to combat the disease. Social Capital and Culture Wars The response to COVID-19 required individuals, families, communities, and other types of groups to refrain from extensive interaction – to stay in their bubble. In these situations, especially given the asymptomatic nature of many COVID-19 infections and the serious imposition lockdowns and social distancing and isolation, the temptation for individuals to breach public health rules in high. From the perspective of policymakers, the response to fighting COVID-19 is a collective action problem. In studying collective action problems, scholars have paid much attention on the role of social and community capital (Ostrom and Ahn 17-35). Ostrom and Ahn comment that social capital “provides a synthesizing approach to how cultural, social, and institutional aspects of communities of various sizes jointly affect their capacity of dealing with collective-action problems” (24). Social capital is regarded as an evolving social type of cultural trait (Fukuyama; Guiso et al.). Adger argues that social capital “captures the nature of social relations” and “provides an explanation for how individuals use their relationships to other actors in societies for their own and for the collective good” (387). The most frequently used definition of social capital is the one proffered by Putnam who regards it as “features of social organization, such as networks, norms and social trust that facilitate coordination and cooperation for mutual benefit” (Putnam, “Bowling Alone” 65). All these studies suggest that social and community capital has at least two elements: “objective associations” and subjective ties among individuals. Objective associations, or social networks, refer to both formal and informal associations that are formed and engaged in on a voluntary basis by individuals and social groups. Subjective ties or norms, on the other hand, primarily stand for trust and reciprocity (Paxton). High levels of social capital have generally been associated with democratic politics and civil societies whose institutional performance benefits from the coordinated actions and civic culture that has been facilitated by high levels of social capital (Putnam, Democracy 167-9). Alternatively, a “good and fair” state and impartial institutions are important factors in generating and preserving high levels of social capital (Offe 42-87). Yet social capital is not limited to democratic civil societies and research is mixed on whether rising social capital manifests itself in a more vigorous civil society that in turn leads to democratising impulses. Castillo argues that various trust levels for institutions that reinforce submission, hierarchy, and cultural conservatism can be high in authoritarian governments, indicating that high levels of social capital do not necessarily lead to democratic civic societies (Castillo et al.). Roßteutscher concludes after a survey of social capita indicators in authoritarian states that social capital has little effect of democratisation and may in fact reinforce authoritarian rule: in nondemocratic contexts, however, it appears to throw a spanner in the works of democratization. Trust increases the stability of nondemocratic leaderships by generating popular support, by suppressing regime threatening forms of protest activity, and by nourishing undemocratic ideals concerning governance (752). In China, there has been ongoing debate concerning the presence of civil society and the level of social capital found across Chinese society. If one defines civil society as an intermediate associational realm between the state and the family, populated by autonomous organisations which are separate from the state that are formed voluntarily by members of society to protect or extend their interests or values, it is arguable that the PRC had a significant civil society or social capital in the first few decades after its establishment (White). However, most scholars agree that nascent civil society as well as a more salient social and community capital has emerged in China’s reform era. This was evident after the 2008 Sichuan earthquake, where the government welcomed community organising and community-driven donation campaigns for a limited period of time, giving the NGO sector and bottom-up social activism a boost, as evidenced in various policy areas such as disaster relief and rural community development (F. Wu 126; Xu 9). Nevertheless, the CCP and the Chinese state have been effective in maintaining significant control over civil society and autonomous groups without attempting to completely eliminate their autonomy or existence. The dramatic economic and social changes that have occurred since the 1978 Opening have unsurprisingly engendered numerous conflicts across the society. In response, the CCP and State have adjusted political economic policies to meet the changing demands of workers, migrants, the unemployed, minorities, farmers, local artisans, entrepreneurs, and the growing middle class. Often the demands arising from these groups have resulted in policy changes, including compensation. In other circumstances, where these groups remain dissatisfied, the government will tolerate them (ignore them but allow them to continue in the advocacy), or, when the need arises, supress the disaffected groups (F. Wu 2). At the same time, social organisations and other groups in civil society have often “refrained from open and broad contestation against the regime”, thereby gaining the space and autonomy to achieve the objectives (F. Wu 2). Studies of Chinese social or community capital suggest that a form of modern social capital has gradually emerged as Chinese society has become increasingly modernised and liberalised (despite being non-democratic), and that this social capital has begun to play an important role in shaping social and economic lives at the local level. However, this more modern form of social capital, arising from developmental and social changes, competes with traditional social values and social capital, which stresses parochial and particularistic feelings among known individuals while modern social capital emphasises general trust and reciprocal feelings among both known and unknown individuals. The objective element of these traditional values are those government-sanctioned, formal mass organisations such as Communist Youth and the All-China Federation of Women's Associations, where members are obliged to obey the organisation leadership. The predominant subjective values are parochial and particularistic feelings among individuals who know one another, such as guanxi and zongzu (Chen and Lu, 426). The concept of social capital emphasises that the underlying cooperative values found in individuals and groups within a culture are an important factor in solving collective problems. In contrast, the notion of “culture war” focusses on those values and differences that divide social and cultural groups. Barry defines culture wars as increases in volatility, expansion of polarisation, and conflict between those who are passionate about religiously motivated politics, traditional morality, and anti-intellectualism, and…those who embrace progressive politics, cultural openness, and scientific and modernist orientations. (90) The contemporary culture wars across the world manifest opposition by various groups in society who hold divergent worldviews and ideological positions. Proponents of culture war understand various issues as part of a broader set of religious, political, and moral/normative positions invoked in opposition to “elite”, “liberal”, or “left” ideologies. Within this Manichean universe opposition to such issues as climate change, Black Lives Matter, same sex rights, prison reform, gun control, and immigration becomes framed in binary terms, and infused with a moral sensibility (Chapman 8-10). In many disputes, the culture war often devolves into an epistemological dispute about the efficacy of scientific knowledge and authority, or a dispute between “practical” and theoretical knowledge. In this environment, even facts can become partisan narratives. For these “cultural” disputes are often how electoral prospects (generally right-wing) are advanced; “not through policies or promises of a better life, but by fostering a sense of threat, a fantasy that something profoundly pure … is constantly at risk of extinction” (Malik). This “zero-sum” social and policy environment that makes it difficult to compromise and has serious consequences for social stability or government policy, especially in a liberal democratic society. Of course, from the perspective of cultural materialism such a reductionist approach to culture and political and social values is not unexpected. “Culture” is one of the many arenas in which dominant social groups seek to express and reproduce their interests and preferences. “Culture” from this sense is “material” and is ultimately connected to the distribution of power, wealth, and resources in society. As such, the various policy areas that are understood as part of the “culture wars” are another domain where various dominant and subordinate groups and interests engaged in conflict express their values and goals. Yet it is unexpected that despite the pervasiveness of information available to individuals the pool of information consumed by individuals who view the “culture wars” as a touchstone for political behaviour and a narrative to categorise events and facts is relatively closed. This lack of balance has been magnified by social media algorithms, conspiracy-laced talk radio, and a media ecosystem that frames and discusses issues in a manner that elides into an easily understood “culture war” narrative. From this perspective, the groups (generally right-wing or traditionalist) exist within an information bubble that reinforces political, social, and cultural predilections. American and Chinese Reponses to COVID-19 The COVID-19 pandemic first broke out in Wuhan in December 2019. Initially unprepared and unwilling to accept the seriousness of the infection, the Chinese government regrouped from early mistakes and essentially controlled transmission in about three months. This positive outcome has been messaged as an exposition of the superiority of the Chinese governmental system and society both domestically and internationally; a positive, even heroic performance that evidences the populist credentials of the Chinese political leadership and demonstrates national excellence. The recently published White Paper entitled “Fighting COVID-19: China in Action” also summarises China’s “strategic achievement” in the simple language of numbers: in a month, the rising spread was contained; in two months, the daily case increase fell to single digits; and in three months, a “decisive victory” was secured in Wuhan City and Hubei Province (Xinhua). This clear articulation of the positive results has rallied political support. Indeed, a recent survey shows that 89 percent of citizens are satisfied with the government’s information dissemination during the pandemic (C Wu). As part of the effort, the government extensively promoted the provision of “political goods”, such as law and order, national unity and pride, and shared values. For example, severe publishments were introduced for violence against medical professionals and police, producing and selling counterfeit medications, raising commodity prices, spreading ‘rumours’, and being uncooperative with quarantine measures (Xu). Additionally, as an extension the popular anti-corruption campaign, many local political leaders were disciplined or received criminal charges for inappropriate behaviour, abuse of power, and corruption during the pandemic (People.cn, 2 Feb. 2020). Chinese state media also described fighting the virus as a global “competition”. In this competition a nation’s “material power” as well as “mental strength”, that calls for the highest level of nation unity and patriotism, is put to the test. This discourse recalled the global competition in light of the national mythology related to the formation of Chinese nation, the historical “hardship”, and the “heroic Chinese people” (People.cn, 7 Apr. 2020). Moreover, as the threat of infection receded, it was emphasised that China “won this competition” and the Chinese people have demonstrated the “great spirit of China” to the world: a result built upon the “heroism of the whole Party, Army, and Chinese people from all ethnic groups” (People.cn, 7 Apr. 2020). In contrast to the Chinese approach of emphasising national public goods as a justification for fighting the virus, the U.S. Trump Administration used nationalism, deflection, and “culture war” discourse to undermine health responses — an unprecedented response in American public health policy. The seriousness of the disease as well as the statistical evidence of its course through the American population was disputed. The President and various supporters raged against the COVID-19 “hoax”, social distancing, and lockdowns, disparaged public health institutions and advice, and encouraged protesters to “liberate” locked-down states (Russonello). “Our federal overlords say ‘no singing’ and ‘no shouting’ on Thanksgiving”, Representative Paul Gosar, a Republican of Arizona, wrote as he retweeted a Centers for Disease Control list of Thanksgiving safety tips (Weiner). People were encouraged, by way of the White House and Republican leadership, to ignore health regulations and not to comply with social distancing measures and the wearing of masks (Tracy). This encouragement led to threats against proponents of face masks such as Dr Anthony Fauci, one of the nation’s foremost experts on infectious diseases, who required bodyguards because of the many threats on his life. Fauci’s critics — including President Trump — countered Fauci’s promotion of mask wearing by stating accusingly that he once said mask-wearing was not necessary for ordinary people (Kelly). Conspiracy theories as to the safety of vaccinations also grew across the course of the year. As the 2020 election approached, the Administration ramped up efforts to downplay the serious of the virus by identifying it with “the media” and illegitimate “partisan” efforts to undermine the Trump presidency. It also ramped up its criticism of China as the source of the infection. This political self-centeredness undermined state and federal efforts to slow transmission (Shear et al.). At the same time, Trump chided health officials for moving too slowly on vaccine approvals, repeated charges that high infection rates were due to increased testing, and argued that COVID-19 deaths were exaggerated by medical providers for political and financial reasons. These claims were amplified by various conservative media personalities such as Rush Limbaugh, and Sean Hannity and Laura Ingraham of Fox News. The result of this “COVID-19 Denialism” and the alternative narrative of COVID-19 policy told through the lens of culture war has resulted in the United States having the highest number of COVID-19 cases, and the highest number of COVID-19 deaths. At the same time, the underlying social consensus and social capital that have historically assisted in generating positive public health outcomes has been significantly eroded. According to the Pew Research Center, the share of U.S. adults who say public health officials such as those at the Centers for Disease Control and Prevention are doing an excellent or good job responding to the outbreak decreased from 79% in March to 63% in August, with an especially sharp decrease among Republicans (Pew Research Center 2020). Social Capital and COVID-19 From the perspective of social or community capital, it could be expected that the American response to the Pandemic would be more effective than the Chinese response. Historically, the United States has had high levels of social capital, a highly developed public health system, and strong governmental capacity. In contrast, China has a relatively high level of governmental and public health capacity, but the level of social capital has been lower and there is a significant presence of traditional values which emphasise parochial and particularistic values. Moreover, the antecedent institutions of social capital, such as weak and inefficient formal institutions (Batjargal et al.), environmental turbulence and resource scarcity along with the transactional nature of guanxi (gift-giving and information exchange and relationship dependence) militate against finding a more effective social and community response to the public health emergency. Yet China’s response has been significantly more successful than the Unites States’. Paradoxically, the American response under the Trump Administration and the Chinese response both relied on an externalisation of the both the threat and the justifications for their particular response. In the American case, President Trump, while downplaying the seriousness of the virus, consistently called it the “China virus” in an effort to deflect responsibly as well as a means to avert attention away from the public health impacts. As recently as 3 January 2021, Trump tweeted that the number of “China Virus” cases and deaths in the U.S. were “far exaggerated”, while critically citing the Centers for Disease Control and Prevention's methodology: “When in doubt, call it COVID-19. Fake News!” (Bacon). The Chinese Government, meanwhile, has pursued a more aggressive foreign policy across the South China Sea, on the frontier in the Indian sub-continent, and against states such as Australia who have criticised the initial Chinese response to COVID-19. To this international criticism, the government reiterated its sovereign rights and emphasised its “victimhood” in the face of “anti-China” foreign forces. Chinese state media also highlighted China as “victim” of the coronavirus, but also as a target of Western “political manoeuvres” when investigating the beginning stages of the pandemic. The major difference, however, is that public health policy in the United States was superimposed on other more fundamental political and cultural cleavages, and part of this externalisation process included the assignation of “otherness” and demonisation of internal political opponents or characterising political opponents as bent on destroying the United States. This assignation of “otherness” to various internal groups is a crucial element in the culture wars. While this may have been inevitable given the increasingly frayed nature of American society post-2008, such a characterisation has been activity pushed by local, state, and national leadership in the Republican Party and the Trump Administration (Vogel et al.). In such circumstances, minimising health risks and highlighting civil rights concerns due to public health measures, along with assigning blame to the democratic opposition and foreign states such as China, can have a major impact of public health responses. The result has been that social trust beyond the bubble of one’s immediate circle or those who share similar beliefs is seriously compromised — and the collective action problem presented by COVID-19 remains unsolved. Daniel Aldrich’s study of disasters in Japan, India, and US demonstrates that pre-existing high levels of social capital would lead to stronger resilience and better recovery (Aldrich). Social capital helps coordinate resources and facilitate the reconstruction collectively and therefore would lead to better recovery (Alesch et al.). Yet there has not been much research on how the pool of social capital first came about and how a disaster may affect the creation and store of social capital. Rebecca Solnit has examined five major disasters and describes that after these events, survivors would reach out and work together to confront the challenges they face, therefore increasing the social capital in the community (Solnit). However, there are studies that have concluded that major disasters can damage the social fabric in local communities (Peacock et al.). The COVID-19 epidemic does not have the intensity and suddenness of other disasters but has had significant knock-on effects in increasing or decreasing social capital, depending on the institutional and social responses to the pandemic. In China, it appears that the positive social capital effects have been partially subsumed into a more generalised patriotic or nationalist affirmation of the government’s policy response. Unlike civil society responses to earlier crises, such as the 2008 Sichuan earthquake, there is less evidence of widespread community organisation and response to combat the epidemic at its initial stages. This suggests better institutional responses to the crisis by the government, but also a high degree of porosity between civil society and a national “imagined community” represented by the national state. The result has been an increased legitimacy for the Chinese government. Alternatively, in the United States the transformation of COVID-19 public health policy into a culture war issue has seriously impeded efforts to combat the epidemic in the short term by undermining the social consensus and social capital necessary to fight such a pandemic. Trust in American institutions is historically low, and President Trump’s untrue contention that President Biden’s election was due to “fraud” has further undermined the legitimacy of the American government, as evidenced by the attacks directed at Congress in the U.S. capital on 6 January 2021. As such, the lingering effects the pandemic will have on social, economic, and political institutions will likely reinforce the deep cultural and political cleavages and weaken interpersonal networks in American society. Conclusion The COVID-19 pandemic has devastated global public health and impacted deeply on the world economy. Unsurprisingly, given the serious economic, social, and political consequences, different government responses have been highly politicised. Various quarantine and infection case tracking methods have caused concern over state power intruding into private spheres. The usage of face masks, social distancing rules, and intra-state travel restrictions have aroused passionate debate over public health restrictions, individual liberty, and human rights. Yet underlying public health responses grounded in higher levels of social capital enhance the effectiveness of public health measures. In China, a country that has generally been associated with lower social capital, it is likely that the relatively strong policy response to COVID-19 will both enhance feelings of nationalism and Chinese exceptionalism and help create and increase the store of social capital. In the United States, the attribution of COVID-19 public health policy as part of the culture wars will continue to impede efforts to control the pandemic while further damaging the store of American community social capital that has assisted public health efforts over the past decades. References Adger, W. Neil. “Social Capital, Collective Action, and Adaptation to Climate Change.” Economic Geography 79.4 (2003): 387-404. Bacon, John. “Coronavirus Updates: Donald Trump Says US 'China Virus' Data Exaggerated; Dr. Anthony Fauci Protests, Draws President's Wrath.” USA Today 3 Jan. 2021. 4 Jan. 2021 <https://www.usatoday.com/story/news/health/2021/01/03/COVID-19-update-larry-king-ill-4-million-december-vaccinations-us/4114363001/>. Berry, Kate A. “Beyond the American Culture Wars.” Regions & Cohesion / Regiones y Cohesión / Régions et Cohésion 7.2 (Summer 2017): 90-95. 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Gert Tinggaard Svendsen and Gunnar Lind Haase Svendsen. Edward Elgar, 2009. 17–35. Paxton, Pamela. “Is Social Capital Declining in the United States? A Multiple Indicator Assessment.” American Journal of Sociology 105.1 (1999): 88-127. People.cn. “Hubeisheng Huanggangshi chufen dangyuan ganbu 337 ren.” [“337 Party Cadres Were Disciplined in Huanggang, Hubei Province.”] 2 Feb. 2020. 10 Sep. 2020 <http://fanfu.people.com.cn/n1/2020/0130/c64371-31565382.html>. ———. “Zai yiqing fangkong douzheng zhong zhangxian weida zhongguo jingshen.” [“Demonstrating the Great Spirit of China in Fighting the Pandemic.”] 7 Apr. 2020. 9 Sep. 2020 <http://opinion.people.com.cn/n1/2020/0407/c1003-31663076.html>. Peters, Jeremy W. “How Abortion, Guns and Church Closings Made Coronavirus a Culture War.” New York Times 20 Apr. 2020. 6 Jan. 2021 <http://www.nytimes.com/2020/04/20/us/politics/coronavirus-protests-democrats-republicans.html>. 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Photo by niu niu on Unsplash ABSTRACT Shackling prisoners has been implemented as standard procedure when transporting prisoners in labor and during childbirth. This procedure ensures the protection of both the public and healthcare workers. However, the act of shackling pregnant prisoners violates the principles of ethics that physicians are supposed to uphold. This paper will explore how shackling pregnant prisoners violates the principle of justice and beneficence, making the practice unethical. INTRODUCTION Some states allow shackling of incarcerated pregnant women during transport and while in the hospital for labor and delivery. Currently, only 22 states have legislation prohibiting the shackling of pregnant women.[1] Although many states have anti-shackling laws prohibiting restraints, these laws also contain an “extraordinary circumstances” loophole.[2] Under this exception, officers shackle prisoners if they pose a flight risk, have any history of violence, and are a threat to themselves or others.[3] Determining as to whether a prisoner is shackled is left solely to the correctional officer.[4] Yet even state restrictions on shackling are often disregarded. In shackling pregnant prisoners during childbirth, officers and institutions are interfering with the ability of incarcerated women to have safe childbirth experiences and fair treatment. Moreover, physicians cannot exercise various ethical duties as the law constrains them. In this article, I will discuss the physical and mental harms that result from the use of restraints under the backdrop of slavery and discrimination against women of color particularly. I argue that stereotypes feed into the phenomenon of shackling pregnant women, especially pregnant women of color. I further assert that shackling makes it difficult for medical professionals to be beneficent and promote justice. BACKGROUND Female incarceration rates in the United States have been fast growing since the 1980s.[5] With a 498 percent increase in the female incarceration population between 1981 and 2021, the rates of pregnancy and childbirth by incarcerated people have also climbed.[6],[7] In 2021, over 1.2 million women were incarcerated in the United States.[8] An estimated 55,000 pregnant women are admitted to jails each year.[9],[10] Many remain incarcerated throughout pregnancy and are transported to a hospital for labor and delivery. Although the exact number of restrained pregnant inmates is unclear, a study found that 83 percent of hospital prenatal nurses reported that their incarcerated patients were shackled.[11] I. Harms Caused by Shackling Shackling has caused many instances of physical and psychological harm. In the period before childbirth, shackled pregnant women are at high risk for falling.[12] The restraints shift pregnant women’s center of gravity, and wrist restraints prevent them from breaking a fall, increasing the risk of falling on their stomach and harming the fetus.[13] Another aspect inhibited by using restraints is testing and treating pregnancy complications. Delays in identifying and treating conditions such as hypertension, pre-eclampsia, appendicitis, kidney infection, preterm labor, and especially vaginal bleeding can threaten the lives of the mother and the fetus.[14] During labor and delivery, shackling prevents methods of alleviating severe labor pains and giving birth.[15] Usually, physicians recommend that women in labor walk or assume various positions to relieve labor pains and accelerate labor.[16] However, shackling prevents both solutions.[17] Shackling these women limits their mobility during labor, which may compromise the health of both the mother and the fetus.[18] Tracy Edwards, a former prisoner who filed a lawsuit for unlawful use of restraints during her pregnancy, was in labor for twelve hours. She was unable to move or adjust her position to lessen the pain and discomfort of labor.[19] The shackles also left the skin on her ankles red and bruised. Continued use of restraints also increases the risk of potentially life-threatening health issues associated with childbirth, such as blood clots.[20] It is imperative that pregnant women get treated rapidly, especially with the unpredictability of labor. Epidural administration can also become difficult, and in some cases, be denied due to the shackled woman’s inability to assume the proper position.[21] Time-sensitive medical care, including C-sections, could be delayed if permission from an officer is required, risking major health complications for both the fetus and the mother.[22] After childbirth, shackling impedes the recovery process. Shackling can result in post-delivery complications such as deep vein thrombosis.[23] Walking prevents such complications but is not an option for mothers shackled to their hospital beds.[24] Restraints also prevent bonding with the baby post-delivery and the safe handling of the baby while breast feeding.[25] The use of restraints can also result in psychological harm. Many prisoners feel as though care workers treat them like “animals,” with some women having multiple restraints at once— including ankles, wrists, and even waist restraints.[26] Benidalys Rivera describes the feeling of embarrassment as she was walking while handcuffed, with nurses and patients looking on, “Being in shackles, that make you be in stress…I about to have this baby, and I’m going to go back to jail. So it’s too much.”[27] Depression among pregnant prisoners is highly prevalent. The stress of imprisonment and the anticipation of being separated from their child is often overwhelming for these mothers.[28] The inhumane action has the potential to add more stress, anxiety, and sadness to the already emotionally demanding process of giving birth. Shackling pregnant prisoners displays indifference to the medical needs of the prisoner.[29] II. Safety as a Pretense While public safety is an argument for using shackles, several factors make escape or violence extremely unlikely and even impossible.[30] For example, administering epidural anesthesia causes numbness and eliminates flight risk.[31] Although cited as the main reason for using shackles, public safety is likely just an excuse and not the main motivator for shackling prisoners. I argue that underlying the shackling exemplifies the idea that these women should not have become pregnant. The shackling reflects a distinct discrimination: the lawmakers allowing it perhaps thought that people guilty of crimes would make bad mothers. Public safety is just a pretense. The language used to justify the use of restraint of Shawanna Nelson, the plaintiff in Nelson v. Correctional Medical Services, discussed below, included the word “aggressive.”[32] In her case, there was no evidence that she posed any danger or was objectively aggressive. Officer Turnesky, who supervised Nelson, testified that she never felt threatened by Nelson.[33] The lack of documented attempts of escape and violence from pregnant prisoners suggests that shackling for flight risk is a false pretense and perhaps merely based on stereotypes.[34] In 2011, an Amnesty International report noted that “Around the USA, it is common for restraints to be used on sick and pregnant incarcerated women when they are transported to and kept in hospital, regardless of whether they have a history of violence (which only a minority have) and regardless of whether they have ever absconded or attempted to escape (which few women have).”[35] In a 2020 survey of correctional officers in select midwestern prisons, 76 percent disagreed or strongly disagreed with restraining pregnant women during labor and delivery.[36] If a correctional officer shackles a pregnant prisoner, it is not because they pose a risk but because of a perception that they do. This mindset is attributed to select law enforcement, who have authority to use restraints.[37] In 2022, the Tennessee legislature passed a bill prohibiting the use of restraints on pregnant inmates. However, legislators amended the bill due to the Tennessee Sherriff Association’s belief that even pregnant inmates could pose a “threat.”[38] Subjecting all prisoners to the same “precautions” because a small percentage of individuals may pose such risks could reflect stereotyping or the assumption that all incarcerated people pose danger and flight risk. To quell the (unjustified) public safety concern, there are other options that do not cause physical or mental harm to pregnant women. For example, San Francisco General Hospital does not use shackles but has deputy sheriffs outside the pregnant women’s doors.[39] III. Historical Context and Race A. Slavery and Post-Civil War The treatment of female prisoners has striking similarities to that of enslaved women. Originally, shackling of female slaves was a mechanism of control and dehumanization.[40] This enabled physical and sexual abuses. During the process of intentionally dehumanizing slaves to facilitate subordination, slave owners stripped slave women of their feminine identity.[41] Slave women were unable to exhibit the Victorian model of “good mothering” and people thought they lacked maternal feelings for their children.[42] In turn, societal perception defeminized slave women, and barred them from utilizing the protections of womanhood and motherhood. During the post-Civil War era, black women were reversely depicted as sexually promiscuous and were arrested for prostitution more often than white women.[43] In turn, society excluded black women; they were seen as lacking what the “acceptable and good” women had.[44] Some argue that the historical act of labeling black women sexually deviant influences today’s perception of black women and may lead to labeling them bad mothers.[45] Over two-thirds of incarcerated women are women of color.[46] Many reports document sexual violence and misconduct against prisoners over the years.[47] Male guards have raped, sexually assaulted, and inappropriately touched female prisoners. Some attribute the physical abuse of black female prisoners to their being depicted or stereotyped as “aggressive, deviant, and domineering.”[48] Some expect black women to express stoicism and if they do not, people label them as dangerous, irresponsible, and aggressive.[49] The treatment of these prisoners mirrors the historical oppression endured by black women during and following the era of slavery. The act of shackling incarcerated pregnant women extends the inhumane treatment of these women from the prison setting into the hospital. One prisoner stated that during her thirty-hour labor, while being shackled, she “felt like a farm animal.”[50] Another pregnant prisoner describes her treatment by a guard stating: “a female guard grabbed me by the hair and was making me get up. She was screaming: ‘B***h, get up.’ Then she said, ‘That is what happens when you are a f***ing junkie. You shouldn’t be using drugs, or you wouldn’t be in here.”[51] Shackling goes beyond punishing by isolation from society – it is an additional punishment that is not justified. B. Reproductive Rights and “Bad Mothers” As with slaves not being seen as maternal, prisoners are not viewed as “real mothers.” A female prison guard said the following: “I’m a mother of two and I know what that impulse, that instinct, that mothering instinct feels like. It just takes over, you would never put your kids in harm’s way. . . . Women in here lack that. Something in their nature is not right, you know?”[52] This comment implies that incarcerated women lack maternal instinct. They are not in line with the standards of what society accepts as a “woman” and “mother” and are thought to have abandoned their roles as caretakers in pursuit of deviant behaviors. Without consideration of racial discrimination, poverty issues, trauma, and restricted access to the child right after delivery, these women are stereotyped as bad mothers simply because they are in prison. Reminiscent of the treatment of female black bodies post-civil war and the use of reproductive interventions (for example, Norplant and forced sterilization) in exchange for shorter sentences, I argue that shackles are a form of reproductive control. Justification for the use of shackles even includes their use as a “punitive instrument to remind the prisoner of their punishment.”[53] However, a prisoner’s pregnancy should have no relevance to their sentence.[54] Using shackles demonstrates to prisoners that society tolerates childbirth but does not support it.[55] The shackling is evidence that women are being punished “for bearing children, not for breaking the law.”[56] Physicians and healthcare workers, as a result, are responsible for providing care for the delivery and rectifying any physical problems associated with the restraints. The issues that arise from the use of restraints place physicians in a position more complex than they experience with regular healthy pregnancies. C. Discrimination In the case of Ferguson v. City of Charleston, a medical university subjected black woman to involuntary drug testing during pregnancy. In doing so, medical professionals collaborated with law enforcement to penalize black women for their use of drugs during pregnancy.[57] The Court held the drug tests were an unreasonable search and violated the Fourth Amendment. Ferguson v. City of Charleston further reveals an unjustified assumption: the medical and legal community seemed suspicious of black women and had perhaps predetermined them more likely to use drugs while pregnant. Their fitness to become mothers needed to be proven, while wealthy, white women were presumed fit.[58] The correctional community similarly denies pregnant prisoners’ medical attention. In the case of Staten v. Lackawanna County, an African American woman whose serious medical needs were treated indifferently by jail staff was forced to give birth in her cell.[59] This woman was punished for being pregnant in prison through the withholding of medical attention and empathy. IV. Failure to Follow Anti-Shackling Laws Despite 22 states having laws against shackling pregnant prisoners, officers do not always follow these laws. In 2015, the Correctional Association of New York reported that of the 27 women who gave birth under state custody, officers shackled 23 women in violation of the anti-shackling laws.[60] The lawyer of Tracy Edwards, an inmate who officers shackled unlawfully during her twelve-hour labor stated, “I don’t think we can assume that just because there’s a law passed, that’s automatically going to trickle down to the prison.”[61] Even with more restrictions on shackling, it may still occur, partly due to the stereotype that incarcerated women are aggressive and dangerous. V. Constitutionality The Eighth Amendment protects people from cruel and unusual punishment. In Brown vs. Plata, the court stated, “Prisoners retain the essence of human dignity inherent in all persons.”[62] In several cases, the legal community has held shackling to be unconstitutional as it violates the Eighth Amendment unless specifically justified. In the case of Nelson v. Correctional Medical Services, a pregnant woman was shackled for 12 hours of labor with a brief respite while she pushed, then re-shackled. The shackling caused her physical and emotional pain, including intense cramping that could not be relieved due to positioning and her inability to get up to use a toilet.[63] The court held that a clear security concern must justify shackling. The court cited a similar DC case and various precedents for using the Eighth Amendment to hold correctional facilities and hospitals accountable.[64] An Arkansas law similarly states that shackling must be justified by safety or risk of escape.[65] If the Thirteenth Amendment applied to those convicted of crimes, shackling pregnant incarcerated people would be unconstitutional under that amendment as well as the Eighth. In the Civil Rights Cases, Congress upheld the right “to enact all necessary and proper laws for the obliteration and prevention of slavery with all its badges and incidents.”[66] Section two of the Thirteenth Amendment condemns any trace or acts comparable to that of slavery. Shackling pregnant prisoners, stripping them of their dignity, and justification based on stereotypes all have origins in the treatment of black female slaves. Viewed through the lens of the Thirteenth Amendment, the act of shackling would be unconstitutional. Nonetheless, the Thirteenth Amendment explicitly excludes people convicted of a crime. VI. Justice As a result of the unconstitutional nature of shackling, physicians should have a legal obligation, in addition to their ethical duty, to protect their patients. The principle of justice requires physicians to take a stand against the discriminatory treatment of their patients, even under the eye of law enforcement.[67],[68] However, “badge and gun intimidation,” threats of noncompliance, and the fear of losing one’s license can impede a physician’s willingness to advocate for their patients. The American College of Obstetricians and Gynecologists (ACOG) finds the use of physical restraints interferes with the ability of clinicians to practice medicine safely.[69] ACOG, The American Medical Association, the National Commission on Correctional Health Care, and other organizations oppose using restraints on pregnant incarcerated people.[70] Yet, legislators can adopt shackling laws without consultation with physicians. The ACOG argues that “State legislators are taking it upon themselves to define complex medical concepts without reference to medical evidence. Some of the penalties [faced by OBGYNs] for violating these vague, unscientific laws include criminal sentences.”[71] Legislation that does not consider medical implications or discourages physicians’ input altogether is unjust. In nullifying the voice of a physician in matters pertaining to the patient’s treatment, physicians are prevented from fulfilling the principle of justice, making the act of shackling patients unethical. VII. Principle of Beneficence The principle of beneficence requires the prevention of harm, the removal of harm, and the promotion of good.[72] Beneficence demands the physician not only avoid harm but benefit patients and promote their welfare.[73] The American Board of Internal Medicine Foundation states that physicians must work with other professionals to increase patient safety and improve the quality of care.[74] In doing so, physicians can adequately treat patients with the goal of prevention and healing. It is difficult to do good when law enforcement imposes on doctors to work around shackles during labor and delivery. Law enforcement leaves physicians and healthcare workers responsible not only to provide care for the delivery, but also rectify any ailments associated with the restraints. The issues arising from using restraints place physicians in a position more complex than they experience with other pregnancies. Doctors cannot prevent the application of the shackles and can only request officers to take them off the patient.[75] Physicians who simply go along with shackling are arguably violating the principle of beneficence. However, for most, rather than violating the principle of beneficence overtly, physicians may simply have to compromise. Given the intricate nature of the situation, physicians are tasked with minimizing potential harm to the best of their abilities while adhering to legal obligations.[76] It is difficult to pin an ethics violation on the ones who do not like the shackles but are powerless to remove them. Some do argue that this inability causes physicians to violate the principle of beneficence.[77] However, promoting the well-being of their patients within the boundaries of the law limits their ability to exercise beneficence. For physicians to fulfill the principle of beneficence to the fullest capacity, they must have an influence on law. Protocols and assessments on flight risks made solely by the officers and law enforcement currently undermine the physician’s expertise. These decisions do not consider the health and well-being of the pregnant woman. As a result, law supersedes the influence of medicine and health care. CONCLUSION People expect physicians to uphold the four major principles of bioethics. However, their inability to override restraints compromises their ability to exercise beneficence. Although pledging to enforce these ethical principles, physicians have little opportunity to influence anti-shackling legislation. Instead of being included in conversations regarding medical complexities, legislation silences their voices. Policies must include the physician's voice as they affect their ability to treat patients. Officers should not dismiss a physician's request to remove shackles from a woman if they are causing health complications. A woman's labor should not harm her or her fetus because the officer will not remove her shackles.[78] A federal law could end shackling pregnant incarcerated people. Because other options are available to ensure the safety of the public and the prisoner, there is no ethical justification for shackling pregnant prisoners. An incarcerated person is a human being and must be treated with dignity and respect. To safeguard the well-being of incarcerated women and the public, it is essential for advocates of individual rights to join forces with medical professionals to establish an all-encompassing solution. - [1] Ferszt, G. G., Palmer, M., & McGrane, C. (2018). 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IntroductionThe Internet (especially in the so-called Web 2.0 phase), digital media and file-sharing networks have thrust copyright law under public scrutiny, provoking discourses questioning what is fair in the digital age. Accessible hardware and software has led to prosumerism – creativity blending media consumption with media production to create new works that are freely disseminated online via popular video-sharing Web sites such as YouTube or genre specific music sites like GYBO (“Get Your Bootleg On”) amongst many others. The term “prosumer” is older than the Web, and the conceptual convergence of producer and consumer roles is certainly not new, for “at electric speeds the consumer becomes producer as the public becomes participant role player” (McLuhan 4). Similarly, Toffler’s “Third Wave” challenges “old power relationships” and promises to “heal the historic breach between producer and consumer, giving rise to the ‘prosumer’ economics” (27). Prosumption blurs the traditionally separate consumer and producer creating a new creative era of mass customisation of artefacts culled from the (copyrighted) media landscape (Tapscott 62-3). Simultaneously, corporate interests dependent upon the protections provided by copyright law lobby for augmented rights and actively defend their intellectual property through law suits, takedown notices and technological reinforcement. Despite a lack demonstrable economic harm in many cases, the propertarian approach is winning and frequently leading to absurd results (Collins).The balance between private and public interests in creative works is facilitated by the doctrine of fair use (as codified in the United States Copyright Act 1976, section 107). The majority of copyright laws contain “fair” exceptions to claims of infringement, but fair use is characterised by a flexible, open-ended approach that allows the law to flex with the times. Until recently the defence was unique to the U.S., but on 2 January Israel amended its copyright laws to include a fair use defence. (For an overview of the new Israeli fair use exception, see Efroni.) Despite its flexibility, fair use has been systematically eroded by ever encroaching copyrights. This paper argues that copyright enforcement has spun out of control and the raison d’être of the law has shifted from being “an engine of free expression” (Harper & Row, Publishers, Inc. v. Nation Enterprises 471 U.S. 539, 558 (1985)) towards a “legal regime for intellectual property that increasingly looks like the law of real property, or more properly an idealized construct of that law, one in which courts seeks out and punish virtually any use of an intellectual property right by another” (Lemley 1032). Although the copyright landscape appears bleak, two recent cases suggest that fair use has not fallen by the wayside and may well recover. This paper situates fair use as an essential legal and cultural mechanism for optimising creative expression.A Brief History of CopyrightThe law of copyright extends back to eighteenth century England when the Statute of Anne (1710) was enacted. Whilst the length of this paper precludes an in depth analysis of the law and its export to the U.S., it is important to stress the goals of copyright. “Copyright in the American tradition was not meant to be a “property right” as the public generally understands property. It was originally a narrow federal policy that granted a limited trade monopoly in exchange for universal use and access” (Vaidhyanathan 11). Copyright was designed as a right limited in scope and duration to ensure that culturally important creative works were not the victims of monopolies and were free (as later mandated in the U.S. Constitution) “to promote the progress.” During the 18th century English copyright discourse Lord Camden warned against propertarian approaches lest “all our learning will be locked up in the hands of the Tonsons and the Lintons of the age, who will set what price upon it their avarice chooses to demand, till the public become as much their slaves, as their own hackney compilers are” (Donaldson v. Becket 17 Cobbett Parliamentary History, col. 1000). Camden’s sentiments found favour in subsequent years with members of the North American judiciary reiterating that copyright was a limited right in the interests of society—the law’s primary beneficiary (see for example, Wheaton v. Peters 33 US 591 [1834]; Fox Film Corporation v. Doyal 286 US 123 [1932]; US v. Paramount Pictures 334 US 131 [1948]; Mazer v. Stein 347 US 201, 219 [1954]; Twentieth Century Music Corp. v. Aitken 422 U.S. 151 [1975]; Aronson v. Quick Point Pencil Co. 440 US 257 [1979]; Dowling v. United States 473 US 207 [1985]; Harper & Row, Publishers, Inc. v. Nation Enterprises 471 U.S. 539 [1985]; Luther R. Campbell a.k.a. Luke Skyywalker, et al. v. Acuff-Rose Music, Inc. 510 U.S 569 [1994]). Putting the “Fair” in Fair UseIn Folsom v. Marsh 9 F. Cas. 342 (C.C.D. Mass. 1841) (No. 4,901) Justice Storey formulated the modern shape of fair use from a wealth of case law extending back to 1740 and across the Atlantic. Over the course of one hundred years the English judiciary developed a relatively cohesive set of principles governing the use of a first author’s work by a subsequent author without consent. Storey’s synthesis of these principles proved so comprehensive that later English courts would look to his decision for guidance (Scott v. Stanford L.R. 3 Eq. 718, 722 (1867)). Patry explains fair use as integral to the social utility of copyright to “encourage. . . learned men to compose and write useful books” by allowing a second author to use, under certain circumstances, a portion of a prior author’s work, where the second author would himself produce a work promoting the goals of copyright (Patry 4-5).Fair use is a safety valve on copyright law to prevent oppressive monopolies, but some scholars suggest that fair use is less a defence and more a right that subordinates copyrights. Lange and Lange Anderson argue that the doctrine is not fundamentally about copyright or a system of property, but is rather concerned with the recognition of the public domain and its preservation from the ever encroaching advances of copyright (2001). Fair use should not be understood as subordinate to the exclusive rights of copyright owners. Rather, as Lange and Lange Anderson claim, the doctrine should stand in the superior position: the complete spectrum of ownership through copyright can only be determined pursuant to a consideration of what is required by fair use (Lange and Lange Anderson 19). The language of section 107 suggests that fair use is not subordinate to the bundle of rights enjoyed by copyright ownership: “Notwithstanding the provisions of sections 106 and 106A, the fair use of a copyrighted work . . . is not an infringement of copyright” (Copyright Act 1976, s.107). Fair use is not merely about the marketplace for copyright works; it is concerned with what Weinreb refers to as “a community’s established practices and understandings” (1151-2). This argument boldly suggests that judicial application of fair use has consistently erred through subordinating the doctrine to copyright and considering simply the effect of the appropriation on the market place for the original work.The emphasis on economic factors has led courts to sympathise with copyright owners leading to a propertarian or Blackstonian approach to copyright (Collins; Travis) propagating the myth that any use of copyrighted materials must be licensed. Law and media reports alike are potted with examples. For example, in Bridgeport Music, Inc., et al v. Dimension Films et al 383 F. 3d 400 (6th Cir. 2004) a Sixth Circuit Court of Appeals held that the transformative use of a three-note guitar sample infringed copyrights and that musicians must obtain licence from copyright owners for every appropriated audio fragment regardless of duration or recognisability. Similarly, in 2006 Christopher Knight self-produced a one-minute television advertisement to support his campaign to be elected to the board of education for Rockingham County, North Carolina. As a fan of Star Wars, Knight used a makeshift Death Star and lightsaber in his clip, capitalising on the imagery of the Jedi Knight opposing the oppressive regime of the Empire to protect the people. According to an interview in The Register the advertisement was well received by local audiences prompting Knight to upload it to his YouTube channel. Several months later, Knight’s clip appeared on Web Junk 2.0, a cable show broadcast by VH1, a channel owned by media conglomerate Viacom. Although his permission was not sought, Knight was pleased with the exposure, after all “how often does a local school board ad wind up on VH1?” (Metz). Uploading the segment of Web Junk 2.0 featuring the advertisement to YouTube, however, led Viacom to quickly issue a take-down notice citing copyright infringement. Knight expressed his confusion at the apparent unfairness of the situation: “Viacom says that I can’t use my clip showing my commercial, claiming copy infringement? As we say in the South, that’s ass-backwards” (Metz).The current state of copyright law is, as Patry says, “depressing”:We are well past the healthy dose stage and into the serious illness stage ... things are getting worse, not better. Copyright law has abandoned its reason for being: to encourage learning and the creation of new works. Instead, its principal functions now are to preserve existing failed business models, to suppress new business models and technologies, and to obtain, if possible, enormous windfall profits from activity that not only causes no harm, but which is beneficial to copyright owners. Like Humpty-Dumpty, the copyright law we used to know can never be put back together.The erosion of fair use by encroaching private interests represented by copyrights has led to strong critiques leveled at the judiciary and legislators by Lessig, McLeod and Vaidhyanathan. “Free culture” proponents warn that an overly strict copyright regime unbalanced by an equally prevalent fair use doctrine is dangerous to creativity, innovation, culture and democracy. After all, “few, if any, things ... are strictly original throughout. Every book in literature, science and art, borrows, and must necessarily borrow, and use much which was well known and used before. No man creates a new language for himself, at least if he be a wise man, in writing a book. He contents himself with the use of language already known and used and understood by others” (Emerson v. Davis, 8 F. Cas. 615, 619 (No. 4,436) (CCD Mass. 1845), qted in Campbell v. Acuff-Rose, 62 U.S.L.W. at 4171 (1994)). The rise of the Web 2.0 phase with its emphasis on end-user created content has led to an unrelenting wave of creativity, and much of it incorporates or “mashes up” copyright material. As Negativland observes, free appropriation is “inevitable when a population bombarded with electronic media meets the hardware [and software] that encourages them to capture it” and creatively express themselves through appropriated media forms (251). The current state of copyright and fair use is bleak, but not beyond recovery. Two recent cases suggest a resurgence of the ideology underpinning the doctrine of fair use and the role played by copyright.Let’s Go CrazyIn “Let’s Go Crazy #1” on YouTube, Holden Lenz (then eighteen months old) is caught bopping to a barely recognizable recording of Prince’s “Let’s Go Crazy” in his mother’s Pennsylvanian kitchen. The twenty-nine second long video was viewed a mere twenty-eight times by family and friends before Stephanie Lenz received an email from YouTube informing her of its compliance with a Digital Millennium Copyright Act (DMCA) take-down notice issued by Universal, copyright owners of Prince’s recording (McDonald). Lenz has since filed a counterclaim against Universal and YouTube has reinstated the video. Ironically, the media exposure surrounding Lenz’s situation has led to the video being viewed 633,560 times at the time of writing. Comments associated with the video indicate a less than reverential opinion of Prince and Universal and support the fairness of using the song. On 8 Aug. 2008 a Californian District Court denied Universal’s motion to dismiss Lenz’s counterclaim. The question at the centre of the court judgment was whether copyright owners should consider “the fair use doctrine in formulating a good faith belief that use of the material in the manner complained of is not authorized by the copyright owner, its agent, or the law.” The court ultimately found in favour of Lenz and also reaffirmed the position of fair use in relation to copyright. Universal rested its argument on two key points. First, that copyright owners cannot be expected to consider fair use prior to issuing takedown notices because fair use is a defence, invoked after the act rather than a use authorized by the copyright owner or the law. Second, because the DMCA does not mention fair use, then there should be no requirement to consider it, or at the very least, it should not be considered until it is raised in legal defence.In rejecting both arguments the court accepted Lenz’s argument that fair use is an authorised use of copyrighted materials because the doctrine of fair use is embedded into the Copyright Act 1976. The court substantiated the point by emphasising the language of section 107. Although fair use is absent from the DMCA, the court reiterated that it is part of the Copyright Act and that “notwithstanding the provisions of sections 106 and 106A” a fair use “is not an infringement of copyright” (s.107, Copyright Act 1976). Overzealous rights holders frequently abuse the DMCA as a means to quash all use of copyrighted materials without considering fair use. This decision reaffirms that fair use “should not be considered a bizarre, occasionally tolerated departure from the grand conception of the copyright design” but something that it is integral to the constitution of copyright law and essential in ensuring that copyright’s goals can be fulfilled (Leval 1100). Unlicensed musical sampling has never fared well in the courtroom. Three decades of rejection and admonishment by judges culminated in Bridgeport Music, Inc., et al v. Dimension Films et al 383 F. 3d 400 (6th Cir. 2004): “Get a license or do not sample. We do not see this stifling creativity in any significant way” was the ruling on an action brought against an unlicensed use of a three-note guitar sample under section 114, an audio piracy provision. The Bridgeport decision sounded a death knell for unlicensed sampling, ensuring that only artists with sufficient capital to pay the piper could legitimately be creative with the wealth of recorded music available. The cost of licensing samples can often outweigh the creative merit of the act itself as discussed by McLeod (86) and Beaujon (25). In August 2008 the Supreme Court of New York heard EMI v. Premise Media in which EMI sought an injunction against an unlicensed fifteen second excerpt of John Lennon’s “Imagine” featured in Expelled: No Intelligence Allowed, a controversial documentary canvassing alleged chilling of intelligent design proponents in academic circles. (The family of John Lennon and EMI had previously failed to persuade a Manhattan federal court in a similar action.) The court upheld Premise Media’s arguments for fair use and rejected the Bridgeport approach on which EMI had rested its entire complaint. Justice Lowe criticised the Bridgeport court for its failure to examine the legislative intent of section 114 suggesting that courts should look to the black letter of the law rather than blindly accept propertarian arguments. This decision is of particular importance because it establishes that fair use applies to unlicensed use of sound recordings and re-establishes de minimis use.ConclusionThis paper was partly inspired by the final entry on eminent copyright scholar William Patry’s personal copyright law blog (1 Aug. 2008). A copyright lawyer for over 25 years, Patry articulated his belief that copyright law has swung too far away from its initial objectives and that balance could never be restored. The two cases presented in this paper demonstrate that fair use – and therefore balance – can be recovered in copyright. The federal Supreme Court and lower courts have stressed that copyright was intended to promote creativity and have upheld the fair doctrine, but in order for the balance to exist in copyright law, cases must come before the courts; copyright myth must be challenged. As McLeod states, “the real-world problems occur when institutions that actually have the resources to defend themselves against unwarranted or frivolous lawsuits choose to take the safe route, thus eroding fair use”(146-7). ReferencesBeaujon, Andrew. “It’s Not the Beat, It’s the Mocean.” CMJ New Music Monthly. April 1999.Collins, Steve. “Good Copy, Bad Copy: Covers, Sampling and Copyright.” M/C Journal 8.3 (2005). 26 Aug. 2008 ‹http://journal.media-culture.org.au/0507/02-collins.php›.———. “‘Property Talk’ and the Revival of Blackstonian Copyright.” M/C Journal 9.4 (2006). 26 Aug. 2008 ‹http://journal.media-culture.org.au/0609/5-collins.php›.Donaldson v. Becket 17 Cobbett Parliamentary History, col. 953.Efroni, Zohar. “Israel’s Fair Use.” The Center for Internet and Society (2008). 26 Aug. 2008 ‹http://cyberlaw.stanford.edu/node/5670›.Lange, David, and Jennifer Lange Anderson. “Copyright, Fair Use and Transformative Critical Appropriation.” Conference on the Public Domain, Duke Law School. 2001. 26 Aug. 2008 ‹http://www.law.duke.edu/pd/papers/langeand.pdf›.Lemley, Mark. “Property, Intellectual Property, and Free Riding.” Texas Law Review 83 (2005): 1031.Lessig, Lawrence. The Future of Ideas. New York: Random House, 2001.———. Free Culture. 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Introduction This paper explores some specific conjunctions that tie together two nations, Japan and the Philippines. Over the past 30 years both have become entwined as a transfer of people, cultures and societies have connected and formed some interesting developments. Relations between both countries have been highly influenced through the deployment of State intervention (historically colonial and post-colonial), as well as through actors’ initiatives, leading to the development of a complex network that links both countries. It is in these relations that I would like to locate a transition between two stages in Japan-Philippine relations. I argue, this is a transition, where marriages of one kind (international marriages), the bonding of social actors from two distinct cultural spheres, gives way to another form of marriage. This transition locates the term marriage as part of an ongoing process and a discursive realm in a larger ‘affective complex’ that has developed. In this paper, I focus on this term ‘affective complex’ as it offers some interesting avenues in order to understand the continuing development of relations between Japan and the Philippines. By ‘affective complex’ I refer to the ‘cultural responses’ that people use in reaction to situations in which they find themselves which are not mediated by language. I suggest that this complex is a product of a specific encounter that exists between two nations as understood and mediated by Japanese actors’ positionings vis-à-vis foreign resident Filipinos. In tracing a moment between Japan and the Philippines, I delineate emerging properties that currently allude to a transition in relations between both countries. I would like to show that the properties of this transition are creating an emergent phenomena, a complex? This is developing through interactions between human actors whose trajectories as transnational migrants and permanent foreign residents are coming under the scrutiny of Japanese State forces in a heavily contested discursive field. This paper focuses upon the nature of the complex that entwines both countries and examines Japan’s particular restructuring of parts of its workforce in an attempt to include foreign migrants. To do this I first offer an outline of my fieldwork and then delineate the complex that ties both countries within present theoretical boundaries. This paper is based on fieldwork which deals with the theme of International Marriages between Japanese and Filipino couples. In the field I have observed the different ways in which Filipinos or Japanese with a connection to the Philippines orientate themselves within Japanese society vis-à-vis the Philippines. For the purpose of this paper, I will focus exclusively on a particular moment in my field: a care-giver course run privately with approval and recognition from local government. This course was offered exclusively for Filipino nationals with permanent residency and a high level of Japanese. As part of a larger field, a number of overlapping themes and patterns were present within the attitudes of those participating in the course. These were cultural responses that social actors carry with them which constitute part of an ‘affective complex’, its gradual emergence and unfolding. To further locate this fieldwork and its theoretical boundaries, I also position this research within current understandings of complexity. Chesters and Welsh have referred to a complex system as being a non-linear, non-deterministic system. However, from my perspective, these parameters are insufficient if institutions, organisations and human actors exhibit linear and deterministic properties (properties that discursively capture, locate and define elements in a system). In my research, I am dealing with actors, in this case Filipinos who are seen first as recipients and then as providers of welfare services. Japanese actors act as suppliers of a service both to long-term residents and to the State. In this case the following question arises: whose ‘complexes’ may be defined by a mixture of both these parameters and how can it be possible to take into account relationships whose existence cuts across them? Could a complex not be any number of these terrains which have emerged through encounters between two countries? Marriage could be a starting point for complexes that can come under scrutiny at a higher level, that of the State forces. In addition, a study of complexity in the Social Sciences focuses on how structures form rather than by focusing on any prior structured existence. Any focus on a complex system is to analyze holistic multiple elements in order to descriptively locate structures, what they penetrate, and what they are penetrated by. Human actors’ actions, strategies and expectations merge under the influence of these structures, while simultaneously influencing them. As elements interact, emergent phenomena (properties that emerge at a higher level) show a system that is process dependent, organic, and always evolving (Arthur 109). Locating Affect Deleuze and Guattari refined the discursive realm to emphasise how spaces of creation, dialogue and the casting of influence are affective, institutional and State-influenced. Within these spaces I locate the existence of ‘affective complexes’ which are discursively constructed and deployed by local actors. I will to argue that international marriages have laid a groundwork in which ‘affect’ itself has become a catalyst, re-orientating perceptions of and toward Filipinos. Following Deleuze, we can understand ‘affect’ as an intensity which, to repeat, is an expression of human relationships not mediated directly through language (Rodriguez). However, I want to suggest ‘affect’ also comes under the scrutiny of, and is discursively appealed to by, State forces as ‘affective capital’. When I refer to ‘affective capital’ I mean the potential labour discursively constructed. This construction is then “projected and tapped” in response to the changing nature of Japan’s labour market – in particular, the shortage of care-givers. This construction itself exists as an ongoing management strategy that deals with certain foreign nationals in Japan. Here, in response to the transformations of service work, ‘affective capital’ is the commoditised value of care inherent the discourse. It is the kernel of ‘affective labour’. This was very clear in my fieldwork, wherein Filipinos were targeted exclusively as the recipients of training in the health-care sector based on an understanding of the form of ‘affect’ that they possess. In this context, ‘affect’ adds intensity to meaning and is used in a wide range of cultural contexts, yet its very essence eludes description, especially when that essence as used by ‘active agents’ may be misconstrued in its deployment or discursively captured. Returning to the Deleuzian interpretation of ‘affect’, it could be interpreted as the outcome of encounters between actors and as such, a ‘mode’ in which becoming can initiate possibilities. I refer to ‘affect’, the deployment of shared, performed, communicated non-verbal ‘content’, as a powerful tool and an essential component in everyday habituated practice. In other areas of my field (not included in this discussion), ‘affect’ deployed by both actors, husband and wife, within and beyond the family, manifests itself as a mode of being. This at times adds to the location of actors’ intentions, be they spoken or performative. In this sense, locating the ‘affect’ in my research has meant observing the way in which Filipinos negotiate the availability of life strategies and opportunities available to them. At the same time, ‘affect’ is also produced by Japanese actors realigning themselves vis-à-vis both foreign actors and social change, as well as by effectuating strategies to emergent situations in Japan such as care management. ‘Affective capital’ is an inherent long-term strategy which has its roots in the cultural resources at the disposal of non-Japanese partners who, over the years, in the short and long term put to use discursively produced ‘affect’. ‘Affect’, produced in reactions to situations, encounters and events, can work in favour of long-term residents who do not have access to the same conditions Japanese may find in the labour sector. From encounters in my fieldwork, the location of ‘affect’ is an asset not just within immediate relationships, but as a possible expression of strategies that have arisen in response to the recognition of reactionary elements in Japanese society. By reactionary elements I refer to the way in which a complex may realign itself when ‘interfered’ with at another level, that of the State. The Japanese State is facing labour shortages in certain sectors due to social change, therefore they must secure other potential sources of labour. Appropriation of human resources locally available has become one Japanese State solution for this labour shortage. As such, ‘affect’ is brought into the capitalist fold in response to labor shortages in the Health Sector. Background The Philippines is a prime example of a nomad nation, where an estimated eight million of the population currently work or live overseas while remitting home (Phillippines Overseas Employment Agency). Post-colonial global conditions in the Asia Pacific region have seen the Philippines cater to external national situations in order to participate in the global labour market. These have been in the form of flows of labour and capital outsourced to those economies which are entangled with the Philippines. In this context, marriage between both countries has come to be made up almost exclusively of Japanese men with Filipina women (Suzuki). These marriages have created nascent partnerships that have formed links within homes in both countries and supported the creation of a complex system tying together both nations. Yet, in the entanglement of what seems to be two economies of desire, some interesting observations can be drawn from what I consider to be the by-products of these marriages. Yet what does this have to do with a marriage? First, I would like to put forward that certain international marriages may have developed within the above discursive framework and, in the case of the Philippines and Japan, defined certain characteristics that I will explain in more detail. Over the past 20 years, Filipinos who came to Japan on entertainment visas or through encounters with Japanese partners in the Philippines have deployed discursively constructed ‘affective capital’ in strategies to secure relationships and a position in both societies. These strategies may be interpreted as being knowledgeable, creative and possessive of the language necessary for negotiating long-term dialogues, not only with partners and surrounding family, but also with Japanese society. These deployments also function as an attempt to secure additional long term benefits which include strengthening ties to the Philippines through increasing a Japanese spouse’s involvement and interest in the Philippines. It is here that Filipinos’ ‘affect’ may be traced back to a previous deployment of categories that influences local Japanese actors’ decisions in offering a course exclusively for Filipino residents. This offers the first hint as to why only Filipinos were targeted. In Japan, secure permanent work for resident Filipinos can be, at times, difficult even when married to a partner with a stable income. The reality of remitting home to support family members and raising a family in Japan is a double burden which cannot be met solely by the spouse’s salary. This is an issue which means actors (in this case, partners) recourse to their ‘affective capital’ in order to secure means towards a livelihood. In this context, marriages have acted as a primary medium entangling both countries. Yet changes in Japan are re-locating ‘possible’ resources that are rationalised as a surplus from these primary encounters. Shifts in Japan’s social landscape have over the past 10 years led to an increasing awareness of the high stakes involved in care for the ageing and invalid in Japanese society. With over 21% of the population now over 65, the care industry has seen a surge in demand for labour, of which there is currently a shortfall (Statistics Bureau Japan). With the Philippines having strategically relocated its economy to accommodate demands for the outsourcing of health care workers and nurses overseas, Japan, realigning its economy to domestic change, has shown a new type of interest (albeit reluctant) in the Philippines. In 2005, changes and reforms to Japan’s Immigration Control and Refugee Recognition Act successfully curtailed the flow of Filipinos applying to Japan to work as entertainers. This was in part due to pressure from the interventionary power of the U.S: in 2006 the U.S. State department published the Trafficking in Persons Report, which stipulated that Japan had yet to comply in improving the situation of persons trafficked to Japan (U.S. State Department). This watershed reform has become a precursor to the Philippines Economic Partnership Agreement ratified by Japan and the Philippines to promote the ‘trans-border flow of goods, person, services and capital between Japan and the Philippines (Ministry of Foreign Affairs) and has now temporarily realigned both economies into a new relationship. Under the terms ‘movement of natural persons’, Filipino candidates for qualified nurses and certified care workers would be allowed a stay of up to three years as nurses, or four for certified care workers (Ministry of Foreign Affairs). Nonetheless, this lip service in showing openness to admit a new category of Filipino is the continuation of a mode of ‘servicing’ within the Japanese nation, albeit under the guise of ‘care work’, and rests upon the capitalist rationalisation of hired workers for Japan’s tertiary sectors. The Philippines, a nation which is positively export-orientated in terms of its human resources in response to care inequalities that exist between nations at a global level (Parreñas 12-30), is now responding to the problematic issue of care that has become a serious concern in Japan. Fieldwork To place these issues in context I want to locate the above issues within a part of my present fieldwork. In 2006, I participated in a privately funded non-profit venture set up for Filipino residents with the aim of training them to be care-givers. The course was validated and acknowledged by the local prefectural government and primarily limited to a group of 20 participants who paid approximately sixty thousand yen ($485) for the three month course including training and text books. One Filipina acquaintance enthusiastically introduced me to the retired bank manager who had set up a fund for the three month care-giver course for Filipina residents. Through interviews with the course providers, one underlying theme in the planning of the course was clear: the core idea that Filipinos have a predisposition to care for the elderly, reflecting Filipino social values no longer existent in Japan. In particular, two Japanese words employed to reflect these views – ‘omoiyari’ (思いやり), meaning “compassion” or “considerateness” and ‘yasashisa’ (優しさ) meaning “kindness toward others” – were reiterated throughout the course as a requisite for dealing with the elderly or those in need of care. One core presupposition underlining the course was that the Philippines still cherishes values which are on the decline in Japan, offering a care ethos based on Christian values ready for deployment in such work. I believe this marks a transition point in how both countries’ relations are moving away from ‘entertainment-based’ care to ‘care within an institutional setting’, such as private nursing homes or hospitals. In both cases, ‘care’ (as it is ironically known in both industries, the deployment of hospitality and attendance), operates as a dynamic of desire within a social field which orientates how residents (i.e. foreign female residents with permanent residency) are used. Yet, why would the Philippines be such an attractor? It is not difficult to see how ‘affect’ is discursively rationalised and deployed and projected onto Philippine society. This ‘affect’ acts as an attractor and belongs to an ‘imagined’ cultural repertoire that Japan has created in response to its turbulent marriage to the Philippines. In this sense, the care course promoted this ‘caring affective side’ of Filipinas here in Japan, and provided a dynamic engagement for potential negotiation, persuasion and tension between ‘local actors’ (course providers and participants) who come under the direct remit of the Japanese State (care institutions, hospitals and nursing homes). I say “tension”, as to date only a handful (three women out of a total of sixty) of those who participated in the course have taken up employment in the care industry. As one participant, a divorcee, commented, the reluctance to seek work as a qualified care worker resided in an economic framework, she says: this is a useful investment, but I don’t know if I can do this work full time to live off and support my families…but it is another arrow in my bow if the situation changes. Yet, for another woman, care work was an extension of something that they were familiar with. She jokingly added with a sigh of resignation: Oh well, this is something we are used to, after all we did nothing but care for our papa-san (husband)! When I discussed these comments with an N.G.O. worker connected to the course she pessimistically summed up what she thought by saying: The problem of care in Japan was until very recently an issue of unpaid work that women have had to bear. In a sense, looking after the aged living at home has been a traditional way to treat people with respect. Yet, here in Japan we have experienced an excessively long period whereby it was de facto that when a woman married into someone’s family, she would care for the husband and his family. Now, this isn’t an individual problem anymore, it’s a societal one. Care is now becoming an institutional practice which is increasing paid work, yet the State works on the assumption that this is low paid work for people who have finished raising their children; hard labour for low wages. All the women have graduated and are licensed to work, yet at 1000 yen (U.S. $8) an hour for psychologically demanding hard labour they will not work, or start and finish realising the demands. Travelling between locations also is also unpaid, so at the most in one day they will work 2-3 hours. It is the worst situation possible for those who choose to work. The above opinion highlights the ambiguities that exist in the constant re-alignment of offering work to foreign residents in the effort to help integrate people into Japan’s tertiary ‘care sector’ in response to the crisis of a lack of manpower. To date most women who trained on this course have not pursued positions within the health sector. This indicates a resistance to the social beliefs that continue to categorise female foreign residents for gendered care work. Through three successive batches of students (sixty women in total) the president, staff and companies who participated in this pilot scheme have been introduced to Filipino residents in Japanese society. In one respect, this has been an opportunity for the course providers to face those who have worked, or continue to work at night. Yet, even this exposure does not reduce the hyper-feminisation of care; rather, it emphasises positions. One male coordinator brazenly mentioned the phrase ashi wo aratte hoshii, meaning ‘we want to give them a clean break’. This expression is pregnant with the connotation that these women have been involved in night work have done or still participate in. These categorisations still do not shake themselves free from previous classifications of female others located in Japanese society; the ongoing legacy that locates Filipinos in a feminised discursive space. As Butler has elucidated, ‘cultural inscriptions’ and ‘political forces with strategic interests’ work to keep the ‘body bounded and constituted’ (Butler 175). It is possible to see that this care course resides within a continuously produced genealogy that tries to constitute bodies. This resides under the rubric of a dominant fantasy that locates the Philippines in Japan as a source of caring and hospitality. Now, those here are relocated under a restructuring industry outsourcing work to those located in the lower tiers of the labour sector. Why other nationals have not been allowed to participate in the course is, I stress, a testimony to this powerful discourse. Major national and international media coverage of both the course and company and those women who found employment has also raised interest in the curious complex that has arisen from this dynamic, including a series of specials aired on Japanese television by NHK (NHK Kaigo no Jinzai ga Nigete iku). This is very reminiscent of a ‘citationary’ network where writings, news items and articles enter into a perpetuating relationship that foments and bolsters the building up of a body of work (Said) to portray Japan’s changing circumstances. As seen from a traced genealogy, initial entanglements between two nations, in conjunction with societal change in Japan, have created a specific moment in both countries’ trajectories. Here, we can see an emergent phenomena and the relocation of a discursive structure. An affective complex can be located that marks a shift in how foreign residents are perceived and on what terms they can participate or contribute to Japanese society. Within this structure, ‘care’ is relocated – or, rather, trapped – and extracted as labour surplus that resides in an antagonistic relationship of domination highlighting how a specific moment existing between two countries can be ‘structured’ by needs in the ‘engaging’ country, in this case Japan. Non-linear elements in a complex system that contest how discursive practices in Japanese society locate foreign residents, within the rubric of an ‘imagined’ ethos of compassion and kindness that emanates from outside of Japan, seem to display ‘affective’ qualities. Yet, are these not projected categories deployed to continue to locate migrant labour (be they permanent or temporary residents) within an ongoing matrix that defines what resources can be discursively produced? However, these categories do not take into account the diverse structures of experience that both Japanese nationals and Filipino nationals experience in Japan (Suzuki). Conclusion In this paper I have briefly delineated a moment which rests between specific trajectories that tie two nations. A complex of marriages brought about within a specific historic post-colonial encounter has contributed to feminising the Philippines: firstly, for women in marriages, and now secondly for ‘potential resources’ available to tackle societal problems in Japan. As I have argued a discursively produced ‘affective complex’ is an authorising source of otherness and could be part of a precursor complex which is now discursively relocating human resources within one country (Japan) as a ‘reluctant source’ of labour, while entering into a new discursive mode of production that shapes attitudes toward others. I also suggest that there is a very specific complex at work here which follows an as of yet faint trajectory that points to the re-organisation of a relationship between Japan and the Philippines. Yet, there are linear elements (macro-level forces rooted in the Japanese State’s approach to care vis-à-vis the Philippines) operating at the fundamental core of this care-giver course that are being constantly challenged and cut across by non-linear elements, that is, human actors and their ambivalence as the beneficiaries/practitioners of such practices. This is the continued feminisation of a highly gendered dynamic that locates labour as and when it sees fit, but through the willing coercion of local agents, with an interest in mediating services through and for the State, for the welfare of the Nation. The desiring-machine that brings together Japan and the Philippines is also one that continues to locate the potential in foreign actors located within Japan’s institutional interpellation for its care market. Within these newly emergent relationships, available political and social capital is being reshaped and imagined in reaction to social change in Japan. By exploring two entangled nations situated within global capitalist production in the twenty-first century, my research points towards new ways of looking at emerged complexes (international marriages) that precludes the reconfigurations of ongoing emerging complexes that discursively locate residents as caregivers, who fall under the jurisdiction and glare of political powers, government subjects and State forces. References Artur, W. Brian. “Complexity and the Economy.” Science 284.2 (1999): 107-109. Butler, Judith. Gender Trouble: Feminism and the Subversion of Identity. New York: Routledge, 2006. Chester, Graeme, and Ian Welsh. “Complexity and Social Movement(s): Process and Emergence in Planetary Action Systems.” Theory, Culture & Society 22.5 (2005): 187-211. Deleuze, Giles, and Felix Guattari. A Thousand Plateaus: Capitalism and Schizophrenia. Minnesota: U of Minnesota P, 1987. Ministry of Foreign Affairs (Japan). 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Ministry of Internal Affairs and Communications (Philippines). 2005. 2 May 2007 http://www.poea.gov.ph/docs/STOCK%20ESTIMATE%202004.xls>. Suzuki, Nobue. “Inside the Home: Power and Negotiation in Filipina-Japanese Marriages.” Women’s Studies: An Interdisciplinary Journal 33.4 (2004): 481-506. “Trafficking in Persons Report.” U.S. State Department. 2006. 29 Apr. 2007. http://www.state.gov/documents/organization/66086.pdf>. Citation reference for this article MLA Style Lopez, Mario. "From Bride to Care Worker?: On Complexes, Japan and the Philippines." M/C Journal 10.3 (2007). echo date('d M. Y'); ?> <http://journal.media-culture.org.au/0706/04-lopez.php>. APA Style Lopez, M. (Jun. 2007) "From Bride to Care Worker?: On Complexes, Japan and the Philippines," M/C Journal, 10(3). Retrieved echo date('d M. Y'); ?> from <http://journal.media-culture.org.au/0706/04-lopez.php>.