Journal articles on the topic 'White Mountains (N. H. et Me.)'

On September 25, 2010, a wood sample was collected from an entirely decayed root ball of an alpine larch (Larix lyallii Parl.), 10 cm in diameter at breast height, recently downed, but still green. No attempts were made to determine whether the decay progressed into the stem. The discovery occurred in a stand in the Bitterroot Mountains, south of Darby, Montana (elev. 2,530 m; 45.893528° N, 114.278322° W). Several adjacent alpine larches were either dead or displayed thin crowns, and an old Heterobasidion basidiocarp was found on the decayed root ball of a neighboring dead tree, suggesting the presence of a root disease pocket. The stand is mature and composed of alpine larch, whitebark pine (Pinus albicaulis Engelm.), and a few subalpine firs (Abies lasiocarpa (Hooker) Nuttall), but only larches were symptomatic. No stumps were visible, and the site is in a designated wilderness area characterized by minimal forest management. Wood chips displaying a white rot with bleached speckles were plated on 2% malt agar, and cultures displaying the typical Heterobasidion anamorph (Spiniger meineckellus) were visible after 7 days. DNA was extracted from two distinct cultures, and the sequences of three nuclear loci, namely the internal transcribed spacer, the elongation factor 1-alpha, and the glyceraldehyde 3-phosphate dehydrogenase, were analyzed. The sequence of the mitochondrial ATPase was also sequenced. All loci were amplified using the primers indicated in Linzer et al. (2). Sequences of all three nuclear loci (GenBank Accession Nos. KF811480 to 82) unequivocally indicated both isolates to be first generation hybrids between H. irregulare (Underw.) Garbel. & Otrosina and H. occidentale Otrosina & Garbel. Cumulatively, sequences were heterozygous at over 40 positions in all three loci, and for the presence of two indels (one in ITS, one in EF 1-alpha). Polymorphisms and indels indicated alleles from both species were present in these heterokaryotic (ploidy n+n) isolates. The mitochondrial ATPase (KF811483 to 84) indicated instead the cytoplasm belonged to H. occidentale, suggesting that species was the first to be established in the infected tree and was either dikaryotized by a basidiopsore of the other species, or subject to nuclear re-assortment through di-mon mating with a genotype of H. irregulare. This is the first report of a Heterobasidion sp. in L. lyalli, and it is the second report of a natural Heterobasidion hybrid in North America (1). This finding indicates Alpine larch may be a host for both Heterobasidion species, as described for pine stumps in California (1). Thus, this conifer may have provided a substrate for the hybridization and interspecific gene introgression documented to have occurred before stumps were generated in high frequency by modern forestry practices (2). References: (1) M. Garbelotto et al. Phytopathology 86:543, 1996. (2) R. Linzer et al. Mol. Phylogenet. Evol. 46:844, 2008.

Lebanon cedar (Cedrus libani A. Rich) is an ecologically, economically, and historically important conifer species that currently mainly occurs in the Taurus Mountains in southern Turkey. In former times, extensive forests of this species were also found in Syria and Lebanon. However, because of intensive cutting, burning, and goat grazing, only small populations are left in these countries. Currently, the range of Lebanon cedar covers approximately 600,000 ha in Turkey, including extremely degraded stands and bare karstic land that was previously covered by this species (1). Therefore, efforts to protect existing forests and promote natural regeneration of this endangered tree species were undertaken in recent years. In addition, reforestations were carried out on bare karstic lands to expand the population of Lebanon cedar in Turkey. During disease surveys, carried out in October 2009 in the Mt. Dedegül Region of the western Taurus Mountains (37°36′54″N, 31°20′00″E), a dieback of lower branches and young plants of C. libani was observed at 1,700 to 1,885 m above sea level. The disease often occurred in scattered patches and was most evident near the timberline. Needles, shoots, and twigs of affected trees or entire small trees were covered or completely enmeshed in silky, shining, blackish brown mycelial felts. Symptoms resembled those of brown felt blight, also known as black snow mold, caused by Herpotrichia juniperi and Neopeckia coulteri on various other conifer species (2). For fungal isolation and identification, 18 twig samples from 14 different C. libani trees were collected. Two colonized needles from each twig were transferred to water agar (16 g liter–1 of agar and 0.1 g liter–1 of streptomycin) and incubated at 4°C for at least 8 days in the dark. Single hyphal-tip cultures were then established from only one of the developing colonies per twig and transferred to 1.5-ml microcentrifuge tubes containing 500 μl of potato dextrose broth. DNA extraction, directly from the mycelium, was performed after 20 days (3). DNA was amplified using primer pair ITS1 and ITS4 (4) and sequenced. Sequences of two representative fungal isolates from C. libani were deposited in GenBank (HM853976 and HM853977). Comparison of the 18 internal transcribed spacer sequences obtained from C. libani showed 99 to 100% nucleotide identity with those of reference strains of H. juniperi (2) from GenBank and variation among the 18 sequences was <1%, which is within the limits reported in a previous study (2). To our knowledge, this is the first report of C. libani as a new host of H. juniperi. Thus, brown felt blight is considered to have a significant impact on regeneration of C. libani as well as on the survival and growth of seedlings and young trees in the study area. References: (1) M. Boydak For. Ecol. Manag. 178:231, 2003. (2) M. Schneider et al. Mycol. Res. 113:887, 2009. (3) D. Smith and G. Stanosz. Phytopathology 85:699, 1995 (4) T. J. T. White et al. PCR Protocols: A Guide to Methods and Applications. Academic Press, New York 1990.

Background and Objective: Suicide attempts are 10-20X more common than completed suicide and an important risk factor for death by suicide, yet most people who attempt suicide do not die by suicide. The process of recovering after a suicide attempt has not been well studied. The Reasons to go on Living (RTGOL) Project, a narrative web-based study, focuses on experiences of people who have attempted suicide and made the decision to go on living, a process not well studied. Narrative research is ideally suited to understanding personal experiences critical to recovery following a suicide attempt, including the transition to a state of hopefulness. Voices from people with lived experience can help us plan and conceptualize this work. This paper reports on a secondary research question of the larger study: what stories do participants tell of the positive role/impact of the mental health system. Material and Methods: A website created for The RTGOL Project (www.thereasons.ca) enabled participants to anonymously submit a story about their suicide attempt and recovery, a process which enabled participation from a large and diverse group of participants. The only direction given was “if you have made a suicide attempt or seriously considered suicide and now want to go on living, we want to hear from you.” The unstructured narrative format allowed participants to describe their experiences in their own words, to include and emphasize what they considered important. Over 5 years, data analysis occurred in several phases over the course of the study, resulting in the identification of data that were inputted into an Excel file. This analysis used stories where participants described positive involvement with the mental health system (50 stories). Results: Several participants reflected on experiences many years previous, providing the privilege of learning how their life unfolded, what made a difference. Over a five-year period, 50 of 226 stories identified positive experiences with mental health care with sufficient details to allow analysis, and are the focus of this paper. There were a range of suicidal behaviours in these 50 stories, from suicidal ideation only to medically severe suicide attempts. Most described one or more suicide attempts. Three themes identified included: 1) trust and relationship with a health care professional, 2) the role of friends and family and friends, and 3) a wide range of services. Conclusion: Stories open a window into the experiences of the period after a suicide attempt. This study allowed for an understanding of how mental health professionals might help individuals who have attempted suicide write a different story, a life-affirming story. The stories that participants shared offer some understanding of “how” to provide support at a most-needed critical juncture for people as they interact with health care providers, including immediately after a suicide attempt. Results of this study reinforce that just one caring professional can make a tremendous difference to a person who has survived a suicide attempt. Key Words: web-based; suicide; suicide attempt; mental health system; narrative research Word Count: 478 Introduction My Third (or fourth) Suicide AttemptI laid in the back of the ambulance, the snow of too many doses of ativan dissolving on my tongue.They hadn't even cared enough about meto put someone in the back with me,and so, frustrated,I'd swallowed all the pills I had with me— not enough to do what I wanted it to right then,but more than enough to knock me out for a good 14 hours.I remember very little after that;benzodiazepines like ativan commonly cause pre- and post-amnesia, says Google helpfullyI wake up in a locked rooma woman manically drawing on the windows with crayonsthe colors of light through the glassdiffused into rainbows of joy scattered about the roomas if she were coloring on us all,all of the tattered remnants of humanity in a psych wardmade into a brittle mosaic, a quilt of many hues, a Technicolor dreamcoatand I thoughtI am so glad to be able to see this. (Story 187)The nurse opening that door will have a lasting impact on how this story unfolds and on this person’s life. Each year, almost one million people die from suicide, approximately one death every 40 seconds. Suicide attempts are much more frequent, with up to an estimated 20 attempts for every death by suicide.1 Suicide-related behaviours range from suicidal ideation and self-injury to death by suicide. We are unable to directly study those who die by suicide, but effective intervention after a suicide attempt could reduce the risk of subsequent death by suicide. Near-fatal suicide attempts have been used to explore the boundary with completed suicides. Findings indicated that violent suicide attempters and serious attempters (seriousness of the medical consequences to define near-fatal attempts) were more likely to make repeated, and higher lethality suicide attempts.2 In a case-control study, the medically severe suicide attempts group (78 participants), epidemiologically very similar to those who complete suicide, had significantly higher communication difficulties; the risk for death by suicide multiplied if accompanied by feelings of isolation and alienation.3 Most research in suicidology has been quantitative, focusing almost exclusively on identifying factors that may be predictive of suicidal behaviours, and on explanation rather than understanding.4 Qualitative research, focusing on the lived experiences of individuals who have attempted suicide, may provide a better understanding of how to respond in empathic and helpful ways to prevent future attempts and death by suicide.4,5 Fitzpatrick6 advocates for narrative research as a valuable qualitative method in suicide research, enabling people to construct and make sense of the experiences and their world, and imbue it with meaning. A review of qualitative studies examining the experiences of recovering from or living with suicidal ideation identified 5 interconnected themes: suffering, struggle, connection, turning points, and coping.7 Several additional qualitative studies about attempted suicide have been reported in the literature. Participants have included patients hospitalized for attempting suicide8, and/or suicidal ideation,9 out-patients following a suicide attempt and their caregivers,10 veterans with serious mental illness and at least one hospitalization for a suicide attempt or imminent suicide plan.11 Relationships were a consistent theme in these studies. Interpersonal relationships and an empathic environment were perceived as therapeutic and protective, enabling the expression of thoughts and self-understanding.8 Given the connection to relationship issues, the authors suggested it may be helpful to provide support for the relatives of patients who have attempted suicide. A sheltered, friendly environment and support systems, which included caring by family and friends, and treatment by mental health professionals, helped the suicidal healing process.10 Receiving empathic care led to positive changes and an increased level of insight; just one caring professional could make a tremendous difference.11 Kraft and colleagues9 concluded with the importance of hearing directly from those who are suicidal in order to help them, that only when we understand, “why suicide”, can we help with an alternative, “why life?” In a grounded theory study about help-seeking for self-injury, Long and colleagues12 identified that self-injury was not the problem for their participants, but a panacea, even if temporary, to painful life experiences. Participant narratives reflected a complex journey for those who self-injured: their wish when help-seeking was identified by the theme “to be treated like a person”. There has also been a focus on the role and potential impact of psychiatric/mental health nursing. Through interviews with experienced in-patient nurses, Carlen and Bengtsson13 identified the need to see suicidal patients as subjective human beings with unique experiences. This mirrors research with patients, which concluded that the interaction with personnel who are devoted, hope-mediating and committed may be crucial to a patient’s desire to continue living.14 Interviews with individuals who received mental health care for a suicidal crisis following a serious attempt led to the development of a theory for psychiatric nurses with the central variable, reconnecting the person with humanity across 3 phases: reflecting an image of humanity, guiding the individual back to humanity, and learning to live.15 Other research has identified important roles for nurses working with patients who have attempted suicide by enabling the expression of thoughts and developing self-understanding8, helping to see things differently and reconnecting with others,10 assisting the person in finding meaning from their experience to turn their lives around, and maintain/and develop positive connections with others.16 However, one literature review identified that negative attitudes toward self-harm were common among nurses, with more positive attitudes among mental health nurses than general nurses. The authors concluded that education, both reflective and interactive, could have a positive impact.17 This paper is one part of a larger web-based narrative study, the Reasons to go on Living Project (RTGOL), that seeks to understand the transition from making a suicide attempt to choosing life. When invited to tell their stories anonymously online, what information would people share about their suicide attempts? This paper reports on a secondary research question of the larger study: what stories do participants tell of the positive role/impact of the mental health system. The focus on the positive impact reflects an appreciative inquiry approach which can promote better practice.18 Methods Design and Sample A website created for The RTGOL Project (www.thereasons.ca) enabled participants to anonymously submit a story about their suicide attempt and recovery. Participants were required to read and agree with a consent form before being able to submit their story through a text box or by uploading a file. No demographic information was requested. Text submissions were embedded into an email and sent to an account created for the Project without collecting information about the IP address or other identifying information. The content of the website was reviewed by legal counsel before posting, and the study was approved by the local Research Ethics Board. Stories were collected for 5 years (July 2008-June 2013). The RTGOL Project enabled participation by a large, diverse audience, at their own convenience of time and location, providing they had computer access. The unstructured narrative format allowed participants to describe their experiences in their own words, to include and emphasize what they considered important. Of the 226 submissions to the website, 112 described involvement at some level with the mental health system, and 50 provided sufficient detail about positive experiences with mental health care to permit analysis. There were a range of suicidal behaviours in these 50 stories: 8 described suicidal ideation only; 9 met the criteria of medically severe suicide attempts3; 33 described one or more suicide attempts. For most participants, the last attempt had been some years in the past, even decades, prior to writing. Results Stories of positive experiences with mental health care described the idea of a door opening, a turning point, or helping the person to see their situation differently. Themes identified were: (1) relationship and trust with a Health Care Professional (HCP), (2) the role of family and friends (limited to in-hospital experiences), and (3) the opportunity to access a range of services. The many reflective submissions of experiences told many years after the suicide attempt(s) speaks to the lasting impact of the experience for that individual. Trust and Relationship with a Health Care Professional A trusting relationship with a health professional helped participants to see things in a different way, a more hopeful way and over time. “In that time of crisis, she never talked down to me, kept her promises, didn't panic, didn't give up, and she kept believing in me. I guess I essentially borrowed the hope that she had for me until I found hope for myself.” (Story# 35) My doctor has worked extensively with me. I now realize that this is what will keep me alive. To be able to feel in my heart that my doctor does care about me and truly wants to see me get better.” (Story 34). The writer in Story 150 was a nurse, an honours graduate. The 20 years following graduation included depression, hospitalizations and many suicide attempts. “One day after supper I took an entire bottle of prescription pills, then rode away on my bike. They found me late that night unconscious in a downtown park. My heart threatened to stop in the ICU.” Then later, “I finally found a person who was able to connect with me and help me climb out of the pit I was in. I asked her if anyone as sick as me could get better, and she said, “Yes”, she had seen it happen. Those were the words I had been waiting to hear! I quickly became very motivated to get better. I felt heard and like I had just found a big sister, a guide to help me figure out how to live in the world. This person was a nurse who worked as a trauma therapist.” At the time when the story was submitted, the writer was applying to a graduate program. Role of Family and Friends Several participants described being affected by their family’s response to their suicide attempt. Realizing the impact on their family and friends was, for some, a turning point. The writer in Story 20 told of experiences more than 30 years prior to the writing. She described her family of origin as “truly dysfunctional,” and she suffered from episodes of depression and hospitalization during her teen years. Following the birth of her second child, and many family difficulties, “It was at this point that I became suicidal.” She made a decision to kill herself by jumping off the balcony (6 stories). “At the very last second as I hung onto the railing of the balcony. I did not want to die but it was too late. I landed on the parking lot pavement.” She wrote that the pain was indescribable, due to many broken bones. “The physical pain can be unbearable. Then you get to see the pain and horror in the eyes of someone you love and who loves you. Many people suggested to my husband that he should leave me in the hospital, go on with life and forget about me. During the process of recovery in the hospital, my husband was with me every day…With the help of psychiatrists and a later hospitalization, I was actually diagnosed as bipolar…Since 1983, I have been taking lithium and have never had a recurrence of suicidal thoughts or for that matter any kind of depression.” The writer in Story 62 suffered childhood sexual abuse. When she came forward with it, she felt she was not heard. Self-harm on a regular basis was followed by “numerous overdoses trying to end my life.” Overdoses led to psychiatric hospitalizations that were unhelpful because she was unable to trust staff. “My way of thinking was that ending my life was the only answer. There had been numerous attempts, too many to count. My thoughts were that if I wasn’t alive I wouldn’t have to deal with my problems.” In her final attempt, she plunged over the side of a mountain, dropping 80 feet, resulting in several serious injuries. “I was so angry that I was still alive.” However, “During my hospitalization I began to realize that my family and friends were there by my side continuously, I began to realize that I wasn't only hurting myself. I was hurting all the important people in my life. It was then that I told myself I am going to do whatever it takes.” A turning point is not to say that the difficulties did not continue. The writer of Story 171 tells of a suicide attempt 7 years previous, and the ongoing anguish. She had been depressed for years and had thoughts of suicide on a daily basis. After a serious overdose, she woke up the next day in a hospital bed, her husband and 2 daughters at her bed. “Honestly, I was disappointed to wake up. But, then I saw how scared and hurt they were. Then I was sorry for what I had done to them. Since then I have thought of suicide but know that it is tragic for the family and is a hurt that can never be undone. Today I live with the thought that I am here for a reason and when it is God's time to take me then I will go. I do believe living is harder than dying. I do believe I was born for a purpose and when that is accomplished I will be released. …Until then I try to remind myself of how I am blessed and try to appreciate the wonders of the world and the people in it.” Range of Services The important role of mental health and recovery services was frequently mentioned, including dialectical behavioural therapy (DBT)/cognitive-behavioural therapy (CBT), recovery group, group therapy, Alcoholics Anonymous, accurate diagnosis, and medications. The writer in Story 30 was 83 years old when she submitted her story, reflecting on a life with both good and bad times. She first attempted suicide at age 10 or 12. A serious post-partum depression followed the birth of her second child, and over the years, she experienced periods of suicidal intent: “Consequently, a few years passed and I got to feeling suicidal again. I had pills in one pocket and a clipping for “The Recovery Group” in the other pocket. As I rode on the bus trying to make up my mind, I decided to go to the Recovery Group first. I could always take the pills later. I found the Recovery Group and yoga helpful; going to meetings sometimes twice a day until I got thinking more clearly and learned how to deal with my problems.” Several participants described the value of CBT or DBT in learning to challenge perceptions. “I have tools now to differentiate myself from the illness. I learned I'm not a bad person but bad things did happen to me and I survived.”(Story 3) “The fact is that we have thoughts that are helpful and thoughts that are destructive….. I knew it was up to me if I was to get better once and for all.” (Story 32): “In the hospital I was introduced to DBT. I saw a nurse (Tanya) every day and attended a group session twice a week, learning the techniques. I worked with the people who wanted to work with me this time. Tanya said the same thing my counselor did “there is no study that can prove whether or not suicide solves problems” and I felt as though I understood it then. If I am dead, then all the people that I kept pushing away and refusing their help would be devastated. If I killed myself with my own hand, my family would be so upset. DBT taught me how to ‘ride my emotional wave’. ……….. DBT has changed my life…….. My life is getting back in order now, thanks to DBT, and I have lots of reasons to go on living.”(Story 19) The writer of Story 67 described the importance of group therapy. “Group therapy was the most helpful for me. It gave me something besides myself to focus on. Empathy is such a powerful emotion and a pathway to love. And it was a huge relief to hear others felt the same and had developed tools of their own that I could try for myself! I think I needed to learn to communicate and recognize when I was piling everything up to build my despair. I don’t think I have found the best ways yet, but I am lifetimes away from that teenage girl.” (Story 67) The author of story 212 reflected on suicidal ideation beginning over 20 years earlier, at age 13. Her first attempt was at 28. “I thought everyone would be better off without me, especially my children, I felt like the worst mum ever, I felt like a burden to my family and I felt like I was a failure at life in general.” She had more suicide attempts, experienced the death of her father by suicide, and then finally found her doctor. “Now I’m on meds for a mood disorder and depression, my family watch me closely, and I see my doctor regularly. For the first time in 20 years, I love being a mum, a sister, a daughter, a friend, a cousin etc.” Discussion The 50 stories that describe positive experiences in the health care system constitute a larger group than most other similar studies, and most participants had made one or more suicide attempts. Several writers reflected back many years, telling stories of long ago, as with the 83-year old participant (Story 30) whose story provided the privilege of learning how the author’s life unfolded. In clinical practice, we often do not know – how did the story turn out? The stories that describe receiving health care speak to the impact of the experience, and the importance of the issues identified in the mental health system. We identified 3 themes, but it was often the combination that participants described in their stories that was powerful, as demonstrated in Story 20, the young new mother who had fallen from a balcony 30 years earlier. Voices from people with lived experience can help us plan and conceptualize our clinical work. Results are consistent with, and add to, the previous work on the importance of therapeutic relationships.8,10,11,14–16 It is from the stories in this study that we come to understand the powerful experience of seeing a family members’ reaction following a participant’s suicide attempt, and how that can be a potent turning point as identified by Lakeman and Fitzgerald.7 Ghio and colleagues8 and Lakeman16 identified the important role for staff/nurses in supporting families due to the connection to relationship issues. This research also calls for support for families to recognize the important role they have in helping the person understand how much they mean to them, and to promote the potential impact of a turning point. The importance of the range of services reflect Lakeman and Fitzgerald’s7 theme of coping, associating positive change by increasing the repertoire of coping strategies. These findings have implications for practice, research and education. Working with individuals who are suicidal can help them develop and tell a different story, help them move from a death-oriented to life-oriented position,15 from “why suicide” to “why life.”9 Hospitalization provides a person with the opportunity to reflect, to take time away from “the real world” to consider oneself, the suicide attempt, connections with family and friends and life goals, and to recover physically and emotionally. Hospitalization is also an opening to involve the family in the recovery process. The intensity of the immediate period following a suicide attempt provides a unique opportunity for nurses to support and coach families, to help both patients and family begin to see things differently and begin to create that different story. In this way, family and friends can be both a support to the person who has attempted suicide, and receive help in their own struggles with this experience. It is also important to recognize that this short period of opportunity is not specific to the nurses in psychiatric units, as the nurses caring for a person after a medically severe suicide attempt will frequently be the nurses in the ICU or Emergency departments. Education, both reflective and interactive, could have a positive impact.17 Helping staff develop the attitudes, skills and approach necessary to be helpful to a person post-suicide attempt is beginning to be reported in the literature.21 Further implications relate to nursing curriculum. Given the extent of suicidal ideation, suicide attempts and deaths by suicide, this merits an important focus. This could include specific scenarios, readings by people affected by suicide, both patients themselves and their families or survivors, and discussions with individuals who have made an attempt(s) and made a decision to go on living. All of this is, of course, not specific to nursing. All members of the interprofessional health care team can support the transition to recovery of a person after a suicide attempt using the strategies suggested in this paper, in addition to other evidence-based interventions and treatments. Findings from this study need to be considered in light of some specific limitations. First, the focus was on those who have made a decision to go on living, and we have only the information the participants included in their stories. No follow-up questions were possible. The nature of the research design meant that participants required access to a computer with Internet and the ability to communicate in English. This study does not provide a comprehensive view of in-patient care. However, it offers important inputs to enhance other aspects of care, such as assessing safety as a critical foundation to care. We consider these limitations were more than balanced by the richness of the many stories that a totally anonymous process allowed. Conclusion Stories open a window into the experiences of a person during the period after a suicide attempt. The RTGOL Project allowed for an understanding of how we might help suicidal individuals change the script, write a different story. The stories that participants shared give us some understanding of “how” to provide support at a most-needed critical juncture for people as they interact with health care providers immediately after a suicide attempt. While we cannot know the experiences of those who did not survive a suicide attempt, results of this study reinforce that just one caring professional can make a crucial difference to a person who has survived a suicide attempt. We end with where we began. Who will open the door? References 1. World Health Organization. Suicide prevention and special programmes. http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/index.html Geneva: Author; 2013.2. Giner L, Jaussent I, Olie E, et al. Violent and serious suicide attempters: One step closer to suicide? J Clin Psychiatry 2014:73(3):3191–197.3. Levi-Belz Y, Gvion Y, Horesh N, et al. Mental pain, communication difficulties, and medically serious suicide attempts: A case-control study. Arch Suicide Res 2014:18:74–87.4. Hjelmeland H and Knizek BL. Why we need qualitative research in suicidology? Suicide Life Threat Behav 2010:40(1):74–80.5. Gunnell D. A population health perspective on suicide research and prevention: What we know, what we need to know, and policy priorities. Crisis 2015:36(3):155–60.6. Fitzpatrick S. Looking beyond the qualitative and quantitative divide: Narrative, ethics and representation in suicidology. Suicidol Online 2011:2:29–37.7. Lakeman R and FitzGerald M. How people live with or get over being suicidal: A review of qualitative studies. J Adv Nurs 2008:64(2):114–26.8. Ghio L, Zanelli E, Gotelli S, et al. Involving patients who attempt suicide in suicide prevention: A focus group study. J Psychiatr Ment Health Nurs 2011:18:510–18.9. Kraft TL, Jobes DA, Lineberry TW., Conrad, A., & Kung, S. Brief report: Why suicide? Perceptions of suicidal inpatients and reflections of clinical researchers. Arch Suicide Res 2010:14(4):375-382.10. Sun F, Long A, Tsao L, et al. The healing process following a suicide attempt: Context and intervening conditions. Arch Psychiatr Nurs 2014:28:66–61.11. Montross Thomas L, Palinkas L, et al. Yearning to be heard: What veterans teach us about suicide risk and effective interventions. Crisis 2014:35(3):161–67.12. Long M, Manktelow R, and Tracey A. The healing journey: Help seeking for self-injury among a community population. Qual Health Res 2015:25(7):932–44.13. Carlen P and Bengtsson A. Suicidal patients as experienced by psychiatric nurses in inpatient care. Int J Ment Health Nurs 2007:16:257–65.14. Samuelsson M, Wiklander M, Asberg M, et al. Psychiatric care as seen by the attempted suicide patient. J Adv Nurs 2000:32(3):635–43.15. 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Quinoa (Chenopodium quinoa Willd.) is a traditional food originally from the Andes Mountains in South America. It was first planted in China in 1987 and is grown in Tibet, Gansu, and Qinghai provinces. In May 2021, 40% of 2-month-old quinoa plants in the 3.4 hm² experimental base of Qinghai University (36.7262° N, 101.7487° E) were found to have leaves with grey-brown subcircular spots (about 0.4 to 0.7 cm) with black dots (acervuli). Severely infected plants exhibited symptoms such as withered and stunted growth. The diseased–healthy junctions of infected leaves (0.5 cm) were cut out, disinfected with 3% NaClO for 1.5 min, washed three times with sterile water, dried, placed on water agar, and incubated at 25°C for 48 h. After sporulation was seen on the leaf surface, spore suspensions were prepared by placing conidia in sterile water using a pipette. Next, 200 μl of each spore suspension was spread on the surface of water agar and incubated at 25°C for 12 h. Single spores were selected under a stereomicroscope and cultured on potato dextrose agar (PDA) (Qi et al. 2022). The mycelium of two representative isolates (20DLMF-5-4-1 and 20DLMF-7-4-1) was grey-black with white edges and included a fluffy aerial mycelium. Conidia were unicellular, colorless, long ellipsoid or curved moon shaped, averaging 14.3 × 1.8 to 20.2 × 2.2 μm (n=100). The light brown appressoria were ovoid, averaging 8.5 × 5.2 to 7.7 × 4.1 μm (n=20). Spherical, dark brown acervuli were observed on the leaves, averaging 160 to 200 μm (n=20), and there were dark brown spiny bristles. The ITS, partial ACT, CHS, GAPDH and TUB2 genes were amplified from genomic DNA of the two isolates (Weir et al. 2012). Sequences were deposited in GenBank (accession no. OQ871595 to OQ871602 for ACT, CHS, GAPDH, and TUB2, and OQ860235 to OQ860236 for ITS) and showed over 99% identities with the corresponding sequences of C. spinaciae CBS125347 and CBS128.57 (Vu et al. 2019; Damm et al. 2009). Both isolates clustered with the type culture of C. spinaciae (CBS125347, CBS128.57), with 100% bootstrap support in the phylogenetic tree. Thus, according to the morphological and molecular characteristics, the two isolates were identified as C. spinaciae. Pathogenicity tests were conducted on 24 healthy, tender leaves of six 1-month-old quinoa plants, with three replicates (Yang et al. 2021). The leaves were gently scratched in 3-4 areas with a sterile needle. A conidial suspension (105 conidia/ml) of the two isolates was sprayed on these wounds. The control group was unscratched and sprayed with sterile water. The plants were incubated in a greenhouse at 25°C for 24 h in the dark and 7 days in the light. Tiny grey-brown spots appeared on day 3 (about 0.4 to 0.6 cm) and continued to enlarge until perforations and ruptures developed on day 7. Subsequently, acervuli were observed on the surface of the leaves. The control leaves remained healthy. Isolates were reisolated from the symptomatic leaves and they had the same morphological and molecular characteristics as the original isolates, confirming Koch’s postulates. To our knowledge, this is the first report of C. spinaciae causing quinoa leaf anthracnose in China. C. spinaciae seriously affects the yield and quality of quinoa and has been previously reported to cause anthracnose of Vicia sativa in China (Wang et al. 2019). The results provide a basis for the study and control of quinoa leaf anthracnose.

Cardamine hupingshanensis is a selenium (Se) and cadmium (Cd) hyperaccumulator plant distributed in wetlands along the Wuling Mountains of China (Zhou et al. 2018). In March of 2020, a disease with symptoms similar to gray mold was observed on leaves of C. hupingshanensis in a nursery located in Changsha, Hunan Province, China. Almost 40% of the C. hupingshanensis (200 plants) were infected. Initially, small spots were scattered across the leaf surface or margin. As disease progressed, small spots enlarged to dark brown lesions, with green-gray, conidia containing mold layer under humid conditions. Small leaf pieces were cut from the lesion margins and were sterilized with 70% ethanol for 10 s, 2% NaOCl for 2 min, rinsed with sterilized distilled water for three times, and then placed on potato dextrose agar (PDA) medium at 22°C in the dark. Seven similar colonies were consistently isolated from seven samples and further purified by single-spore isolation. Strains cultured on PDA were initially white, forming gray-white aerial mycelia, then turned gray and produced sclerotia after incubation for 2 weeks, which were brown to blackish, irregular, 0.8 to 3.0 × 1.2 to 3.5 mm (n=50). Conidia were unicellular, globose or oval, colourless, 7.5 to 12.0 × 5.5 to 8.3 μm (n=50). Conidiophores arose singly or in group, straight or flexuous, septate, brownish to light brown, with enlarged basal cells, 12.5 to 22.1 × 120.7 to 310.3 μm. Based on their morphological characteristics in culture, the isolates were putatively identified as Botrytis cinerea (Ellis 1971). Genomic DNA of four representative isolates, HNSMJ-1 to HNSMJ-4, were extracted by CTAB method. The internal transcribed spacer region (ITS), glyceraldehyde-3-phosphate dehydrogenase gene (G3PDH), heat-shock protein 60 gene (HSP60), ATP-dependent RNA helicaseDBP7 gene (MS547) and DNA-dependent RNA polymerase subunit II gene (RPB2) were amplified and sequenced using the primers described previously (Aktaruzzaman et al. 2018) (MW820311, MW831620, MW831628, MW831623 and MW831629 for HNSMJ-1; MW314722, MW316616, MW316617, MW316618 and MW316619 for HNSMJ-2; MW820519, MW831621, MW831627, MW831624 and MW831631 for HNSMJ-3; MW820601, MW831622, MW831626, MW831625 and MW831630 for HNSMJ-4). BLAST searches showed 99.43 to 99.90% identity to the corresponding sequences of B. cinerea strains, such as HJ-5 (MF426032.1, MN448500.1, MK791187.1, MH727700.1 and KX867998.1). A combined phylogenetic tree using the ITS, G3PDH, HSP60 and RPB2 sequences was constructed by neighbor-joining method in MEGA 6. It revealed that HNSMJ-1 to HNSMJ-4 clustered in the B. cinerea clade. Pathogenicity tests were performed on healthy pot-grown C. hupingshanensis plants. Leaves were surface-sterilized and sprayed with conidial suspension (106 conidia/ mL), with sterile water served as controls. All plants were kept in growth chamber with 85% humidity at 25℃ following a 16 h day-8 h night cycle. The experiment was repeated twice, with each three replications. After 4 to 7 days, symptoms similar to those observed in the field developed on the inoculated leaves, whereas controls remained healthy. The pathogen was reisolated from symptomatic tissues and identified using molecular methods, confirming Koch’s postulates. B. cinerea has already been reported from China on C. lyrate (Zhang 2006), a different species of C. hupingshanensis. To the best of our knowledge, this is the first report of B. cinerea causing gray mold on C. hupingshanensis in China and worldwide. Based on the widespread damage in the nursery, appropriate control strategies should be adopted. This study provides a basis for studying the epidemic and management of the disease.

Introdução: A terapia fotodinâmica representa uma abordagem alternativa para a desinfecção do tecido cariado e tem apresentando resultados promissores no que diz respeito ao seu efeito deletério sobre os microrganismos envolvidos na progressão da cárie dentária. Objetivo: Investigar a produção científica brasileira sobre Terapia Fotodinâmica no manejo da Cárie dentária. Material e método: Tratou-se de uma pesquisa transversal, com abordagem quantitativa, a partir de dados secundários. Realizou-se uma análise bibliométrica dos resumos apresentados nas últimas dez Reuniões da Sociedade Brasileira de Pesquisa Odontológica. A pesquisa dos trabalhos procedeu-se através da seguinte estratégia: localização do fragmento “terapia fotodinâmica” e/ou “fotodinâmica” entre os resumos publicados nos anais do evento (1ª fase), em seguida foi realizada a busca pelo fragmento “cárie” e/ou “cardiologia” nos resumos selecionados na 1ª fase. Resultados: Foram selecionados 21 resumos, desses, 15 (71,43%) foram realizadas em universidades públicas, 13 (61,91%) receberam auxílio financeiro, 11 (52,38%) foram desenvolvidas na região Sudeste do Brasil, 9 (42,86%) eram do tipo in vitro, 6 (28,58%) utilizaram apenas o azul de toluidina como fotossensibilizante e 5 (23,81%) utilizaram apenas o LED vermelho como fonte de luz. Conclusão: Apesar dos resultados promissores da Terapia Fotodinâmica como terapia adjunta ao manejo da cárie, observou-se que poucas pesquisas abordando esse procedimento foram desenvolvidas nos últimos dez anos no Brasil.Descritores: Fotoquimioterapia; Cárie Dentária; Coleta de Dados.ReferênciasBradshaw DJ, lynch RJ. Diet and the microbial aetiology of dental caries: new paradigms. Int Dent J. 2013;63(Suppl 2):64-72.Hasan S, Singh K, Danisuddin M, Verma PK, Khan AU. Inhibition of major virulence pathways of Streptococcus mutansby quercitrin and deoxynojirimycin: a synergistic approach of infection control. 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Involuntarily celibate men (Incels) form online communities in which they “often bemoan their lack of a loving relationship with a woman while simultaneously dehumanizing women and calling for misogynistic violence” (Glace et al., 2021, p. 288). Several studies investigate this dehumanization and misogyny including (gendered) hate speech in online comments from Incels (e.g., Glace et al., 2021). However, not all online comments from Incels contain misogyny or gendered hate speech. To get a better understanding of the phenomenon of Incels, it would be better to not only focus on these problematic comments. Thus, we propose a new construct called “Online Incel speech”, which is defined as the sum of all online comments from Incels that are related to Inceldom, that is, being or becoming an Incel. In an approach to provide an extensive system of categorization, Grau Chopite (2022) synthesized codebooks from several studies on Incels (see example studies table note) and put it to an empirical test. She found that most Incel comments found online can be categorized into three subdimensions. The first two subdimensions cover framing by Incels, namely how Incels frame the subjective causes of becoming an Incel and how they frame the subjective emotional consequences of being an Incel. Both subdimensions can also be interpreted as part of a subjective theory (sensu Groeben et al., 1988) of Inceldom. In contrast to this, the third subdimension does not consist of framing, but of observable verbal behaviors, which are often linked to gendered hate speech. When trying to categorize online comments from Incels, former studies often applied the construct “Hybrid Masculinities” (e.g., Glace et al, 2021). This construct from Bridge and Pascoe (2014) suggests that “some men develop masculinities which appear to subvert, but actually reaffirm, White hegemonic masculinities” (Glace et al., 2021, p. 289). Glace et al. (2021) structure the construct into three subdimensions, namely (1) discursive distancing (claiming distance from hegemonic masculine roles without actually relinquishing masculine power), (2) strategic borrowing (appropriating the cultures of nondominant groups of men), and (3) fortifying boundaries (continually using hegemonic standards to constrain masculinity and demeaning men who fail to meet them). However, the construct only covers a part of Inceldom, which Glace et al. (2021) indirectly acknowledge by adding two inductive categories, that is, hostile sexism (shaming and degrading women) and suicidality (reporting suicidal thoughts, feelings, and intentions). Field of application/theoretical foundation: The construct “Online Incel speech” was coined by Grau Chopite (2022), and there are currently no other studies making use of it. However, there are studies (e.g., Vu & Lynn, 2020; also see the entry “Frames (Automated Content Analysis”) based on the framing theory by Entman (1991) where the subdimension “subjective causes” would correspond to Entman’s “causal interpretation frame”, while the “subjective emotional consequences” would correspond to Entman’s “problem definition frame”. The “subjective causes” also correspond to the “discursive distancing” and the “emotional consequences” to “suicidality” in the construct of Hybrid Masculinities. The third subdimension “verbal behavior” corresponds to gendered online hate speech (e.g., Döring & Mohseni, 2019), but also to “hostile sexism” and “fortifying boundaries” in the construct of Hybrid Masculinities. References/combination with other methods: The study by Grau Chopite (2022) employs a quantitative manual content analysis using a deductive approach. Studies based on the construct of Hybrid Masculinities also employ manual online content analyses or manual thematic analyses, but those are often qualitative in nature (e.g., Glace et al., 2021). Framing is also often assessed with manual content analyses (e.g., Nitsch & Lichtenstein, 2019), but newer studies try to assess it computationally (e.g., Vu & Lynn, 2020). Hate speech is often assessed with manual content analyses (e.g., Döring & Mohseni, 2019) and surveys (e.g., Oksanen et al., 2014), but some newer studies try to assess it computationally (e.g., Al-Hassan & Al-Dossari, 2019). As Online Incel Speech is related to framing and gendered hate speech, it seems plausible that manual content analyses of Online Incel Speech could be combined with computational analyses, too, to enable the investigation of large samples. However, computational analyses of subtle forms of verbal behavior can be challenging because the number of wrong categorizations increases (e.g., for sexism detection see Samory et al., 2021; for hate speech detection see Ruiter et al., 2022). Example studies: Example study Construct Dimensions Explanation Reliability Online Incel speech Grau Chopite (2022) Subjective Causes of Inceldom Race/Ethnicity having certain racial features and/or belonging to a certain ethnic κ = .55;AC1 = .80 Mental Health suffering from any mental health issue κ = .58;AC1 = .90 Employment difficulties with getting and/or maintaining employment; experiencing dissatisfaction in the workplace κ = .85;AC1 = .98 Family having family issues (e.g., an abusive family member) κ = .66;AC1 = .98 Subjective Emotional Consequences of Inceldom Hopelessness expressing hopelessness κ = .37;AC1 = .89 Sadness expressing sadness κ = .26;AC1 = .91 Suicidality expressing suicidality κ = .24;AC1 = .95 Anger expressing anger κ = .44;AC1 = .87 Hatred expressing hatred κ = .40;AC1 = .83 Verbal Behavior of Incels Using Gendered Hate Speech Against Women hostile sexism against women and misogynistic speech κ = .80;AC1 = .87 Adopting Social Justice Language claiming unfairness/ injustice of being discriminated by society or groups (e.g., other men, other races) κ = .48;AC1 = .82 Claiming Lack of Masculine Traits lacking masculine traits (e.g., muscles, a big penis) κ = .62;AC1 = .86 Shaming Other Men shaming of other men directly by calling them terms related to being “effeminate” or “unmanly” κ = .71;AC1 = .91 Claiming Lack of Female Interest being unable to attract women or being rejected by women κ = .61;AC1 = .87 Hybrid Masculinities Glace et al. (2021) Discursive Distancing Lack of Female Interest claiming a lack of ability to attract female romantic companionship and sexual interest n/a Lack of Masculine Traits claiming a lack of traditionally attractive masculine physical traits n/a Strategic Borrowing Race and Racism appropriating the culture of racial and ethnic minority men n/a Social Justice Language using the language of the marginalized to diminish one’s own position of power n/a Fortifying Boundaries Soyboys deriding non-Incel men as weak and desperate n/a Cucks deriding non-Incel men as being cheated or exploited by women n/a Hostile Sexism Women are Ugly deriding women for being unattractive n/a Slut-Shaming deriding women for having sex n/a False Rape Claims claiming that women make false rape claims (e.g., when approached by an Incel) n/a Women’s Only Value is Sex claiming that women’s only value is their sexuality n/a Women are Subhuman dehumanizing women n/a Suicidality Due to Incel Experience attributing suicidal thoughts, feelings, and intentions to Incel status n/a The “Clown World” claiming that the world is meaningless and nonsensical n/a Note: The codebook from Grau Chopite (2022) is based on the codebook and findings of Glace et al. (2021) and other studies (Baele et al., 2019; Bou-Franch & Garcés-Conejos Blitvich, 2021; Bridges & Pascoe, 2014; Cottee, 2020; Döring & Mohseni, 2019; D’Souza et al., 2018; Marwick & Caplan, 2018; Mattheis & Waltman, 2021; Maxwell et al., 2020; Rogers et al., 2015; Rouda & Siegel, 2020; Scaptura & Boyle, 2019; Williams & Arntfield, 2020; Williams et al., 2021). Gwet’s AC1 was calculated in addition to Cohen’s Kappa because some categories were rarely coded, which biases Cohen’s Kappa. The codebook is available at http://doi.org/10.23668/psycharchives.5626 References Al-Hassan, A., & Al-Dossari, Hmood (2019). Detection of hate speech in social networks: A survey on multilingual corpus. In D. Nagamalai & D. C. Wyld (Eds.), Computer Science & Information Technology. Proceedings of the 6th International Conference on Computer Science and Information Technology (pp. 83–100). AIRCC Publishing. doi:10.5121/csit.2019.90208 Baele, S. J., Brace, L., & Coan, T. G. (2019). From “Incel” to “Saint”: Analyzing the violent worldview behind the 2018 Toronto attack. Terrorism and Political Violence, 1–25. doi:10.1080/09546553.2019.1638256 Bou-Franch, P., & Garcés-Conejos Blitvich, P. (2021). Gender ideology and social identity processes in online language aggression against women. In R. M. DeKeyser (Ed.), Benjamins Current Topics: Vol. 116. Aptitude-Treatment Interaction in Second Language Learning (Vol. 86, pp. 59–81). John Benjamins Publishing Company. doi:10.1075/bct.86.03bou Bridges, T., & Pascoe, C. J. (2014). Hybrid masculinities: New directions in the sociology of men and masculinities. Sociology Compass, 8(3), 246–258. doi:10.1111/soc4.12134 Cottee, S. (2021). Incel (e)motives: Resentment, shame and revenge. Studies in Conflict & Terrorism, 44(2), 93–114. doi:10.1080/1057610X.2020.1822589 Döring, N., & Mohseni, M. R. (2018). Male dominance and sexism on YouTube: Results of three content analyses. Feminist Media Studies, 19(4), 512–524. doi:10.1080/14680777.2018.1467945 D'Souza, T., Griffin, L., Shackelton, N., & Walt, D. (2018). Harming women with words: The failure of Australian law to prohibit gendered hate speech. University of New South Wales Law Journal, 41(3), 939–976. Entman, R. M. 1991. Framing U.S. coverage of international news: contrasts in narratives of the KAL and Iran Air incidents. Journal of Communication, 41(4), 6-7. Glace, A. M., Dover, T. L., & Zatkin, J. G. (2021). Taking the black pill: An empirical analysis of the “Incel”. Psychology of Men & Masculinities, 22(2), 288–297. doi:10.1037/men0000328 Grau Chopite, J. (2022). Framing of Inceldom on incels.is: A content analysis [Master’s thesis, TU Ilmenau]. Psycharchives. doi:10.23668/psycharchives.5626 Groeben, N., Wahl, D., Schlee, J., & Scheele, B. (Eds.). (1988). Das Forschungsprogramm Subjektive Theorien: eine Einführung in die Psychologie des reflexiven Subjekts. Francke. Retrieved from https://nbn-resolving.org/urn:nbn:de:0168-ssoar-27658 Marwick, A. E., & Caplan, R. (2018). Drinking male tears: language, the manosphere, and networked harassment. Feminist Media Studies, 18(4), 543–559. doi:10.1080/14680777.2018.1450568 Mattheis, A. A., & Waltman, M. S. (2021). Gendered hate online. In K. Ross & I. Bachmann (Eds.), The Wiley Blackwell-ICA international encyclopedias of communication. The international encyclopedia of gender, media, and communication (pp. 1–5). John Wiley & Sons Inc. doi:10.1002/9781119429128.iegmc019 Maxwell, D., Robinson, S. R., Williams, J. R., & Keaton, C. (2020). “A short story of a lonely guy”: A qualitative thematic analysis of involuntary celibacy using Reddit. Sexuality & Culture, 24(6), 1852–1874. doi:10.1007/s12119-020-09724-6 Nitsch, C. & Lichtenstein, D. (2019). Satirizing international crises. The depiction of the Ukraine, Greek debt and migration crises in political satire. Studies in Communication Science (SComS), 19(1), 85-103. doi:10.24434/j.scoms.2019.01.007 Oksanen, A., Hawdon, J., Holkeri, E., Näsi, M., & Räsänen, P. (2014). Exposure to online hate among young social media users. In N. Warehime (Ed.), Soul of Society: A focus on the lives of children & youth (p. 253-273). doi:10.1108/S1537-466120140000018021 Rogers, D. L., Cervantes, E., & Espinosa, J. C. (2015). Development and validation of the belief in female sexual deceptiveness scale. Journal of Interpersonal Violence, 30(5), 744–761. doi:10.1177/0886260514536282 Rouda, B., & Siegel, A. (2020). I’d kill for a girl like that”: The black pill and the Incel uprising. International Multidisciplinary Program in the Humanities, Tel Aviv University. Retrieved from https://www.academia.edu/43663741/_Id_kill_for_a_girl_like_that_The_Black_Pill_and_the_Incel_Uprising Ruiter, D., Reiners, L., Geet D’Sa, A., Kleinbauer, Th., Fohr, D., Illina, I., Klakow. D., Schemer, Ch., & Monnier, A. (2022). Placing m-phasis on the plurality of hate. A feature-based corpus of hate online. Preprint. Retrieved from https://doi.org/10.48550/arXiv.2204.13400 Samory, M., Sen, I., Kohne, J., Flöck, F., & Wagner, C. (2021). “Call me sexist, but...”: Revisiting sexism detection using psychological scales and adversarial samples. Proceedings of the International AAAI Conference on Web and Social Media, 15(1), 573-584. Retrieved from https://ojs.aaai.org/index.php/ICWSM/article/view/18085 Scaptura, M. N., & Boyle, K. M. (2019). Masculinity threat, “Incel” traits, and violent fantasies among heterosexual men in the United States. Feminist Criminology, 15(3), 278–298. doi:10.1177/1557085119896415 Vu, H. T., & Lynn, N. (2020). When the news takes sides: Automated framing analysis of news coverage of the Rohingya crisis by the elite press from three countries. Journalism Studies. Online first publication. doi:10.1080/1461670X.2020.1745665 Williams, D. J., & Arntfield, M. (2020). Extreme sex-negativity: An examination of helplessness, hopelessness, and misattribution of blame among “Incel” multiple homicide offenders. Journal of Positive Sexuality, 6(1), 33–42. doi:10.51681/1.613 Williams, D. J., Arntfield, M., Schaal, K., & Vincent, J. (2021). Wanting sex and willing to kill: Examining demographic and cognitive characteristics of violent "involuntary celibates". Behavioral Sciences & the Law, 39(4), 386–401. doi:10.1002/bsl.2512

Introdução: Devido às altas taxas de mortalidade, a candidemia têm se tornado um grave problema de saúde na realidade pediátrica, sobretudo quando se considera o aumento de infecções e a letalidade dos casos em grupos de risco como as crianças hospitalizadas e com sistema imunológico deficiente. Ultimamente têm-se percebido um aumento de infecções fúngicas provocadas por espécies não-albicans, trazendo uma nova realidade para o combate destas infecções, especialmente por envolver espécies resistentes à terapia convencional. Já foi demonstrado que o óleo essencial de Cymbopogon winterianus possui uma vasta gama de propriedades farmacológicas, incluindo atividade antifúngica. Objetivo: Este trabalho buscou avaliar a atividade antifúngica do óleo essencial de Cymbopogon winterianus Jowitt ex Bor (Poaceae) contra isolados de Candida não-albicans de importância clínica pediátrica. Material e Método: A concentração inibitória mínima (CIM) e a concentração fungicida mínima (CFM) foram determinadas pelas técnicas de microdiluição em caldo. Resultados: Tanto a CIM50 quanto a CFM50 do óleo essencial de C. winterianus para os isolados testados foi de 128 μg/mL.Conclusão: Este produto natural apresentou potencial antifúngico in vitro contra cepas de Candida não-albicans clinicamente relevante para a pediatria médica. Contudo, mais estudos são necessários para elucidar seu mecanismo de ação.Descritores: Técnicas de Tipagem Micológica; Candida; Candidemia; Cymbopogon; Óleos; Pediatria.ReferênciasSteinbach WJ. Pediatric invasive candidiasis: epidemiology and diagnosis in children. J Fungi (Basel). 2016;2(1):5.Ruiz LS, Khouri S, Hahn RC, da Silva EG, de Oliveira VK, Gandra RF et al. Candidemia by species of the Candida parapsilosis complex in children’s hospital: prevalence, biofilm production and antifungal susceptibility. Mycopathologia. 2013;175(3-4):231-39.Oliveira VKP, Ruiz LS, Oliveira NAJ, Moreira D, Hahn RC, Melo ASA et al. Fungemia caused by candida species in a Children´s Public Hospital in the city of São Paulo, Brazil: study in the period 2007-2010. Rev Inst Med Trop Sao Paulo. 2014;56(4):301-5.Morace G, Borghi E, Iatta R, Amato G, Andreoni S, Brigante G et al. Antifungal susceptibility of invasive yeast isolates in Italy: the GISIA3 study in critically ill patients. BMC Infect Dis. 2011;11:130.Khan SMA, Malik A, Ahmad I. Anti-candidal activity of essential oils alone and in combination with amphotericin B or fluconazole against multi-drug resistant isolates of Candida albicans. Med Mycol. 2012;50(1):33-42.Svetaz L, Aguero MB, Alvarez S, Luna L, Feresin G, Derita M et al. Antifungal activity of Zuccagnia punctata Cav.: evidence for the mechanism of action. Planta Med. 2007;73(10):1074-80.Ganjewala D, Silviya S, Khan HK. Biochemical composition and antibacterial activities of Lantana Camera plants with yellow, lavender, red and white flowers. EurAsia J BioSci. 2009;3:69-77.Scazzocchio F, Garzoli S, Conti C, Leone C, Renaioli C, Pepi F et al. Properties and limits of some essential oils: chemical characterisation, antimicrobial activity, interaction with antibiotics and cytotoxicity. Nat Prod Res. 2016;30(17):1909-18.Silva MR, Ximenes RM, da Costa JG, Leal LK, de Lopes AA, Viana GS. Comparative anticonvulsant activities of the essential oils (EOs) from Cymbopogon winterianus Jowitt and Cymbopogon citratus (DC) Stapf. in mice. Naunyn Schmiedebergs Naunyn Schmiedebergs Arch Pharmacol. 2010;381(5):415-26.Silva CT, Wanderley-Teixeira V, Cunha FM, Oliveira JV, Dutra KA, Navarro DM et al. Biochemical parameters of Spodoptera frugiperda (J. E. Smith) treated with citronella oil (Cymbopogon winterianus Jowitt ex Bor) and its influence on reproduction. Acta Histochem. 2016;118(4):347-52.Oliveira WA, Pereira FO, Luna GCDG, Lima IO, Wanderley PA, Lima RB et al. Antifungal activity of Cymbopogon winterianus Jowitt ex Bor against Candida albicans. Braz J Microbiol. 2011;42(2):433-41.Eloff JN. A sensitive and quick microplate method to determine the minimal inhibitory concentration of plant extracts for bacteria. Planta Med. 1998;64(8):711-13.Hadacek F, Greger H. Testing of antifungal natural products: methodologies, comparability of results and assay choice. Phytochem Anal. 2000;11(3):137-47.CLSI. Clinical and laboratory standards institute. protocol M27-A3. Reference method for broth dilution antifungal susceptibility testing of yeasts. 3ed. Wayne, PA, USA. 2008.Espinel-Ingroff A, Chaturvedi V, Fothergill A, Rinaldi MG. Optimal testing conditions for determining MICs and minimum fungicidal concentrations of new and established antifungal agents for uncommon molds: NCCLS collaborative study. J Clin Microbiol. 2002;40(10):3776-81.Falagas ME, Roussos N, Vardakas KZ. Relative frequency of 3 albicans and the various non-albicans Candida spp among candidemia isolates from inpatients in various parts of the world: a systematic review. Int J Infect Dis. 2010;14(11):e954-66.Nucci M, Queiroz-Telles F, Alvarado-Matute T, Tiraboschi IN, Corte J, Zurita J et al. Epidemiology of candidemia in Latin America: a laboratory-based survey. Plos One. 2013;8(3):e59373.Simões ER, Santos EA, de Abreu MC, Silva JN, Nunes NM, da Costa MP et al. Biomedical properties and potentiality of Lippia microphylla Cham. and its essential oils. J Intercult Ethnopharmacol. 2015;4(3):256-63.Bilia AR, Santomauro F, Sacco C, Bergonzi MC, Donato R. Essential Oil of Artemisia annua L.: An Extraordinary Component with Numerous Antimicrobial Properties. Evid Based Complement Alternat Med. 2014; 2014:159819.Duarte MCT, Figueira G M, Sartoratto A, Rehder VLG, Delarmelina C. Anti-Candida activity of Brazilian medicinal plants. J Ethnopharmacol. 2005;97(2):305-11.Sartoratto A, Machado ALM, Delarmelina C, Figueira GM, Duarte MCT, Rehder VLG. Composition and antimicrobial activity of essential oils from aromatic plants used in Brazil. Braz J Microbiol. 2004;35(4):275-80.Morales G, Paredes A, Sierra P, Loyola LA. Antimicrobial activity of three baccharis species used in the traditional medicine of Northern Chile. Molecules. 2008;13(4):790-94.Oliveira WA, Arrua JMM, Wanderley PA, Lima RB, Lima EO. Effects of the essential oil of Cymbopogon winterianus against Candida albicans. Rev Pan-Amaz Saude. 2015;6(3):21-6.Tragiannidis A, Tsoulas C, Groll AH. Invasive candidiasis and candidaemia in neonates and children: update on current guidelines. Mycoses 2015;58(1):10-21.Hafidh RR, Abdulamir AS, Vern LS, Bakar FA, Abas F, Jahanshiri F et al. Inhibition of growth of highly resistant bacterial and fungal pathogens by a natural product. Open Microbiol J. 2011;5:96-106.Monk BC, Goffeau A. Outwitting multidrug resistance to antifungals. Sci. 2008;321(5887):367-69.

Introduction: We present a case report of posterior reversible leukoencephalopathy syndrome (PRES) following transarterial chemoembolization (TACE) of liver metastasis of an intestinal neuroendocrine tumour.Case presentation: A 62-year-old female was evaluated for progressive bilateral vision loss following transarterial chemoembolization (TACE) of hepatic metastasis of a midgut carcinoid tumour with cisplatin. Vital signs were remarkable for significant hypertension (170-210/85-110) since having undergone TACE (baseline BP 136/74), despite pre-procedure administration of octreotide. Blood pressure failed to correct with administration of amlodipine, hydralazine, captopril and labetalol infusion but responded promptly to octreotide infusion. Magnetic resonance imaging showed findings compatible with PRES. The patient’s vision gradually corrected to her baseline over 2 days. Conclusion: TACE for neuroendocrine tumours can be complicated by carcinoid crisis despite pre-administration of octreotide. Rarely, this may present as a hypertensive emergency of which PRES is a manifestation. Prompt recognition and treatment with high dose octreotide are important and can avoid permanent neurological injury in patients.RésuméIntroduction : Il s’agit d’une étude de cas de syndrome de leuco encéphalopathie réversible postérieure (SERP) consécutive à la chimioembolisation transartérielle (CETA) d’une métastase hépatique d’une tumeur neuro-endocrinine intestinale.Présentation du dossier: Une femme de 62 ans est évaluée pour une perte de vision bilatérale progressive à la suite de la chimioembolisation transartérielle (CETA) de métastases hépatiques d’une tumeur du tube digestif effectuée au moyen du cisplatine. Les signes vitaux sont remarquables malgré une hypertension importante (170-210/85-110) depuis la CETA (p.a. de base 136/74) et l’administration d’octréotide préalable à l’intervention. La pression artérielle ne s’est pas corrigée avec l’administration d’amlodipine, d’hydralazine, de captopril et de labétalol en perfusion, mais a répondu promptement à l’octréotide en perfusion. Une imagerie par résonnance magnétique a fourni des résultats compatibles avec un diagnostic de SERP. La vision de la patiente s’est graduellement corrigée pour revenir à son état habituel en deux jours.Conclusion : Dans le cas de tumeurs neuro-endocriniennes, la CETA peut être compliquée d’une crise carcinoïde malgré l’administration d’octréotide au préalable. Cette condition peut, quoique rarement, représenter une urgence hypertensive dont le SERP est une manifestation. L’identification rapide de la condition et un traitement à l’aide d’octréotide à dose élevée sont de la plus haute importance et peuvent éviter des dommages neurologiques permanents.Carcinoid syndrome is a syndrome classically consisting of diarrhea, paroxysms of cutaneous flushing with or without hypotension and bronchospasm arising most frequently in the setting of hepatic metastases originating from midgut carcinoid tumours. However, these neuroendocrine tumours can synthesize a wide variety of polypeptides, prostaglandins, and biogenic amines and hence present atypical clinical manifestations such as pellagra, abdominal pain, right-sided heart failure from valvular lesions and paroxysmal hypertension. Tumour manipulation may result in a massive influx of hormones into the systemic vasculature, potentially resulting in life threatening swings in blood pressure, cardiac arrhythmias and bronchoconstriction, even in patients without liver metastases or preoperative carcinoid syndrome.1 We present a case report of hypertensive emergency presenting as posterior reversible leukoencephalopathy syndrome (PRES) after transarterial chemoembolization (TACE) of a hepatic metastasis of carcinoid tumour.Case PresentationA 62-year-old caucasian female was evaluated on the surgical ward for progressive bilateral vision loss about 10 hours following transarterial chemoembolization (TACE) of a hepatic metastasis of a midgut carcinoid tumour (Figure 1, Figure 2) with Lipiodol and cisplatin. Premedication with octreotide 100 mcg subcutaneously and dexamethasone 8 mg IV pre-procedure was given, and post-procedure orders were given for dexamethasone 4 mg bid, ondansetron as needed and D5% NaCl 0.45% at a rate of 150 mL/h. The rest of her past medical history was unremarkable, specifically without history of hypertension, cerebrovascular disease, or clinical manifestations of carcinoid syndrome prior to admission. She had undergone two intra-abdominal surgeries without complication. Her usual medication was limited to inhaled glycopyrronium and indacaterol. Figure 1. Axial computed tomography scan of hepatic metastasis. A mass is visible in hepatic parenchyma corresponding to a metastasis of the midgut carcinoid tumour. Figure 2. Fluroscopic image of transarterial chemoembolization of hepatic metastasis. Upon evaluation, the patient was somnolent but otherwise well oriented. Eye exam confirmed bilateral 0/20 vision though pupils were 4 mm and reactive. On motor exam, the patient had diffuse hyperreflexia with upgoing plantar reflexes but without focal weakness. Chart review was remarkable for blood pressures ranging from 170-210/85-110 since TACE (pre-procedure blood pressure 136/74). A presumptive diagnosis of PRES due to cisplatin was made.Initial cerebral computed tomography scan was suspicious for a right occipital sub-cortical hypodensity of 3 cm, possibly of ischemic nature. IV fluids were discontinued (NaCl 0.9% at a rate of 250 mL/h) and anti-hypertensive agents were begun. After failure of improvement of blood pressure or symptoms despite amlodipine, hydralazine, labetalol, and captopril, a diagnosis of carcinoid crisis was suspected and octreotide 300mcg IV bolus followed by an infusion of 50 mcg/h was started. The suspected diagnosis of carcinoid crisis was later confirmed by 24h urinary 5-HIAA dosing at 141.4 umol/day (normal 0–42, previously within normal limits pre-operatively). Serum chromogranin A was also elevated at 138.2 ug/L (normal 0–82), compatible with a neuroendocrine tumour.Characteristic changes of PRES were seen on cerebral magnetic resonance imaging (MRI) (Figure 3) including predominantly sub-cortical hyperintensities in the bilateral parietal and occipital lobes on T2 and FLAIR sequences which were also hyperintense on diffusion-weighted imaging (DWI), likely from T2 shine through, and apparent diffusion coefficient (ADC) maps without restricted diffusion, hence confirming the finding of vasogenic edema compatible with PRES. Figure 3. FLAIR sequence, axial slice, cerebral magnetic resonance imaging. Subcortical hyperintensies in the bilateral occipital lobes reflecting vasogenic edema of the visual white matter tracts are seen. The patient’s blood pressure and her visual symptoms progressively normalized over 48 hours. On last follow-up 1 month after procedure, vital signs were normal (blood pressure 115/54) and vision was normal.DiscussionCarcinoid tumours are classically described as slow growing, mainly affecting the gastrointestinal (GI) tract. They are known to internists mainly for their capability to produce the carcinoid syndrome. However, only about 25% of carcinoids actually produce the mediators which produce the carcinoid syndrome and less than 10% of patients actually develop the carcinoid syndrome.2 The syndrome usually presents when midgut carcinoids metastasize to the liver, hence bypassing hepatic metabolism. Typical symptoms include secretory diarrhea (80%) and flushing of the head, neck, and upper torso (90%) which may be associated with hypotension and tachycardia. Less frequent manifestations are right heart failure due to carcinoid valve disease (30%), bronchospasm (15%) and pellagra (5%). 3 The classic triad of flushing, diarrhea and wheezing is infrequently found. Foregut (e.g., bronchial) and extra-digestive midgut (e.g., ovarian) bypass the liver and may result carcinoid syndrome without hepatic metastasis, although symptoms are usually atypical in these cases.Perioperative carcinoid crisis occurs in 10–30% of patients undergoing operative resection. Absence of preoperative carcinoid syndrome decreases the risk of carcinoid crisis, however it may still occur.1 This has led to the recommendation by some that patients be premedicated with somatostatin analogues to block bioactive peptide release and action, with or without other hormone antagonists (e.g., anti-histamines).3 However, the benefit of octreotide prophylaxis has been questioned by other studies.1 Once a carcinoid crisis has occurred, bolus doses of 25–500 mcg and intravenous infusions at rates of 50–150 mcg/h have been effective in case reports and case series, with higher doses being potentially required in patients on maintenance octreotide therapy or with carcinoid heart disease.4Despite a lack of data comparing it to surgical management, transarterial chemoembolization (TACE).5 is a frequent management strategy for patients with liver metastases, especially when patients present with hormonal symptoms and multiple metastases preclude resection. Rates of complication from TACE are difficult to estimate ranging from 0 to 100%, likely due to variable definitions and reporting. Only one study reported on the incidence of post embolization carcinoid crisis,6 with 2 of 12 patients developing the complication. Both had a history of carcinoid syndrome and had been premedicated with octreotide 200 mcg SC before procedure and q8h afterward. One group7 did report a patient who developed transient cortical blindness following TACE which possibly could have been due to PRES.PRES is a syndrome of failure of cerebral blood pressure autoregulation with acute onset elevations of blood pressure from baseline and a combination of altered level of consciousness, visual symptoms, headache and seizures.8 Blood pressure is often only moderately elevated, though significantly above the patient’s baseline. Etiologies are varied but include cytotoxic chemotherapy, eclampsia and other causes of hypertensive emergency. It was originally felt that the patient’s PRES was due to the cisplatin received during TACE with contribution from dexamethasone and iatrogenic fluid overload (NaCl 0.9% at 150 mL/h had been running for several hours) as she had no history of carcinoid syndrome, had been premedicated and had no other findings associated with the disease. However, her lack of response to standard anti-hypertensives and prompt response to octreotide suggest carcinoid crisis as the cause.Neuroimaging with MRI confirms the diagnosis. Findings are compatible with symmetrical white matter edema in the posterior cerebral hemispheres, particularly the parieto-occipital regions. The cortex, basal ganglia, brainstem, and cerebellar may also be involved though less so than the subcortical white matter, while anterior cortical involvement is seen only with the most severe cases. Importantly, the distribution is not confined to a single vascular territory. Classically lesions appear as punctate or confluent areas of hyperintensity on T2 and FLAIR sequences.9 DWI usually shows hypo or iso-intense signal (though sometimes mildly hyperintense from T2 shine through) while ADC maps show increased signal, thus distinguishing PRES from ischemic stroke. With prompt recognition and management, full recovery over a period of days to weeks can be expected. ConclusionsCarcinoid crisis is a well-known and dreaded complication of surgical manipulation of carcinoid tumours. Transarterial chemoembolization of these tumours may also result in carcinoid crisis and our report suggests that pre-procedure carcinoid syndrome is not a prerequisite for this. Presentation may be atypical, as it was in our patient, and so clinical suspicion should be high. When suspected, prompt management with octreotide and other supportive therapies should be instituted.Key Points1. Patients undergoing transarterial chemoembolization for carcinoid tumour metastases are at risk for carcinoid crisis, even if they have been premedicated with octreotide and have no history of carcinoid syndrome.2. Carcinoid crisis may present as hypertensive crisis rather than hypotension, and may give rise to PRES.References1. Condron ME, Pommier SJ, Pommier RF. Continuous infusion of octreotide combined with perioperative octreotide bolus does not prevent intraoperative carcinoid crisis. Surgery 2016;159:358–67.2. Van Der Lely AJ, Herder WWd. Carcinoid syndrome: diagnosis and medical management. Arquivos Brasileiros de Endocrinologia & Metabologia 2005;49:850–60.3. Mancuso K, Kaye AD, Boudreaux JP, et al. Carcinoid syndrome and perioperative anesthetic considerations. J Clin Anesth 2011;23:329–41.4. Seymour N, Sawh SC. Mega-dose intravenous octreotide for the treatment of carcinoid crisis: a systematic review. Can J Anesth/J can d'anesthés2013;60:492–9.5. Kennedy A, Bester L, Salem R, Sharma RA, Parks RW, Ruszniewski P. Role of hepatic intra‐arterial therapies in metastatic neuroendocrine tumours (NET): guidelines from the NET‐Liver‐Metastases Consensus Conference. HPB 2015;17:29–37.6. Maire F, Lombard-Bohas C, O’Toole D, et al. Hepatic arterial embolization versus chemoembolization in the treatment of liver metastases from well-differentiated midgut endocrine tumours: a prospective randomized study. Neuroendocrinology 2012;96:294–300.7. Gupta S, Johnson MM, Murthy R, et al. Hepatic arterial embolization and chemoembolization for the treatment of patients with metastatic neuroendocrine tumours. Cancer 2005;104:1590–602.8. Hinchey J, Chaves C, Appignani B, et al. A reversible posterior leukoencephalopathy syndrome. N Engl J Med 1996;334:494–500.9. Pedraza R, Marik PE, Varon J. Posterior reversible encephalopathy syndrome: a review. Crit Care Shock 2009;12:135–43.

Photo by Sam McGhee on Unsplash ABSTRACT Medical education has a long history of discriminatory practices. Because of the hierarchy inherent in medical education, underrepresented-in-medicine (URiM) students are particularly vulnerable to discrimination and often feel they have limited recourse to respond without repercussions. URiM student leaders at a USA medical school needed their peers, faculty, and administration to know the institutional racism and other forms of discrimination they regularly experienced. The students wanted to share first-person narratives of their experiences; however, they feared retribution. This paper describes how the medical students partnered with a theater company that applied elements of verbatim theater to anonymously present student narratives and engage their medical school community around issues of racism and discrimination. The post-presentation survey showed the preponderance of respondents increased understanding of URiM student experiences, desired to engage in conversation about inclusion, equity, and diversity, and wanted to make the medical school more inclusive and equitable. Responses from students showed a largely positive effect from sharing stories. First-person narratives can challenge discriminatory practices and generate dialogue surrounding the experiences of URiM medical students. Authors of the first-person narratives may have a sense of empowerment and liberation from sharing their stories. The application of verbatim theater provides students the safety of anonymity, thereby mitigating fears of retribution. INTRODUCTION The field of medicine has a long history of discriminatory practices toward racial and ethnic minorities, women, and members of the LGBTQ+ community.[1] Because of the inherent hierarchy in medical education, medical students are particularly vulnerable to discriminatory practices and may feel they have limited recourse to respond to discrimination.[2] Underrepresented-in-medicine (URiM) students experience “death by a thousand cuts,” often with the perception that they are alone to shoulder and overcome injurious behavior inflicted by peers, faculty, and administrators. l. Social Impetus and Desire for Change Spring 2020 saw the confluence of three social exigencies in the United States: the disproportionate burden of the COVID-19 pandemic on people of color;[3] wide-spread awareness of racist police brutality;[4] and resurgence of demands for equity within medicine by the White Coats for Black Lives organization.[5] URiM student leaders at the Frank H. Netter MD School of Medicine at Quinnipiac University, CT, USA, felt compelled to awaken their medical school community to the bias and discrimination they faced regularly. The URiM student leaders (15 people representing Student National Medical Association, Latinx Medical Student Association, Netter Pride Alliance, Asian Pacific American Medical Student Association, Student Government Association, and White Coats for Black Lives) met regularly with the medical school dean and associate deans to address issues of culture and institutional racism. They needed their peers, faculty, and administration to know that institutional racism and other forms of discrimination were present in the school of medicine, despite vision and mission statements that prioritize equity and inclusion. To that end, in addition to advocating for policy changes, the URiM student leaders wanted to share personal stories from their classmates with the hope that the narratives had the power to instigate change for the better at the school of medicine. They wanted to be heard and seen and to have their perceptions recognized and valued; yet, they could not shake the fear of retribution if they were truly honest about their experiences. Therefore, the students concluded that anonymous storytelling was the safest approach. ll. Foundational Deliberations and Partnership To anonymizing their stories, the students first had to deliberate two foundational features: One: How to account for a plurality of opinions and make decisions? Two: How to speak about their personal experiences and maintain anonymity? The 15 URiM student leaders elected three students (GH, VS, SD) to organize the event and imbued the three organizers with decision-making capacity. The three students, named the Crossroads Organizers, arrived at decisions by consensus. With the aim of maintaining student anonymity, a faculty member (AW) suggested the students investigate using a theater company to present their stories – the premise being that the actors would provide anonymous cover for the students while speaking the students’ words. Having a script comprised exclusively of storytellers’ words is a foundational technique of verbatim theater.[6] The students decided the Crossroads Organizers would meet theater company representatives to seek assurance that their stories would be presented with respect and appropriate representation. Squeaky Wheelz Productions[7] is a theatrical production company specializing in giving voice to the stories of minoritized individuals. lll. Recruit Story Authors The Crossroads Organizers used email and social media platforms such as Facebook, GroupMe, and Instagram to invite medical students to author stories. Authors were given three weeks to submit their stories via an anonymous survey drop on Google Forms, thus assuring that no one, including the Crossroads Organizers, knew the identity of the story authors. lV. Work with the Theater Company The Crossroads Organizers met with the director of the theater company (AMW) multiple times to discuss logistics for the production. The director guided the medical students to refine their goals for the audience and authors (see Theater Company Process) and establish the timeline and task list to arrive at a finished product promptly. Initially, the Crossroads Organizers thought it would be a good idea to have the authors and actors meet to discuss their specific stories and roles. However, after further discussion, they decided that meeting would compromise the anonymity of the student authors and might discourage them from coming forward. Instead, they let the authors know they had the option of meeting their actor. In the Google Forms survey, the Crossroads Organizers provided the opportunity for authors to list specific demographic characteristics of the actor they wanted to portray their story. For example, a Latinx author could choose to have a Latinx actor portray their story. V. Theater Company Process The Squeaky Wheelz actors and director met to discuss how best to use their artistic skills to serve the students’ goals. Given that the collaboration occurred amid the COVID-19 pandemic, there were health, safety, technology, and geography parameters that informed the creative decisions. Actors were recorded individually, and then the footage was edited to create one cohesive piece. Using video meant that in addition to the artistic choices about casting, tone, pacing, and style (which are elements of an in-person event), there were also choices about editing, sound, and mise-en-scéne (“putting in the scene” or what is seen on screen). The Squeaky Wheelz director collaborated with the Crossroads Organizers about the project goals for their audience and colleagues. For example, the theater company encouraged the Crossroads Organizers to consider questions such as: Do they want to tell the viewer what to feel? If a student author identified their race or ethnicity in their story, should casting reflect that as well? Is there anything they would like the audience to know in a disclaimer, or should the stories stand on their own? Consequent to the discussions, the theater company made the decision to not include music or sound (often used in film to dictate emotion), to cast actors of the same race or ethnicity if the author included such identifiers, and to create an introduction for the piece. The introduction stated: “The stories you are about to hear are the true, lived experiences of students in this program, read by actors. Students submitted these words anonymously. We, the actors, ask you to listen.” The Crossroads Organizers expressed their goal was to share the stories authentically and to be clear that these were real experiences, not fictional accounts performed by actors. To serve these goals artistically in the mise-en-scéne, each actor was filmed in front of a plain white wall, in a medium-close-up, and holding a piece of white paper in the bottom corner of the frame from which they read the story. The actors looked straight to the camera for most of their reading, occasionally looking down to the paper to indicate that these words belonged to someone else visually. Actors were directed to “read the words,” not “perform the story” – to communicate the words simply and clearly rather than projecting an assumed emotionality behind the story. This choice was made for two reasons: One, the stories were submitted anonymously, and an assumed emotion may have been inaccurate to the author’s intention; two, without projecting assumed emotionality, the audience has permission to feel and think for themselves in response. All the actors worked independently to prepare for their virtual shoot dates. They also were available if any student authors wanted to meet about their personal stories. [One author chose to meet with their actor.] The final production, comprised of 16 student stories, was entitled Netter Crossroads: A Discourse on Race, Gender, Sexuality, and Class. Vl. Finding the Audience Knowing the unique features and importance of the video as a tool to increase awareness of institutional racism and discrimination within the school community, the Crossroads Organizers aimed to secure as large a viewing audience as possible. To that end, they sought and obtained approval from the dean of the school of medicine to show the video during the Annual State of the School Address, which historically is delivered on the first day of classes and attracts a sizable cross-section of students, faculty, and staff. The Crossroads Organizers asked the dean and associate deans to make event attendance mandatory to engage as many students and faculty as possible in active reflection about discrimination, racial inequality, and social injustice within the medical education community. The deans agreed to make attendance mandatory for first-year medical students and to strongly encourage all other students, faculty, and staff to attend. The Annual State of the School Address is typically an in-person event. Because of the COVID-19 pandemic, all university events had to be hosted virtually on Zoom. The Crossroads Organizers valued the real-time shared experience of viewing the video as a community, so they decided to divide the video into four short segments. The shorter length increased the likelihood that the video’s audio and visual quality was not affected. Between the video segments, the Crossroads Organizers presented national data about underrepresentation in medicine. Vll. Attendee Feedback The 2020 State of the School event had 279 attendees who watched the video, Netter Crossroads: A Discourse on Race, Gender, Sexuality, and Class, in real-time. The audience was comprised of medical students, medical school faculty, staff, and administrators, and university administrators. A four-question Likert-scale survey and open-response field disseminated after the event indicated the vast preponderance of attendees were favorably impressed by the Crossroads video (see Table 1). Approximately 84 percent (67/80) of respondents strongly agreed or agreed with the statement that their understanding of URiM student experiences had increased based on the presentation. Approximately 82 percent (66/80) of respondents strongly agreed or agreed with the statement that the Crossroads presentation effectively conveyed the challenges of URiM students. Seventy percent of respondents (56/80) strongly agreed or agreed with the statement that they were more inclined to engage in conversation about inclusion, equity, and diversity since seeing the Crossroads presentation. Approximately 77 percent (62/80) of respondents strongly agreed or agreed that since seeing the Crossroads presentation, they wanted to learn more about how to help make the medical school more inclusive and equitable. Table 1. Likert-scale survey results after viewing Crossroads video (N=80). The open-response field attracted 24 commentators who largely made favorable comments. Representative favorable comments included: “That was a great presentation. I wish I could hear more from students like that.” “A big thank you to the students who conveyed their stories to the actors – that was a heavy lift.” “Hearing the stories of people at Netter made this presentation hit close to home.” “The Crossroads presentation was outstanding and really opened my eyes to things that I had no idea were happening or that I had never even thought about.” “Definitely we need to hear more of these voices. Very powerful and moving session!” “It was powerful to hear real students’ experiences, played by actors…It communicated to me that Netter is…really committed to improving diversity and inclusion.” Representative unfavorable comments include: “I found this style confrontational instead of conversant/dialogue, and that may have been what the students were going for…but dialogue might have been just as, if not more, effective…” “I fear that welcoming new students virtually to our school by sharing stories of bias, racism, and sexism at our own institution may have left them feeling even more isolated and insecure.” “We need less of these presentations.” Vlll. Student Author Survey After the assembly, the Crossroads Organizers posted announcements on their social media sites inviting the student authors to respond to two queries about their experiences of sharing their stories. Since the student authors were anonymous and unknown to the Crossroads Organizers, they could not directly query the student authors. Instead, the posted announcement asked for open responses to the following questions: a. How did writing and sharing your personal experience at Netter make you feel? b. How did viewing your story portrayed by actors during the state of the school address make you feel? Six of the sixteen student authors put their responses anonymously in a Google Forms survey drop. The authors indicated a range of feelings about writing and sharing their personal experiences. Several authors expressed appreciation for the process and the psychotherapeutic effects. “I feel as though it was an opportunity for my voice to be heard in an anonymous way.” [student author #3] “Empowered to get that frustration out.” [student author #4] “It helped me process some thoughts and emotions that were bothering me subconsciously. I was allowing things like microaggressions affect me without actually addressing the issues.” [student author #6] Others focused on the value of having an audience for their experience. “I feel as though at school, I am never in safe spaces to be able to share my concerns, and that my voice is never heard. I just appreciated being able to vent to someone else about my experiences other than my friends.” [student author #3] “Before this presentation, I had only shared my feelings about being viewed as a minority at school privately with my close friends. Hearing someone else’s stories normalized my feelings of isolation (unfortunately).” [student author #5] Two authors expressed concern about how their stories would be received. “A little worried about the reaction.” [student author #1] “Vulnerable, scared, apprehensive.” [student author #2] The authors also had a range of responses about their experience of seeing their stories portrayed by actors. For some, there was a sense of exuberance and activation. “Really empowered!” [student author #1] “The actors were excellent and really funneled our voices. Viewing both my story and the other students’ [stories] made me realize there is so much work that needs to be done in predominantly white medical schools.” [student author #5] Others conveyed hopefulness. “Heard…like attempts were made to at least take my experience seriously.” [student author #2] Some students experienced conflicting and even negative emotions. “It made me feel sad, but also proud…” [student author #3] “The negative stress racism and discrimination that plays on underrepresented medical students is traumatizing and completely unfair. We are all trying to succeed as future physicians and none of us should carry the burden of feeling targeted based on our skin color or physical features. Viewing the other stories made me feel angry that these micro/macro-aggressions are tolerated every single day.” [student author #5] “It made me feel vulnerable that my experience was on display for the community to see.” [student author #6] And finally, there was mention of the psychodynamic processing that took place from seeing their experiences. “I felt that it was relatively therapeutic.” [student author #3] “It also helped me work through the emotions that I had been suppressing.” [student author #6] CONCLUSION Discriminatory practices often go unnoticed or unmentioned in the medical education setting. Failure to address discriminatory practices leads to isolation, stress, and disempowerment. To mitigate these harms, the medical school curriculum should enable conversations and events about racism and other forms of discrimination. URiM student narratives can aid faculty and student development. After viewing the stories, facilitated conversations could address questions such as the following: a. What could you do to prevent this scenario from ever even occurring? b. Now that it has occurred, how will you support this student? c. What structural changes and/or policies need to be in place for corrective action to be effective? d. If the scenario in the video happened to you, what would you do next? e. Why would you make that choice? f. Alternatively, if you witnessed this happen to a student or faculty member, what would you do? g. Why would you make that choice? h. What are the potential personal and professional consequences of your choice? In alignment with the published literature, our small sample of student author respondents experienced positive therapeutic effects from the process of writing and sharing their stories.[8] At the same time, seeing other authors’ stories of discrimination portrayed by actors ignited anger and sadness for some of our students as they recognized the depth of trauma within the community. Partnership with a theater company provides students the safety of anonymity when telling their stories, thereby allaying their fears of retribution. While some student authors maintained a sense of vulnerability despite the anonymity, they also expressed a sense of empowerment, hopefulness, and pride. Medical educators and administrators must take bold steps to address institutional racism in a meaningful way. Health humanities, including theater, can help the medical education community recognize and overcome the harms imposed on URiM students by institutional racism and other forms of discrimination and awaken capacity for compassionate, respectful, relationship-based education. [1] Hess, Leona, Palermo, Ann-Gel, and David Muller. 2020. “Addressing and Undoing Racism and Bias in the Medical School Learning and Working Environment” Academic Medicine, 95, no. 12 (December): S44-S50. https://pubmed.ncbi.nlm.nih.gov/32889933/ [2] Naif Fnais et al., “Harassment and Discrimination in Medical Training: A Systematic Review and Meta-analysis,” Academic Medicine 89, no. 5 (2014): 817-827, https://doi.org/10.1097/ACM.0000000000000200; Melody P. Chung et al., “Exploring Medical Students’ Barriers to Reporting Mistreatment During Clerkships: A Qualitative Study,” Medical Education Online 23, no. 1 (December 2018): 1478170, https://doi.org/10.1080/10872981.2018.1478170 [3] “Racial Data Transparency,” Coronavirus Resource Center, Johns Hopkins University & Medicine, accessed July 15, 2021, https://coronavirus.jhu.edu/data/racial-data-transparency [4] Radley Balko, “There’s Overwhelming Evidence that the Criminal Justice System is Racist. Here’s the Proof,” Washington Post, June 10, 2020, https://www.washingtonpost.com/graphics/2020/opinions/systemic-racism-police-evidence-criminal-justice-system/. [5] “WC4BL,” White Coats for Black Lives, accessed May 15, 2021, www.whitecoats4blacklives.org. [6] Will Hammond and Dan Steward, eds., Verbatim: Contemporary Documentary Theatre (London: Oberon Books, 2012). [7] “Our Vision,” Squeaky Wheelz Productions, accessed June 30, 2021, www.squeakywheelzproductions.com/. [8] James Pennebaker and Joshua Smyth, Opening Up by Writing It Down: How Expressive Writing Improves Health and Eases Emotional Pain, 3rd ed (New York, London: The Guilford Press, 2016).

Introduction While individuals from marginalised and vulnerable communities have long been confronted with the task of developing coping strategies, COVID-19 lockdowns intensified the conditions under which resilience and wellbeing were/are negotiated, not only for marginalised communities but for people from all walks of life. In particular, the pandemic has highlighted in simple terms the stark divide between the “haves” and “have nots”, and how pre-existing physical conditions and material resources (or lack thereof), including adequate income, living circumstances, and access to digital and other resources, have created different conditions for people to be able to physically isolate, avoid working in conditions that put them at greater risk of exposure to the virus, and maintain up-to-date information. The COVID-19 pandemic has changed the way we live, and its conditions have tested our capacity for resilience to varying degrees. Poor mental health has become an increasingly urgent concern, with almost one in ten people contemplating suicide during Victoria’s second wave and prolonged lockdown in 2020 (Ali et al.; Czeisler & Rajaratnam; Paul). The question of what enables people to cope and adapt to physical distancing is critical for building a more resilient post-pandemic society. With the understanding that resilience is comprised of an intersection of material and immaterial resources, this project takes as its focus the material dimensions of everyday resilience. Specifically, “Objects for Everyday Resilience” explores the intersection of material objects and everyday resilience, focussing on the things that have supported mental and physical health of different sections of the community in Melbourne, Australia, during the pandemic. People in the Victorian city of Melbourne, Australia – including the research team authors of this article – experienced 262 days of lockdown due to the COVID-19 pandemic, more than any other city in the world. The infection rate was high, as was the death rate. Hospitals were in crisis attempting to deal with the influx (McReadie). During lockdowns in 2020 and 2021, all movement in the city was restricted, with 9 pm to 5 am curfews and a five-kilometre travel limit. Workplaces, schools, businesses, sports and leisure clubs were closed. One person per household could shop. Masks were mandatory at all times. PCR testing was extensive. People stayed in their homes, with no visitors. The city limits were closed by roadblocks. Rare instances of air travel required a hard-to-get exemption. Vaccines were delayed. The state government provided financial support for most workers who lost income from their regular work due to the restrictions. However, the financial assistance criteria rejected many casual workers, including foreign students who normally supported themselves through casual employment (McReadie). The mental health toll of protracted lockdowns on Melbourne residents was high (Klein, Tyler-Parker, and Bastian). Yet people developed measures of resilience that helped them cope with lockdown isolation (Gerrand). While studies of resilience have been undertaken during the pandemic, including increased attention towards the affordances of online platforms in lockdown, relatively little attention has been paid to whether and how material objects support everyday resilience. The significant amount of literature on objects and things (e.g. Whitlock) offers a wide range of potential applications when brought to bear on the material conditions of resilience in the COVID-19 pandemic as it continues to unfold. As ethnographer Paula Zuccotti notes in her study of objects that people used in lockdowns around the world, “Future Archeology of a Global Lockdown”, the everyday items we use tell us stories about how we exist (Zuccotti). Paying attention to the intersection of objects with resilience in everyday contexts can enable us to view resilience as a potential practice that can shape the conditions of social life that produce adversity in the first place (Chalmers). By studying relationships between material objects and people in conditions of adversity, this project aims to enhance and extend emerging understandings of multisystemic resilience (Ungar). Objects have been central to human history, culture, and life. According to Maurizio Ferraris, objects are characterised by four qualities: sensory-ness, manipulability, ordinariness, and relationality. “Unlike the three spheres of biological life – the mineral, the vegetable and the animal – objects and things have been customarily considered dependent on humans’ agency and presence” (Bartoloni). In everyday life, objects can enhance resilience when they are mobilised in strategies of resourcefulness and “making do” (de Certeau). Objects may also support the performance of identity and enable inter-subjective relations that create a sense of agency and of being at home, wherever one is located (Ahmed et al.; Gerrand). From an existential perspective, the experience of being confined in lockdown, “stuck” in one place, challenges cosmopolitan connectedness and sense of belonging. It also bears some similarities to the experiences of migrants and refugees who have endured great uncertainty, distance, and immobility due to detention or vintage of migration (Yi-Neumann et al.). It is possible that certain objects, although facilitating resilience, might also trigger mixed feelings in the individuals who relied on them during the lockdown (Svašek). From domestic accoutrements to digital objects, what kinds of things supported wellbeing in situations of confinement? Multisystemic Resilience in Lockdown It is especially useful to consider the material dimensions of resilience when working with people who have experienced trauma, marginalisation, or mental health challenges during the pandemic, as working with objects enables interaction beyond language barriers and enables alternatives to the re-telling of experiences. Resilience has been theorised as a social process supported (or inhibited) by a range of “everyday” intersecting external and contextual factors at individual, family, social, institutional, and economic resource levels (Ungar; Sherrieb et al.; Southwick et al.). The socio-ecological approach to resilience demonstrates that aspects of individual, family, and community resilience can be learned and reinforced (Bonanno), but they can also be eroded or weakened, depending on the dynamic interplay of various forces and influences in the social ecology of an individual or a group. This means that while factors at the level of the individual, family, community, or institutions may strengthen resistance to harms or the ability to overcome adversity in one context, the same factors can promote vulnerability and erode coping abilities in others (Rutter). Our project asked to what extent this social-ecological understanding of resilience might be further enhanced by attending to nonhuman materialities that can contribute or erode resilience within human relations. We were particularly interested in understanding the potential of the exhibition for creating an inclusive and welcoming space for individuals who had experienced long COVID lockdowns to safely reflect on the material conditions that supported their resilience. The aim of this exercise was not to provide answers to a problem, but to draw attention to complexity, and generate additional questions and uncertainties, as encouraged by Barone and Eisner. The exhibition, through its juxtaposition of (lockdown-induced) loneliness with the conviviality of the public exhibition format, enabled an exploration of the tension between the neoliberal imperative to physically isolate oneself and the public messaging concerning the welfare of the general populace. Our project emerged from insights collected on the issue of mental health during “Living Lab” Roundtables undertaken in 2020 by our Centre For Resilient and Inclusive Societies, convened as part of the Foundation Project (Lam et al.). In particular, we deployed an object-based analysis to investigate the art- and object-based methodology in the aftermath of a potentially traumatising lockdown, particularly for individuals who may not respond as well to traditional research methods. This approach contributes to the emerging body of work exploring the affordances of visual and material methods for capturing feelings and responses generated between people and objects during the pandemic (Watson et al.). “Objects for Everyday Resilience” sought to facilitate greater openness to objects’ vitality (Bennett) in order to produce new encounters that further understandings of multisystemic resilience. Such insights are critically tied to human mental health and physical wellbeing. They also enabled us to develop shared resources (as described below) that support such resilience during the period of recovery from the pandemic and beyond. Arts and Objects as Research The COVID-19 pandemic provoked not only a global health response, but also a reorientation of the ways COVID-related research is conducted and disseminated. Javakhishvili et al. describe the necessity of “a complex, trauma-informed psycho-socio-political response” in the aftermath of “cultural/societal trauma” occurring at a society-wide scale, pointing out the prevalence of mental health issues following previous epidemics (1). As they note, an awareness of such trauma is necessary “to avoid re-traumatization and to facilitate recovery”, with “safety, trustworthiness, transparency, collaboration and peer support, empowerment, choice” among the key principles of trauma-informed policies, strategies, and practices (3). Our project received funding from the Centre for Resilient and Inclusive Societies (CRIS) in July 2021, and ethics approval in November 2021. Centring materiality, in November 2021 we circulated a “call for objects” through CRIS’ and the research team’s social media channels, and collected over 40 objects from participants of all ages for this pilot study. Our participants comprised 33 women and 10 men. Following is a breakdown of the self-described cultural background of some participants: Five Australian (including one ‘6th generation Australian’); four Vietnamese; two Caucasian; one Anglo-Australian; one Asian; one Brazilian; one British; one Caucasian/English Australian; one Filipino; one Filipino-Australian; one German/Portuguese/US; one Greek Australian; one Iranian; one Irish and Welsh; one Israeli; one Half German, Half Middle Eastern; one Middle Eastern; one Singaporean; one White British. Participants’ objects and stories were analysed by the team both in terms of their ‘people, place, and things’ affordances – enhancing participants’ reflections of life in the pandemic – and through the prism of their vibrancy, drawing on object-oriented ontology and materiality as method (Ravn). Our participants were encouraged to consider how their chosen object(s) supported their resilience during the pandemic. For example, some objects enabled linking with memories that assist in elaborating experiences of loss or grief (Trimingham Jack and Devereux). To guide those submitting objects, we asked about: 1) their relationship to the object, 2) the meaning of the object, and 3) which features of resilience are mobilised by the object. From an analysis of our data, we have developed a working typology of objects to understand their particular relationship role to features of resilience (social capital, temporality) and to thematise our data in relation to emerging priorities in research in multisystemic resilience, materiality, and mental health. Things on Display Whilst we were initially unable to gather in person, we built an online Instagram gallery (@objectsforeverydayresilience) of submitted objects, with accompanying stories from research participants. Relevant hashtags in several languages were added to each post by the research team to ensure their widest possible visibility. This gallery features objects such as a female participant’s jigsaw puzzle which “helped me to pass the downtime in an enjoyable way”. Unlike much of her life in lockdown that was consumed by chores that “did not necessarily make me feel content or happy”, jigsaw puzzles made this participant “happy for that time I was doing them, transport[ing] me out of the confines of the lockdown with landscapes and images from across the globe”. Another female participant submitted a picture of her worn sneakers, which she used to go on what she called her “sanity walks”. To counteract the overwhelm of “being in the house all the time with 3 (autistic) children who were doing home learning and needed a lot of support”, while attempting to work on her PhD, going for walks every day helped clear my mind, get some fresh air, keep active and have some much needed quiet / me time. I ordered these shoes online because we couldn’t go to the shops and wore them almost daily during the extended lockdowns. Books were also popular. During lockdowns, according to a female participant, reading helped me connect with the outside world and be able to entertain myself without unhealthy coping mechanisms such as scrolling endlessly through TikTok. It also helped me feel less alone during the pandemic. Another female participant found that her son’s reading gave her time to work. Olfactory objects provided comfort for a participant who mourned the loss of smell due to mask wearing: perfumes were my sensory transport during this time – they could evoke memories of places I’d travelled to, seasons, people, feelings and even colours. I could go to far-off places in my mind through scent even though my body was largely stationary within my home. (Female participant) Through scent objects, this participant was “able to bring the world to meet me when I was unable to go out to meet the world”. Other participants sought to retreat from the world through homely objects: throughout lockdown I felt that my bed became an important object to my sanity. When I felt overwhelmed, I would come to bed and take a nap which helped me feel less out of control with everything going on in the world. (Female participant) For an essential worker who injured her leg whilst working in a hospital, an Ikea couch enabled recovery: “the couch saved my throbbing leg for many months. It served as a place to eat, paint and rest.” (Female participant) While pets were not included as objects within this project, several participants submitted their pets’ accoutrements. A female participant who submitted a photograph of her cat’s collar and tree movingly recounts how while I was working online in lockdown, this cat tree kept my cat entertained. She was so enthusiastic while scratching (covered in her fur) she somehow managed to remove her collar. I call Bouny my Emotional support cat … . She really stepped up her treatments of me during the pandemic. My mother had advanced dementia and multiple lockdowns [which] meant I could not see her in the weeks leading up to her death. These objects highlight the ways in which this participant found comfort during lockdown at a time of deep grief. For other participants, blankets and shawls provided sources of comfort “since much of lockdown was either in cool weather or deepest winter”. I found myself taking [my shawl] whenever I went out for any of the permitted activities and I also went to bed with it at night. The soft texture and the warmth against my face, neck and shoulders relaxed my body and I felt comforted and safe. (Female participant) Another used a calming blanket during lockdown “for time-outs on my bed (I was confined to a tiny flat at the time and separated from my family). It gave me a safe space”. (Female participant) In a similar vein, journalling provided several participants with “a safe space to explore thoughts and make them more tangible, acting as a consistent mindful practice I could always turn to”. The journal provided consistency throughout the ever-changing lockdown conditions and a strong sense of stability. Recording thoughts daily allowed me to not only process adversity, but draw attention to the areas in my life which I was grateful for … even from home. (Female participant) In addition to fostering mindfulness, the creative practice of journalling enabled this participant to exercise her imagination: writing from the perspectives of other people, from friends to strangers, also allowed me to reflect on the different experiences others had during lockdown. I found this fostered empathy and motivated me to reach out and check in on others, which in turn also benefited my own mental health. (Female participant) Creative practices were critical to sustaining many participants of this study. The Norman family, for example, submitted an acrylic on canvas artwork, Surviving COVID in Port Melbourne (2021), as their object of resilience: this work represents the sentiments and experiences of our family after a year of successive COVID lockdowns. Each section of the canvas has been completed a member of our family – 2 parents and a 21, 18 and 14 year-old. (Norman family) Likewise, musical instruments and sound objects – whether through analogue or digital means – helped participants to stay sane in long lockdowns: wen I didn’t know what to do with myself I always turned to the guitar. (Male participant) Music was so important to us throughout the lockdowns. It helped us express and diffuse big feelings. We played happy songs to amplify nice moments, funny songs to cheer each other up, angry songs to dance out rage. (Family participants) Curating the Lockdown Lounge To enhance the capacity of our project’s connections to the wider community, and respond to the need we felt to gather in person to reflect on what it meant for each of us to endure long lockdowns, we held an in-person exhibition after COVID-19 restrictions had eased in Melbourne in November 2022. The decision to curate the “Lockdown Lounge” art and research exhibition featuring objects submitted by research participants was consistent with a trauma-informed approach to research as described above. According to Crowther, art exhibits have the potential to redirect viewers’ attention from “aesthetic critique” to emotional connection. They can facilitate what Moon describes as “relational aesthetics”, whereby viewers may connect with the art and artists, and enhance their awareness of the self, artist, and the world. As a form of “guided relational viewing” (Potash), art exhibits are non-coercive in that they invite responses, discussion, and emotional involvement while placing no expectation on viewers to engage with or respond to the exhibition in a particular way. When considering such questions, our immersive in-person exhibition featured a range of object-based installations including audio-visual and sound objects, available for viewing in our Zine, The Lockdown Lounge (Walimunige et al.). The living room design was inspired by French-Algerian artist Zineb Sedira’s immersive living room installation, “Dreams Don’t Have Titles”, at the 59th Venice Art Biennale’s French pavilion (Sedira), attended by project co-lead Vivian Gerrand in June 2022. The project team curated the gallery space together, which was located at Deakin University’s city conference venue, “Deakin Downtown”, in Melbourne, Australia. Fig. 1: The Lockdown Lounge, living room. “What Got You through Lockdown?” research exhibition and experience, Deakin Downtown, Melbourne, 21-25 November 2022. In the centre of the Lockdown Lounge’s living room (see fig. 1), for example, a television screen played a looped collection of popular YouTube videos, many of which had gone viral in the early months of the COVID-19 pandemic. There was Victorian Premier Daniel Andrews, admonishing Victorians to avoid non-essential activities through the example of an illicit dinner party held that resulted in a spike in coronavirus cases in March 2020 (ABC News). This short video excerpt of the Premier’s press conference concluded with his advice not to “get on the beers”. While not on display in this instance, many visitors would have been familiar with the TikTok video remix made later in the pandemic that featured the same press conference, with Premier Andrews’s words spliced to encourage listeners to “get on the beers!” (Kutcher). We recalled the ways in which such videos provided light relief through humour at a time of grave illness and trauma: when army trucks were being summoned to carry the deceased from Northern Italian hospitals to makeshift gravesites, those of us privileged to be at home, at a remove from the ravages of the virus, shared videos of Italian mayors shouting at their constituents to “vai a casa!” (Go home!). Or of Italians walking fake dogs to have an excuse to go outside. We finished the loop with a reproduction of the viral Kitten Zoom Filter Mishap, in which in online American courtroom defendant Rod Ponton mistakenly dons a cat filter while telling the judge, ‘I am not a cat’. The extraordinary nature of living in lockdown initially appeared as an opportunity to slow down, and this pandemic induced immobility appeared to prompt a kind of “degrowth” as industries the world over paused operation and pollution levels plummeted (Gerrand). In reflection of this, we included videos in our YouTube playlist of wild animals returning to big cities, and of the waters of Venice appearing to be clear. These videos recalled how the pandemic has necessitated greater appreciation of the power of things. The spread of the novel coronavirus’s invisible variants has permanently altered the conditions and perceptions of human life on the planet, forcing us to dwell on the vitality intrinsic to materiality, and renewing awareness of human lives as taking place within a broader ecology of life forms (Bennett). Within this posthuman perspective, distinctions between life and matter are blurred, and humans are displaced from a hierarchical ontological centre. In an essay titled “The Go Slow Party”, anthropologist Michael Taussig theorises a “mastery of non-mastery” that yields to the life of the object. This yielding – a necessary response to the conditions of the pandemic – can enable greater attentiveness to the interconnectedness and enmeshment of all things, leading to broader understandings of self and of resilience. To understand how participants responded to the exhibition, we asked them to respond to the following questions in the form of open-ended comments: What if anything affected you most? Did any of the objects resonate with you? Did the exhibition provide a safe environment for you to reflect on your sense of resilience during the pandemic? Fig. 2: Research exhibition participant standing beside artwork by the Norman family: Surviving COVID in Port Melbourne, acrylic on canvas (2021), The Lockdown Lounge. Through curating the art exhibition, we engaged in what Wang et al. describe as “art as research”, whereby the artist-researcher aims to “gain a deeper understanding of what art, art creation, or an artistic installation can do or activate … either in terms of personal experiences or environmental circumstances” (15). As Wang et al. write, “the act of creating is simultaneously the act of researching”, neither of which can be distinguished from one another (15). Accordingly, the process of curating the gallery space triggered memories of living in lockdown for members of our team, including one male youth researcher who remembers: as the space gradually began to be populated with object submissions … the objects began to find their place … . We slowly developed an understanding of the specific configurations of objects and the feelings that these combinations potentially could invoke. As we negotiated where my object might be placed, I felt an odd sense of melancholy seeing my record player and guitar at the exhibition, reminiscing about the music that I used to play and listen to with my family when we were all in lockdown … . As my Bon Iver record spun, and the familiar melodies rung out into the space, I felt as if I was sharing an intimate memory with others … . It also reminded me of the times when I had felt the most uplifted, when I was with family, near and far, knowing that we all were a unit. Another of our youth researcher team members served as an assistant curator and agreed to monitor the gallery space by being there for most of the five days of the exhibition’s opening to the public. She describes her work in the gallery thus: my role involved general exhibition upkeep – setup, answering visitor inquiries and monitoring the space – which meant being in the exhibition space for around 7.5 hours a day. Although it cannot be fully compared to living through Melbourne’s lockdowns, being in a space meant to mimic that time meant that comparisons naturally arose. I can see similarities between the things that supported my resilience during the lockdowns and the things that made my time at the gallery enjoyable. Through engaging with the gallery, this researcher was reminded of how spending time engaging in hands-on tasks made physical distancing more manageable. Spending time in the exhibition space also facilitated her experience of the lockdowns and the material conditions supporting resilience. She reflects that the hands-on, creative tasks of setting up the exhibition space and helping design a brochure reminded me of how I turned to baking so I could create something using my hands … . In the beginning, I approached my time at the gallery as a requirement of my work in this project … . Looking back now, I believe I understand both the person I was those years ago, and resilience itself, a little bit better. Fig. 3: Research exhibition participant wearing an Oculus virtual reality headset, watching the film Melbourne Locked Down (van Leeuwen), The Lockdown Lounge, November 2022. As these examples demonstrate, complex assemblages of people, places, and things during the COVID-19 pandemic were, and are, “suffused with multisensory and affective feelings”; exploring the ways affect is distributed through socio-spatialities of human experience enables researchers to better unpack individuals’ COVID experiences in ways that include their surroundings (Lupton). This was further evident in the feedback received from participants who attended the exhibition. Exhibition Feedback Feedback from participants suggested that the public exhibition format enabled them to explore this tension between isolation and orientation to the greater good in a safe and inclusive way (e.g. fig. 2). For Harry (29/m/Argentinian/New Zealand), interacting with the exhibition “reminded me that I wasn’t the only one that went through it”, while Sam (40/m/Chinese Australian) resonated with “many … people’s testimonials” of how objects helped support their resilience during long periods of confinement. Sam further added that participating in the exhibition was a “pleasant, friendly experience”, and that “everyone found something to do”, speaking to the convivial and inclusive nature of the exhibition. This resonates with Chaplin’s observation that “the production and reception of visual art works are social processes” that cannot be understood with reference to aesthetic factors alone (161-2). In the quotes above, it is evident that participants’ experience of the exhibition was inherently entwined with the sociality of the exhibition, evoking a sense of connection to others who had experienced the pandemic (in Harry’s case), and other exhibition attendees, whom he observed “all found something to do”. Additionally, participants’ responses highlighted the crucial role of the “artist researcher”, whom Wang et al. describe as qualitative researchers who use “artistically inspired methods or approaches” to blend research and art to connect with participants (10). In particular, the curation of the exhibition was something participants highlighted as key to facilitating their recollections of the pandemic in ways that were relatable. Nala (19/f/East-African Australian) commented that “the room’s layout allowed for this the most”: “the room was curated so well, it encaptured [sic] all the various stages of COVID lockdown – it made me feel like I was 16 again”. Returning to Wang et al.’s description of “art as research” as a means through which artist researchers can “gain a deeper understanding of what art, art creation, or an artistic installation can do or activate” (15), participant responses suggest that the curation of Lockdown Lounge as a trauma-informed art exhibition allowed participants to re-experience the pandemic lockdowns in ways that did not re-traumatise, but enabled the past and present to coexist safely and meaningfully for participants. Conclusion: Object-Oriented Wellbeing From different sections of the community, “Objects for Everyday Resilience” collected things that tell stories about how people coped in long lockdowns. Displaying the objects and practices that sustained us through the peak of the COVID-19 health crisis helped our participants to safely reflect on their experiences of living through long lockdowns. The variety of objects submitted and displayed draws our attention to the complex nuances of resilience and its material and immaterial intersections. These contributions composed, as fig. 1 illustrates, an almost accidentally curated diorama of a typical lockdown scene, imitating not only the materiality of living room itself but something also, through the very process of contribution, of the strange collectivity that the city of Melbourne experienced during lockdown periods. Precisely partitioned within domestic zones (with important differences for many “essential workers”, residents of public housing high-rises, and other exceptions), lockdowns enforced a different and necessarily unifying rhythm: attention to daily briefings on COVID numbers, affective responses to the heaves and sighs of infection rates, mourning over a new and untameable cause of loss of life, and routine check-ins on newly isolated friends and family. In hindsight, as the city has regained – perhaps redoubled, a sign of impatience with earlier governmental languages of austerity and moderation? – its economic and hedonistic pulse, there are also signs that any lockdown collectivity – which we also acknowledge was always partial and differentiated – has dispersed into the fragmentation of social interests and differences typical of late capitalism. The fascination with “public” objects – the Northface jacket of the state premier, COVID masks and testing kits, even toilet paper rolls, serving metonymically for a shared panic over scarcity – has receded. To the point, less than two years on, of this media attention being a scarcely remembered dream. The Lockdown Lounge is an example of a regathering of experiences through a process that, through its methods, also serves as a reminder of a common sociality integral to resilience. Our project highlights the role of objects- and arts-based research approaches in understanding the resources required to enhance and enable pandemic recovery and multisystemic wellbeing. Acknowledgments We would like to thank the Centre for Resilient and Inclusive Societies for their funding and support of the Objects for Everyday Resilience Project. Thanks also to the Alfred Deakin Institute’s Mobilities, Diversity and Multiculturalism Stream for providing a supplementary grant for our research exhibition. Objects for Everyday Resilience received ethics clearance from Deakin University in November 2021, project ID: 2021-275. References ABC News. “’No Getting on the Beers’ at Home with Mates as Coronavirus Clampdown Increases.” Daniel Andrews Coronavirus Press Conference, 22 Mar. 2020. <https://www.theguardian.com/world/video/2020/mar/23/no-getting-on-the-beers-at-home-with-mates-as-coronavirus-clampdown-increases-video>. Ahmed, Sara, et al. Uprootings, Regrounding: Questions of Home and Migration. Oxford: Berg, 2003. Ali, Kathina, et al.“ A Cross-Sectional Investigation of the Mental Health and Wellbeing among Individuals Who Have Been Negatively Impacted by the COVID-19 International Border Closure in Australia.” Globalization and Health 18.1 (2022): 1–10. Bartoloni, Paolo. Objects in Italian Life and Culture: Fiction, Migration and Artificiality. Palgrave Macmillan, 2016. Bennett, Jane. Vibrant Matter: A Political Ecology of Things. Durham: Duke UP, 2010. Bolzan, Natalie, and Fran Gale. “Using an Interrupted Space to Explore Social Resilience with Marginalized Young People.” Qualitative Social Work 11.5 (2011): 502–516. Bonanno, George A. “Resilience in the Face of Potential Trauma.” Current Directions in Psychological Science 14 (2005): 135-38. Candlin, Fiona, and Railford Guins. The Object Reader. London: Routledge, 2009. Carter, Paul. Material Thinking: The Theory and Practice of Cultural Research. Melbourne: Melbourne UP, 2004. Centre for Resilient and Inclusive Societies. “Youth Diversity and Wellbeing in a Digital Age”. <https://www.crisconsortium.org/youth-diversity-wellbeing>. Chaplin, Elizabeth. Sociology and Visual Representation. London: Routledge, 1994. Crowther, Paul. Art and Embodiment: From Aesthetics to Self-Consciousness. Oxford: Oxford UP, 1993. Czeisler, Mark et al. “Mental Health, Substance Abuse, and Suicidal Ideation during a Prolonged COVID-19-Related Lockdown in a Region with Low SARS-CoV-2 Prevalence.” Journal of Psychiatric Research 140 (2021): 533–544. De Certeau, Michel. The Practice of Everyday Life. Berkeley: U of California P, 1984. Ferraris, Maurizio. Documentalità: Perché è Necessario Lasciar Tracce. Bari: Laterza, 2009. Flemming, Jennie. “Young People’s Involvement in Research: Still a Long Way to Go?” Journal of Qualitative Social Work 10.2 (2010): 326-340. Foundation Project. “Youth Diversity and Wellbeing in a Digital Age”. 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Photo by Hush Naidoo Jade Photography on Unsplash INTRODUCTION In this collection of narratives, the authors describe their own experiences with and reflections on healthcare worker vaccine hesitancy. The narratives explore each author’s engagement with different communities experiencing vaccine hesitancy, touching on reasons for hesitancy, proposed solutions, and legal aspects. Author’s names appear above their narratives. l. Johanna T. Crane Vaccine hesitancy, defined as “a delay of acceptance or refusal of vaccination despite the availability of vaccination services,”[1] is a worldwide but locally shaped phenomenon that pre-dates the COVID-19 pandemic.[2] Contrary to some portrayals, vaccine hesitancy is not the same as the more absolute antivaccination stance, or what some call “anti-vax.” Many people who are hesitant are not ideologically opposed to vaccines. Hesitancy is also sometimes framed as anti-science, yet reluctance to vaccinate is often about managing risk, trustworthiness, and doubt in the context of uncertainty; it represents an effort to “talk back to science” about unaddressed needs and concerns.[3] In the US, the newness of the vaccines, the unprecedented speed at which they were developed, and their remaining under emergency use authorization at first complicated public confidence. Political polarization and racial and social inequality shape vaccine acceptance and public distrust as well. While vaccine acceptance has increased in the months since the vaccines first became available, many eligible individuals have not yet been vaccinated, including a significant number of healthcare workers.[4] Vaccine hesitancy among healthcare workers may seem surprising, especially given their frontline experience – I confess that it surprised me at first. But when I began interviewing health care workers for a study on COVID vaccine roll-out at community health centers, I learned to take a more complex view. Although the study was focused on patient vaccine access,[5] many of the frontline health care workers we spoke with also described hesitancy among some of their colleagues (and, in a few cases, themselves). From these conversations, I learned that these “healthcare heroes” are also regular people and members of communities. Their concerns about COVID vaccination often reflect the prevailing concerns advanced in their communities, such as worries about vaccine side effects and safety. Like other workers, some fear missing work and losing income, as not all healthcare employers offer paid time off for vaccination or recovery. (Importantly, reluctance to vaccinate is highest among healthcare workers in lower-paid positions with little job security, such as clerks, housekeepers, patient care assistants, and home health aides.)[6] For some healthcare workers of color, the protection offered by the vaccine sits in tension with both current and historical experiences of medical abuse and neglect. Some interviewees, fully vaccinated themselves, rejected the framework of “hesitancy” entirely, arguing that Black and Brown reluctance to be vaccinated first should be understood through the lens of “self-protection”. Due to the nature of their work, healthcare workers have faced great social pressure to vaccinate and vaccinate first. This is understandable, given that vaccination against COVID-19 protects not only workers themselves but aligns with the ethical duty to prevent harm to patients by reducing the risk of transmission in healthcare settings. When the FDA approved COVID-19 vaccines under emergency use authorization in December 2020, many healthcare workers were extremely grateful to be designated “1a” – the first group prioritized to receive the shots.[7] For many bioethicists, prioritization of healthcare workers represented a recognition of the extreme risks that many front-line workers had endured since the onset of the pandemic, including critical shortages in PPE. But it is important to remember that for some workers, going first may have felt like serving as guinea pigs for new vaccines that had yet to be granted full FDA approval. For these individuals, the expectation that they would vaccinate first may have felt like an additional risk rather than a reward. Healthcare workers who are hesitant to vaccinate may feel ashamed or be subject to shaming by others;[8] this may make it difficult to discuss their concerns in the workplace. Throughout the pandemic, healthcare workers have been lauded as “heroes”, and some healthcare employers have promoted vaccination among their workforce as a “heroic” action. This messaging implies that waiting to vaccinate is shameful or cowardly and is echoed in opinion pieces and op-eds describing unvaccinated people as “selfish” or “free riders.”[9] By fostering the proper dialogue, we can respond respectfully to hesitancy among healthcare workers while still working towards the goal of increased vaccination. We in the bioethics and medical community should be willing to listen to our colleagues’ concerns with respect. Top-down approaches aimed at “correcting” hesitancy cannot address the more fundamental issues of trust that are often at stake. Instead, there must be dialogue over time. Conversations with a trusted healthcare provider have a crucial role.[10] Blaming and shaming rhetoric, whether explicit or implicit, gets us nowhere – in fact, it likely moves us backward by likely exacerbating any existing distrust or resentment that workers may hold toward their employers.[11] Lastly, the onus of trust must be with institutions, not individuals. There is a lot of talk about getting communities of color, and Black people, particularly, to "trust" healthcare institutions and the COVID vaccines. This racializes trust and puts the burden on harmed communities rather than on institutions acting in trustworthy ways.[12] Dialogue, respect, and trustworthiness must guide us even in the new era of workplace mandates. Mandates make these strategies even more important as we look toward an uncertain future. As Heidi Larson, founder of the Vaccine Confidence Project, recently said, “We should not forget that we are making people's future history now. Are people going to remember that they were treated respectfully and engaged?”[13] ll. Kara Simpson Since the release of the vaccine for COVID-19 in late 2020, there have been robust discussions within the medical community, the media, and political arenas about vaccine hesitancy among healthcare workers. The public became aware that healthcare workers, the first group to become eligible for the vaccine, were not rushing to “take the shot.” Many people’s opinions were aligned by race, ethnicity, socioeconomic status, and political affiliation. People of color were one of the first groups to be labeled vaccine hesitant as our experiences of distrust of the medical community and the politicization of the vaccine explained the low turnout.[14] It was not uncommon to hear, “this vaccine just came out; let’s wait and see if there are side effects.” Interestingly, many people in the healthcare community and in the public did not understand why healthcare workers of color remained hesitant. Trust is a vital component of any viable relationship, especially in the clinical realm. To have successful health outcomes, it is essential for clinicians to build trusting relationships with their patients and peers. Many people of color are distrustful towards the medical institution due to the years of systemic racism and abuses that they have experienced, witnessed, or learned about. Healthcare workers of color are not excluded from the experiences of their communities outside of work. In fact, I assert that healthcare of color may have an additional burden of hesitation because of their lived experiences of distrust in receiving care and inequality within their professional environment. These dual traumas can work in tandem to strengthen hesitancy. I assert that building trusting clinical relationships will address hesitancy over time. Currently, many healthcare workers are worried about vaccine mandates. For a group of people that have experienced intergenerational enslavement and marginalization, mandates feel coercive and serve as a reminder of how “lesser” bodies are considered unworthy of voice, fundamental human rights, independent decision making. To call the vaccine mandate paternalistic would be an understatement. An unintended result of vaccine mandates will be the reinforcement of hesitancy and distrust of the medical institution as trust and coercion cannot coexist. This mandate will give more power to the conspiracy theories and harm those who already do not seek or receive adequate health care because of systemic inequalities. Furthermore, mandates can also dissuade people of color from becoming healthcare workers, and others may leave the field. In essence, vaccine hesitancy is a symptom of a much larger problem: the distrust of the medical establishment. As bioethicists, our mission should be to support interventions that foster “trustworthiness” of the institutions rather than those that cause trauma. Several organizations have proposed mask mandates and weekly testing as a measure to protect the population at large and still respect the autonomy of the unvaccinated.[15] lll. Jennifer Breznay I work in a very large community teaching hospital in Brooklyn, and we were extremely hard hit by COVID in March 2020. I worked on inpatient medical units and witnessed a lot of suffering. And after nine months of fear and despair about COVID’s toll, I felt tremendous frustration in December when I heard that many healthcare workers would reject the vaccine. As the co-chair of the Bioethics Committee, I drafted a statement recommending vaccination for all employees. When the draft was revised and approved by the Bioethics Committee, I began to discuss it with employees, and I appreciated different perspectives I had not heard before. In the end, rather than releasing the statement, we directed our efforts at creating a dialogue. I also volunteer at a not-for-profit which operates seven early childhood education centers in Northern Brooklyn. The Executive Director invited me to collaborate on strategies to encourage staff vaccination, and we decided to offer a Zoom conference to 20 members of the staff. I was extremely nervous about how the audience would perceive me, a white doctor whom they did not know. I felt awkward about coming to them with an agenda. And there was also the question of whether I was an appropriate messenger compared to a person of color. Yet, I felt like I shouldn't back away from this. So, I chose to simply disclose my discomfort at the beginning of the Zoom. I said, “Thanks for having me. You know, as a white physician, I understand you might have concerns about trusting what I say. Four hundred years of inequity and abuse by the healthcare system can create a lot of mistrust, but I’m here to try to answer your questions.” Ultimately the Executive Director reported that the Zoom was successful in stimulating a lot of conversation among the staff about the vaccine. I think the critical piece is the intimate but open conversation, where you can elicit values. lV. Ashley L. Stewart In the rural areas of our state, healthcare institutions are inextricably tied to their communities. Rural hospitals hire from, serve, and function in the community where they are located. Successful implementation of a vaccine roll-out in such rural areas requires explicit recognition of the role and influence of the community. After identifying issues common to the area, rural institutions can address them. Even when rural institutions find that healthcare worker concerns seem to be unique or personal, they are often related to the larger concerns of the community.[16] Community-based increased vaccine hesitancy may coincide with an underlying issue, such as lack of information rather than principled or experience-based resistance.[17] When the vaccines became available, rural vaccination coordinators encountered a wealth of misinformation that left many people initially undecided. Compounding this lack of information, workers expressed a sense of fear about the professional consequences of voicing concerns, especially in tight-knit communities. Many workers expressed concern about being judged merely for sharing their questions or decisions.[18] They also felt that saying or doing something to promote the value of vaccination might change their relationship with members of the community where they live and work.[19] As there was a fear of engaging in productive conversations, it was difficult for them to find valuable information, and the lack of information discouraged them from being vaccinated. Vaccine coordinators wanted to get information to the entire community based on the most current research and release unbiased, consistent, and timely information from sources all people in the community could trust, including from multiple sources at once. Communication must focus on answering many types of questions, which must often be done in private or anonymously. Where poorly supported or incorrect information is widely available, sharing objective information is crucial to turning the tide of distrust. If the healthcare community dismisses concerns or assumes that answering questions based on misinformation is a waste of time, the community-based institutions will further the distrust. Some may feel that vaccine coordinators should not address misinformation directly, yet avoidance has been widely unsuccessful.[20] Being respectful and non-judgmental in answering questions posed by people who do not know what is true can be hard, but in rural communities, answering completely and honestly without judgment is a critical component of any effort to inform people. Telling people to get vaccinated “for the greater good” can sound the same as being told not to get a vaccine because it is “bad” if both sources of information fail to back up their claims. Ultimately rural institutions are respected because they are a resource to their communities, a priority we must preserve. It is also critical to treat everyone respectfully regardless of vaccine status.[21] People may perceive mandates, divisive policies, or disrespectful treatment of people based on vaccination status as discriminatory or coercive, weakening the appeal of vaccination. Such practices may make people less trusting and more anchored to their position as they come to see vaccination proponents as untrustworthy or authoritarian. We must work to maintain respect for human autonomy. Using unethical means to achieve even a just end will not lead to a “greater good” but rather to the perception that people in positions of authority would achieve a result “by any means necessary.” V. David N. Hoffman The central moral quandary that arises whenever vaccine hesitancy among healthcare workers is discussed is whether workers who refuse to get vaccinated should or could be fired. We should clarify that we are applying a definition of mandate in the employment context for private employers, the violation of which results in loss of employment. Government-controlled provider organizations are just now weighing in on this topic and are generally pursuing strategies that impose periodic, usually weekly, testing requirements for those workers who decline to get vaccinated. In the private sector, employers can require their employees to do a great many things as a condition of employment, and one of them is to get vaccinated against COVID -19. In the most prominent case to date, just such a mandate gave rise to a lawsuit in Texas involving Houston Methodist Hospital. In that case, 170 employees asserted that an employer should not be allowed to force them to get vaccinated. The judge held that, while no employer can force an employee to get vaccinated, no employer is obligated to continue the employment of any employee who declines to follow rules established by that employer, including the obligation to get vaccinated.[22] In Texas, what the judge said is you are not being forced to get vaccinated, but your employer is allowed to set limits and conditions on employment, including vaccination. Employees do not have an obligation to get vaccinated, but they also have no right to their jobs. That is because of a widely misunderstood legal concept: “employment at will.” Employment at will sounds like a rule that employees can do what they want at work, but in fact, employment at will means only that you can quit your job whenever you want (we do not permit indentured servitude). At the same time, your employer can fire you at any time, for any reason or no reason, unless the reason is a pretext and involves one of the protected statuses (race, color, religion, sex, or national origin, and in some jurisdictions gender orientation, gender identity). Generally, any employers, including hospitals, can decide that if someone is not willing to get a vaccination, or if they are not willing to complete sexual harassment training or participate in the hospital’s infection control program, that is the employee’s right, but it will mean that an employer can similarly decline to continue providing employment. The evolution of this hesitancy discussion will be influenced by the narrower debate playing out in the court of public opinion, and the courts of law, over the enforceability of New York’s recently enacted vaccine mandate. Regardless of whether that mandate survives, with or without medical and religious exemptions, healthcare employers will be left with a profound ethical dilemma. At the end of all the litigation, if there is a religious exemption, employers will always be burdened with the responsibility to determine whether an individual employee has asserted a genuine and sincere religious objection to vaccination and whether the employer is able to provide an accommodation that is safe and effective in protecting the interests of co-workers and patients. The anticipated federal mandate, which reportedly will have a test/mask alternative, will only make this ethical task more challenging. This leads to the final point in this analysis, which is that while private employers, including hospitals, can deprive an individual of their employment if those individuals refuse to get vaccinated, just because an employer can do so does not mean it should do so.[23] - [1] MacDonald NE. Vaccine hesitancy: Definition, scope and determinants. Vaccine. 2015;33(34):4161-4164. doi:10.1016/j.vaccine.2015.04.036 [2] Larson HJ, de Figueiredo A, Xiahong Z, et al. The State of Vaccine Confidence 2016: Global Insights Through a 67-Country Survey. EBioMedicine. 2016;12:295-301. doi:10.1016/j.ebiom.2016.08.042 [3] Larson H. Stuck: How Vaccine Rumors Start - and Why They Don’t Go Away. Oxford University Press; 2020; Benjamin R. Informed Refusal: Toward a Justice-based Bioethics. Sci Technol Hum Values. 2016;41(6):967-990. doi:10.1177/0162243916656059 [4] Deepa Shivaram, In The Fight Against COVID, Health Workers Aren't Immune To Vaccine Misinformation September 18, 2021. NPR Special Series: The Coronavirus. https://www.npr.org/2021/09/18/1037975289/unvaccinated-covid-19-vaccine-refuse-nurses-heath-care-workers [5] Crane JT, Pacia D, Fabi R, Neuhaus C, and Berlinger N. Advancing Covid vaccination equity at Federally Qualified Health Centers: A rapid qualitative review. Accepted and awaiting publication at JGIM. [6] Ashley Kirzinger. “KFF/The Washington Post Frontline Health Care Workers Survey - Vaccine Intentions.” KFF, 22 Apr. 2021, https://www.kff.org/report-section/kff-washington-post-frontline-health-care-workers-survey-vaccine-intentions/. [7] Johanna Crane, Samuel Reis-Dennis and Megan Applewhite. “Prioritizing the ‘1a’: Ethically Allocating Scarce Covid Vaccines to Health Care Workers.” The Hastings Center, 21 Dec. 2020, https://www.thehastingscenter.org/prioritizing-the-1a-ethically-allocating-covid-vaccines-to-health-care-workers/. [8] “'I'm Not an Anti-Vaxxer, but...' US Health Workers' Vaccine Hesitancy Raises Alarm.” The Guardian, Guardian News and Media, 10 Jan. 2021, https://www.theguardian.com/world/2021/jan/10/coronavirus-covid-19-vaccine-hesitancy-us-health-workers. [9] Gerson M. If you are healthy and refuse to take the vaccine, you are a free-rider. Washington Post. April 15, 2021. [10] Crane JT, Pacia D, Fabi R, Neuhaus C, and Berlinger N. Advancing Covid vaccination equity at Federally Qualified Health Centers: A rapid qualitative review. Accepted and awaiting publication at JGIM. [11] Larson H. Stuck : How Vaccine Rumors Start - and Why They Don’t Go Away. Oxford University Press; 2020. [12] Benjamin R. Race for Cures: Rethinking the Racial Logics of ‘Trust’ in Biomedicine. Sociology Compass. 2014;8(6):755-769. doi:10.1111/soc4.12167; Warren RC, Forrow L, David Augustin Hodge S, Truog RD. Trustworthiness before Trust — Covid-19 Vaccine Trials and the Black Community. N Engl J Med. Published online October 16, 2020. doi:10.1056/NEJMp2030033 [13] Offri D. Heidi Larson, Vaccine Anthropologist. New Yorker. Published online June 12, 2021. Accessed August 11, 2021. https://www.newyorker.com/science/annals-of-medicine/heidi-larson-vaccine-anthropologist [14] Razai M S, Osama T, McKechnie D G J, Majeed A. Covid-19 Vaccine Hesitancy Among Ethnic Minority Groups. BMJ 2021; 372 :n513 doi:10.1136/bmj.n513 [15] Dasgupta, Sharoda, et al. “Differences in Rapid Increases in County-Level COVID-19 Incidence by Implementation of Statewide Closures and Mask Mandates — United States, June 1–September 30, 2020.” Annals of Epidemiology, vol. 57, Sept. 2021, pp. 46–53., https://doi.org/10.1016/j.annepidem.2021.02.006. [16] Do, Tuong Vi C et al. “COVID-19 Vaccine Acceptance Among Rural Appalachian Healthcare Workers (Eastern Kentucky/West Virginia): A Cross-Sectional Study.” Cureus vol. 13,8 e16842. 2 Aug. 2021, doi:10.7759/cureus.16842; Danabal, K.G.M., Magesh, S.S., Saravanan, S. et al. Attitude towards COVID 19 vaccines and vaccine hesitancy in urban and rural communities in Tamil Nadu, India – a community-based survey. BMC Health Serv Res 21, 994 (2021). https://doi.org/10.1186/s12913-021-07037-4 [17] Scott C. Ratzan MD, MPA, MA, Lawrence O. Gostin JD, Najmedin Meshkati PhD, CPE, Kenneth Rabin PhD & Ruth M. Parker MD (2020) COVID-19: An Urgent Call for Coordinated, Trusted Sources to Tell Everyone What They Need to Know and Do, Journal of Health Communication, 25:10, 747-749, DOI: 10.1080/10810730.2020.1894015 [18] Huang, Pien. “Some Health Care Workers Are Wary of Getting COVID-19 Vaccines.” NPR, NPR, 1 Dec. 2020, https://www.npr.org/sections/health-shots/2020/12/01/940158684/some-health-care-workers-are-wary-of-getting-covid-19-vaccines. Portnoy, Jenna. “Several Hundred Virginia Health-Care Workers Have Been Suspended or Fired over Coronavirus Vaccine Mandates.” The Washington Post, WP Company, 4 Oct. 2021, https://www.washingtonpost.com/local/covid-vaccine-mandate-hospitals-virginia/2021/10/01/b7976d16-21ff-11ec-8200-5e3fd4c49f5e_story.html. [19] Jennifer A. Lueck & Alaina Spiers (2020) Which Beliefs Predict Intention to Get Vaccinated against COVID-19? A Mixed-Methods Reasoned Action Approach Applied to Health Communication, Journal of Health Communication, 25:10, 790-798, DOI: 10.1080/10810730.2020.1865488 [20] Lockyer, Bridget, et al. “Understanding Covid-19 Misinformation and Vaccine Hesitancy in Context: Findings from a Qualitative Study Involving Citizens in Bradford, UK.” Health Expectations, vol. 24, no. 4, 4 May 2021, pp. 1158–1167., https://doi.org/10.1101/2020.12.22.20248259. Scott C. Ratzan & Ruth M. Parker (2020) Vaccine Literacy—Helping Everyone Decide to Accept Vaccination, Journal of Health Communication, 25:10, 750-752, DOI: 10.1080/10810730.2021.1875083. [21] Zimmerman, Anne. Columbia Academic Commons, 2020, Toward a Civilized Vaccination Discussion: Abandoning the False Assumption That Scientific Goals Are Shared by All, https://academiccommons.columbia.edu/doi/10.7916/d8-rzh0-1f73. [22] Bridges, et al v. Houston Methodist Hospital et al, https://docs.justia.com/cases/federal/districtcourts/texas/txsdce/4:2021cv01774/1830373/18 [23] David N. Hoffman, “Vaccine Mandates for Health Care Workers Raise Several Ethical Dilemmas,” Hasting Center Bioethics Forum. August 2021. https://www.thehastingscenter.org/vaccine-mandates-for-health-care-workers-raise-several-ethical-dilemmas/

Introduction Exploring the ways in which children merge education, play and connection in their digital device use, this article critiques the established definitions of the Internet of Things and the Internet of Toys and suggests an alternative. Using evidence emerging from The Internet of Toys: Benefits and Risks of Connected Toys for Children, we deconstruct these traditional terms, and advocate for a revised terminology. Such a reconsideration helps frame children’s use of digital devices and the important roles these play in children’s everyday lives. The Internet of Things is defined by Mascheroni and Holloway as “physical objects that are embedded with electronics, sensors, software and connectivity that support the exchange of data”. These objects have become omnipresent in Western society, resulting in different subsets of the Internet of Things, such as the Internet of Toys. Such connected toys are physical toys that are (just as the Internet of Things is) connected to the Internet through Bluetooth and/or Wi-Fi (Mascheroni and Holloway). The features of such toys include network connectivity, sensors and voice/image recognition software, and controllability and programmability via apps on smartphones or tablets (Holloway and Green). CogniToys Dino, Fisher-Price Smart Toy Bear, Skylanders, Hello Barbie, Cloudpets, and Wiggy Piggy Bank are just a few examples of these connected playthings (Ihamäki and Heljakka; Mascheroni and Holloway; Shasha et al.). The ‘Internet of Toys’ category can thus be understood as physical toys with digital features (Ihamäki and Heljakka). However, Ling et al. argue that, “if the item is to be included in the IoT[hings] devices and … if the object is also used for play, then despite its designed purpose, this internet connected item becomes a member of the subset of the IoToys” (Ling et al.). Therefore, the conceptualisation of toys should not be limited to products designed for play. This raises questions about the concept of the Internet of Toys, and whether the distinction between the Internet of Things and the Internet of Toys is (still) relevant. We argue that there is no longer a meaningful distinction to be made between the Internet of Toys and the Internet of Things: instead, all such phrases indicate fragmentary attention to the Internet of Life. The Internet of Life can be defined as: devices which encompass all facets of online connectivity and technological management, and the interpolation of the digital with the everyday. The Research Project In 2018, the Australian Research Council funded a Discovery grant investigating The Internet of Toys: Benefits and Risks of Connected Toys for Children. Initially the project gave each household involved in the case study a Cozmo robot, to see how the toy was used and integrated into the household. The project foundered somewhat as the robot was initially played with but after a short while the children stopped engaging with Cozmo. Researchers believed this was due to novelty, Internet connectivity issues and the overly complicated nature of the toy. Parents had hoped their children would learn to code through using the robot but were not always willing to or capable of helping the child to navigate this aspect of the toy. In this regard Cozmo failed their expectations. After a short hiatus on the project, it was stripped back to its original purpose, to explore how households define Internet-connected toys, and the risks and benefits of playing with them. The qualitative data forming the basis of this article come from the second iteration of the project and interviews conducted in 2021 and 2022. The academics working on this research are increasingly questioning the relevance of these terms in today’s world. Ethnographic (Rinaldo and Guhin) one-on-one interviews with Australian children aged 6–12 have revealed just how diverse the digital technologies they play with have become. Those conversations and technology tours (Plowman) demonstrate the extent to which these digital devices are seamlessly integrated into children’s daily lives. Referring to many digital devices (such as the iPad and other tablets) as “toys”, children appear unaware of the distinction made by adults. Indeed, children mobilise elements of education, communication, self-actualisation, curiosity, and play within all their digital engagements. While parents may still be encouraged to distinguish between the educational use of digital devices and children’s use of such technology for entertainment, the boundary between the two is becoming more and more blurred. The bring-your-own-device (BYOD) policies that have been implemented within many Australian, English, and American schools expose children to digital devices within multiple contexts, frameworks, and environments, encouraging ubiquity of use. Laptops and tablets originally provided for school and educational purposes are also used for play. Seiter suggested that parents believe that a computer should be used by their children for serious matters such as learning or “purposeful” play, but children’s use patterns convert the tool into the toy. This elision of purpose may be referred to as “edutainment”, or the “toyification of education”, which suggests that education is increasingly reinforced by, and benefits from, “toyish” elements or dimensions (Ihamäki and Heljakka). Tablets offer children a diverse range of digital play options. Touch and swipe technology means that, from before their first birthday, “children are no longer only observants of digital technologies, but they are players and users, with tablets becoming the digital toy of choice” (Fróes 43). This is reinforced in much recent academic literature, with Brito et al., Healey et al., and Nixon and Hateley, for example, referring to tablets as “toys”. This is in line with the evolution of these devices from computer to educational tool to child-friendly toy. Fróes argues that the tablet supports “playful literacy”: “the ability to use, interact, relate, communicate, create, have fun with and challenge digital tools through playful behavior”. Having fun encourages and reassures children while they learn about, and become familiar with, these technologies. This, in turn, supports the valuable skill-building and scaffolding (Verenikina, citing Vygotsky) necessary for when a child begins using a tablet in an educational context once they start school. The omnipresence of screens challenges parents who believe that to be a good parent is to mediate their child’s digital engagement (Page Jeffery). Although the focus on “screen time” (the amount of time that children spend on their screens) is increasingly critiqued (e.g. Livingstone and Blum-Ross), some research suggests that, on average, parents underestimate their child’s daily screen time by more than 60 minutes (Radesky et al.). This conflicts with other research that argues that parents' preferred approach to mediation is setting clear rules regarding media usage, particularly in terms of time spent in device use (Valcke et al.; Brito et al.). Ironically, even though parents voice concern regarding their children’s technology use and digital footprints (Buchanan, Southgate, and Smith), they feel a “necessary culture of care” (Leaver) that may incite them to use their own technology to monitor their children’s data and behaviour. Such strategies can lead to “intimate surveillance” becoming a normalised parenting practice (Mascheroni and Holloway), while modelling to children their caregivers’ own reliance on devices. Hadlington et al. state that tablets may offer a barrier against the offline, “real” world. Children may become immersed in digital engagement, losing awareness of their surroundings, or they may actively use the tablet as a barrier between themselves and their environment. Parents may feel concern that their child is cutting themselves off from the family, potentially undermining family relationships and delaying the development of social skills (Radesky et al.). In contrast, Desjarlais and Willoughby’s article describes how children’s digital activities, for example chatting with friends, can be a useful starting point for social relationships. Hietajarvi et al. could not identify significant negative effects from using chat functions whilst studying, and suggest that digital engagement has a negligible effect on academic progress. While it is possible to characterise tablets and other digital devices as “toys”, this fails to capture the full contribution of such technology in children’s daily lives. Tablets, such as the iPad and Samsung’s Galaxy’s Tab range, function as a significant bridge that connects both children’s and adults’ everyday lives. The Internet of Life While the suggestion of an Internet of Life may require further investigation and refinement, this article proposes to define the term as follows: devices which encompass all facets of online connectivity and technological management, and the interpolation of the digital with the everyday. We argue that there is no longer a meaningful distinction to be made between the Internet of Toys and the Internet of Things: all such phrases indicate fragmentary attention to the Internet of Life. Digital devices cannot be bound by narrow definitions and distinctions between “things” and “toys”. Instead, these devices transcend the boundaries of “toys” and “things”, becoming relevant to all facets of people’s everyday lives. This is increasingly evident in lives of young children, as demonstrated by the one-on-one interviews with Australian child participants (aged 6–12). When asked if they could show the researcher some of their toys, every child produced their tablet, or spoke about it, if it was not within their reach at that time. Defining their tablets as toys, children nonetheless described myriad ways in which they were used: for leisure and entertainment, education, sociality, self-expression, and to satisfy their curiosity amongst others. Parents sometimes wondered at how children navigated technology without seeming to need assistance and noted that children could easily outstrip their parents’ skill level. Even so, parents described their struggle to “allow” their children screen time, finding it difficult to believe that it’s okay for their child to use a device for extended periods of time. Interestingly, when parents were asked if they were willing to model the behaviour they expected of their children—time limits on devices, going outside and playing—they struggled to imagine themselves doing so. As one parent said: “everything's there [on the device]. It's just so hard because everything I do, and need, is there”. This perspective reinforces our assertion that digital devices are inherently and instinctively interwoven within daily life: not toys, not things. Maybe the concept of the Internet of Life will support parents’, educators’, policy-makers’, and academics’ richer appreciation of the multitude of ways in which children use devices. It may also recognise how device use includes the acquisition of life skills, in both digital and IRL (“in real life”) domains. A reframing of digital devices may aid recognition of the benefits and experiences they offer the young (and old). Such a perspective might assuage significant parental guilt and take the sting out of increasingly frequent debates around screen time quality versus quantity (Livingstone and Pothong). This article now addresses some parents’ and children’s comments relating to their engagement with the Internet of Life. Parents’ Perspectives Seeking to explain what parents understand by the concept of play, Hayes (a father of three) suggested: “children entertaining themselves hopefully positively … . [They’re] doing something either physical or educational or it’s benefitting them in some way and having fun and relaxing”, while the mum from a different family, Farida, feels that play is “something that brings about joy, really” (a mother of two). Parents experience challenges in assigning different regulations around digital device usage to children in the same family, reflecting their different circumstances. Thus Bethany, mother to Aiden (11, below) and older sibling Sophie (13), differentiates her approach to regulating her children’s play in digital spaces: With him [Aiden] I don’t feel so bad when he – having a downtime because I know he’s quite active whereas [Sophie] my daughter’s not, she’s the complete opposite and she will sit on there usually, ‘cause she’s chatting to her friend Gemma who’s over east but, she’ll try and sit on there for two or three hours just doing really mundane boring stuff. (Mum, Bethany) Interestingly, for both Sophie and Aiden, their use of digital devices is a reassuring opportunity to retreat. One of the many advantages of chatting online to a distant friend is that it’s a space separate from the everyday contexts of classroom politics. Mum to Bryce (8, male), Farida identifies specific benefits in her son’s digital device use across a range of skills and competencies. [He] has actually improved significantly with his communication skills and his maths skills like his problem-solving and reasoning. Like he’s trying to, for instance, work out how much money he’s got to scam off me to get the things that he wants, adds it all up, works out his amount of money that he’s got to ask for so he can buy all the stuff that he’s looking for. So that has really improved. (Farida) Some parents might see games that teach children how to calculate what they need to achieve what they want as an annoyance due to a trivial extra expense, but Bryce has a range of learning challenges. Consequently, Farida is delighted with the progress she sees: “his trajectory has actually been quite astounding, and I do think that a lot of it is to do with the fact that he’s built up so many of these other skills from his hand eye co-ordination, his communication skills and stuff from digital play”. Children’s Perspectives Children’s own perspectives on their use of digital devices were varied but speak to the development of individual competencies and the managing of important friend- and family-based relationships. So, Aiden (11) characterised his use of such digital media as “calming. Since there’s nothing to really lose in the game or anything, it’s not like ‘oh you stuffed something up, you have to restart the whole thing’.” He adds, as if this is a significant benefit, “it’s more if you stuff something up it’s fine, you can just get it back again”. Aiden is in a children’s elite sport squad and explains “I do football for four hours. Then I have piano lesson for 30 minutes. I’m really tired”. His digital sphere is a welcoming place of safety and relaxation where there are no consequences when things go wrong. For Lisa, also 11, her digital device is for communicating. Explaining that she has “Snapchat, Messages and TikTok and I think that’s it”, Lisa says that she and her friend from school “normally just chat to each other and we’ll chat about what we’re doing”. She adds that sometimes “we’ll roleplay”. As Lisa continues there’s an implicit acknowledgement of the risks around collaborating with others in play spaces. Speaking of her friend, she notes “she used to play this game, Brook Game, and she doesn’t really do it anymore. In Brooking Gaming you roleplay with people and you can do jobs and stuff”. Digital play and device use may be a place of relaxation, but it’s also a place of negotiation and of learning to compromise as a price of sharing experiences with friends. Killian’s (12 years old, male) example of gaming implicates the ways he negotiates autonomy and connection with his older brother. Explaining that “I talk to my friends over Discord which is a social thing and that”, Killian explains how (older brother) “Xander helped me set up the safety settings”. The boys worked together to find a means through which their toys and games allowed them to bypass technical barriers preventing full service on their mobile devices. They had originally thought: “we could text each other” but because their devices were set so they “won’t allow us—Xander had Discord on his phone and—he did. I could text him via that”. A variety of remote communication strategies support Killian’s and Xander’s connected play in different spaces. The interviewer notes, “so you prefer playing individually like that because you just have that one screen to yourself, that solo experience, but still playing together?”, allowing Killian to add “Yes, and also Xander doesn’t hit me every time I do something that Xander doesn’t like”. Killian subsequently identifies himself as something of negotiator, working out the different rules and settings for the different areas in his life. Saying he uses his iPad “kust for stuff I’m interested in, or something that I found out is good, that I want”, he also says he has a workaround for if “the website’s blocked or then—stuff like that—or, I want to watch it at home”. One of the implications of these examples is that parents tend to develop over-arching narratives about their children’s digital device use and compartmentalise concerns, differentiating them from positive aspects of children’s online activities. Children’s experiences, however, speak to lessons around learning skills, managing relationships and conflicts, negotiating autonomy, absence, and different rules in different spaces. In these respects, children’s multifaceted use of digital devices is indeed creating an Internet of Life. Reimagining Children’s Digital Activity Engagement with digital devices and online activities has become a core part of childhood development (Borisova). The reimagining of the concepts of the Internet of Things and the Internet of Toys as the Internet of Life allows children, parents, researchers, and policy-makers to broaden their understanding of what it means to grow up in a digital world. Defining an Internet of Life and conceptualising digital devices as an inherent part of the everyday, allows greater understanding and appreciation of how, what, and why children use such devices, and the potential benefits (and risks) they may afford. This perspective also empowers children’s understandings of what digital devices are, and how the digital environment relates to them, and their daily lives. This article argues for a need to widen understandings of children’s digital device use, including the role that Internet-connected toys play in fostering social and digital literacies, to explore the multifaceted and ubiquitous nature of tablets and other digital devices (Ihamäki and Heljakka). Previous research on children’s digital engagement, along with a large portion of public reporting, has focussed on the risks and harms that children are exposed to, rather than the potential benefits of digital engagement, along with the rights of a child to digital access (CRC; Odgers and Jensen; Third et al.). The Internet of Life recognises that children’s digital engagement includes some exposure to risks, but also reflects the potential benefits that this exposure can have in terms of helping navigate these risks and problem-solving. It allows digital engagement to be reframed as a normal part of daily life and everyday routines, expanding understandings of how children engage with digital devices. Parents and children alike spoke about their tablets and the myriad of ways in which they used them: as a toy, for leisure, entertainment, formal education, sociality, and to satisfy their own curiosities to name but a few. Not only do these devices satisfy parental expectations, in that children can navigate them without assistance, but children can also outstrip a parent’s skill level rapidly. This is pleasing to some parents who do not possess such skills to teach their child. However, parents still struggle to “allow” their children screentime and justify to themselves that it is okay for their child to be on their own device for extended periods of time. The distinction between the overarching Internet of Things and the subset of the Internet of Toys, as well as the categorisation of these devices as “education-only” or “entertainment-only”, does not accurately represent children’s engagement with and use of digital devices. Children’s multi-faceted and multi-layered digital activities offer a complex interplay of motivations and intentions, pleasures and challenges, intrinsic and extrinsic. 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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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What strikes me about the habits of the people who spend so much time on the Net—well, it’s so new that we don't know what will come next—is in fact precisely how niche in character it is. You ask people what nets they are on, and they’re all so specialised! The Argentines on the Argentine Net and so forth. And it’s particularly the Argentines who are not in Argentina. (Anderson, in Gower, par. 5) The preceding quotation, taken from his 1996 interview with Eric Gower, sees Benedict Anderson reflecting on the formation of imagined, transnational communities on the Internet. Anderson is, of course, famous for his work on how nationalism, as an “imagined community,” gets constructed through the shared consumption of print media (6-7, 26-27); although its readers will never all see each other face to face, people consuming a newspaper or novel in a shared language perceive themselves as members of a collective. In this more recent interview, Anderson recognised the specific groupings of people in online communities: Argentines who find themselves outside of Argentina link up online in an imagined diaspora community. Over the course of the last decade and a half since Anderson spoke about Argentinian migrants and diaspora communities, we have witnessed an exponential growth of new forms of digital communication, including social networking sites (e.g. Facebook), Weblogs, micro-blogging (e.g. Twitter), and video-sharing sites (e.g. YouTube). Alongside these new means of communication, our current epoch of globalisation is also characterised by migration flows across, and between, all continents. In his book Modernity at Large, Arjun Appadurai recognised that “the twin forces of mass migration and electronic mediation” have altered the ways the imagination operates. Furthermore, these two pillars, human motion and digital mediation, are in constant “flux” (44). The circulation of people and digitally mediatised content proceeds across and beyond boundaries of the nation-state and provides ground for alternative community and identity formations. Appadurai’s intervention has resulted in increasing awareness of local, transnational, and global networking flows of people, ideas, and culturally hybrid artefacts. In this article, we analyse the various innovative tactics taken up by migrant youth to imagine digital diasporas. Inspired by scholars such as Appadurai, Avtar Brah and Paul Gilroy, we tease out—from a postcolonial perspective—how digital diasporas have evolved over time from a more traditional understanding as constituted either by a vertical relationship to a distant homeland or a horizontal connection to the scattered transnational community (see Safran, Cohen) to move towards a notion of “hypertextual diaspora.” With hypertextual diaspora, these central axes which constitute the understanding of diaspora are reshuffled in favour of more rhizomatic formations where affiliations, locations, and spaces are constantly destabilised and renegotiated. Needless to say, diasporas are not homogeneous and resist generalisation, but in this article we highlight common ways in which young migrant Internet users renew the practices around diaspora connections. Drawing from research on various migrant populations around the globe, we distinguish three common strategies: (1) the forging of transnational public spheres, based on maintaining virtual social relations by people scattered across the globe; (2) new forms of digital diasporic youth branding; and (3) the cultural production of innovative hypertexts in the context of more rhizomatic digital diaspora formations. Before turning to discuss these three strategies, the potential of a postcolonial framework to recognise multiple intersections of diaspora and digital mediation is elaborated. Hypertext as a Postcolonial Figuration Postcolonial scholars, Appadurai, Gilroy, and Brah among others, have been attentive to diasporic experiences, but they have paid little attention to the specificity of digitally mediated diaspora experiences. As Maria Fernández observes, postcolonial studies have been “notoriously absent from electronic media practice, theory, and criticism” (59). Our exploration of what happens when diasporic youth go online is a first step towards addressing this gap. Conceptually, this is clearly an urgent need since diasporas and the digital inform each other in the most profound and dynamic of ways: “the Internet virtually recreates all those sites which have metaphorically been eroded by living in the diaspora” (Ponzanesi, “Diasporic Narratives” 396). Writings on the Internet tend to favour either the “gold-rush” mentality, seeing the Web as a great equaliser and bringer of neoliberal progress for all, or the more pessimistic/technophobic approach, claiming that technologically determined spaces are exclusionary, white by default, masculine-oriented, and heteronormative (Everett 30, Van Doorn and Van Zoonen 261). For example, the recent study by Ito et al. shows that young people are not interested in merely performing a fiction in a parallel online world; rather, the Internet gets embedded in their everyday reality (Ito et al. 19-24). Real-life commercial incentives, power hierarchies, and hegemonies also get extended to the digital realm (Schäfer 167-74). Online interaction remains pre-structured, based on programmers’ decisions and value-laden algorithms: “people do not need a passport to travel in cyberspace but they certainly do need to play by the rules in order to function electronically” (Ponzanesi, “Diasporic Narratives” 405). We began our article with a statement by Benedict Anderson, stressing how people in the Argentinian diaspora find their space on the Internet. Online avenues increasingly allow users to traverse and add hyperlinks to their personal websites in the forms of profile pages, the publishing of preferences, and possibilities of participating in and affiliating with interest-based communities. Online journals, social networking sites, streaming audio/video pages, and online forums are all dynamic hypertexts based on Hypertext Markup Language (HTML) coding. HTML is the protocol of documents that refer to each other, constituting the backbone of the Web; every text that you find on the Internet is connected to a web of other texts through hyperlinks. These links are in essence at equal distance from each other. As well as being a technological device, hypertext is also a metaphor to think with. Figuratively speaking, hypertext can be understood as a non-hierarchical and a-centred modality. Hypertext incorporates multiplicity; different pathways are possible simultaneously, as it has “multiple entryways and exits” and it “connects any point to any other point” (Landow 58-61). Feminist theorist Donna Haraway recognised the dynamic character of hypertext: “the metaphor of hypertext insists on making connections as practice.” However, she adds, “the trope does not suggest which connections make sense for which purposes and which patches we might want to follow or avoid.” We can begin to see the value of approaching the Internet from the perspective of hypertext to make an “inquiry into which connections matter, why, and for whom” (128-30). Postcolonial scholar Jaishree K. Odin theorised how hypertextual webs might benefit subjects “living at the borders.” She describes how subaltern subjects, by weaving their own hypertextual path, can express their multivocality and negotiate cultural differences. She connects the figure of hypertext with that of the postcolonial: The hypertextual and the postcolonial are thus part of the changing topology that maps the constantly shifting, interpenetrating, and folding relations that bodies and texts experience in information culture. Both discourses are characterised by multivocality, multilinearity, openendedness, active encounter, and traversal. (599) These conceptions of cyberspace and its hypertextual foundations coalesce with understandings of “in-between”, “third”, and “diaspora media space” as set out by postcolonial theorists such as Bhabha and Brah. Bhabha elaborates on diaspora as a space where different experiences can be articulated: “These ‘in-between’ spaces provide the terrain for elaborating strategies of selfhood—singular or communal—that initiate new signs of identity, and innovative sites of collaboration, and contestation (4). (Dis-)located between the local and the global, Brah adds: “diaspora space is the point at which boundaries of inclusion and exclusion, of belonging and otherness, of ‘us’ and ‘them,’ are contested” (205). As youths who were born in the diaspora have begun to manifest themselves online, digital diasporas have evolved from transnational public spheres to differential hypertexts. First, we describe how transnational public spheres form one dimension of the mediation of diasporic experiences. Subsequently, we focus on diasporic forms of youth branding and hypertext aesthetics to show how digitally mediated practices can go beyond and transgress traditional formations of diasporas as vertically connected to a homeland and horizontally distributed in the creation of transnational public spheres. Digital Diasporas as Diasporic Public Spheres Mass migration and digital mediation have led to a situation where relationships are maintained over large geographical distances, beyond national boundaries. The Internet is used to create transnational imagined audiences formed by dispersed people, which Appadurai describes as “diasporic public spheres”. He observes that, as digital media “increasingly link producers and audiences across national boundaries, and as these audiences themselves start new conversations between those who move and those who stay, we find a growing number of diasporic public spheres” (22). Media and communication researchers have paid a lot of attention to this transnational dimension of the networking of dispersed people (see Brinkerhoff, Alonso and Oiarzabal). We focus here on three examples from three different continents. Most famously, media ethnographers Daniel Miller and Don Slater focused on the Trinidadian diaspora. They describe how “de Rumshop Lime”, a collective online chat room, is used by young people at home and abroad to “lime”, meaning to chat and hang out. Describing the users of the chat, “the webmaster [a Trini living away] proudly proclaimed them to have come from 40 different countries” (though massively dominated by North America) (88). Writing about people in the Greek diaspora, communication researcher Myria Georgiou traced how its mediation evolved from letters, word of mouth, and bulletins to satellite television, telephone, and the Internet (147). From the introduction of the Web, globally dispersed people went online to get in contact with each other. Meanwhile, feminist film scholar Anna Everett draws on the case of Naijanet, the virtual community of “Nigerians Living Abroad”. She shows how Nigerians living in the diaspora from the 1990s onwards connected in global transnational communities, forging “new black public spheres” (35). These studies point at how diasporic people have turned to the Internet to establish and maintain social relations, give and receive support, and share general concerns. Establishing transnational communicative networks allows users to imagine shared audiences of fellow diasporians. Diasporic imagination, however, goes beyond singular notions of this more traditional idea of the transnational public sphere, as it “has nowadays acquired a great figurative flexibility which mostly refers to practices of transgression and hybridisation” (Ponzanesi, “Diasporic Subjects” 208). Below we recognise another dimension of digital diasporas: the articulation of diasporic attachment for branding oneself. Mocro and Nikkei: Diasporic Attachments as a Way to Brand Oneself In this section, we consider how hybrid cultural practices are carried out over geographical distances. Across spaces on the Web, young migrants express new forms of belonging in their dealing with the oppositional motivations of continuity and change. The generational specificity of this experience can be drawn out on the basis of the distinction between “roots” and “routes” made by Paul Gilroy. In his seminal book The Black Atlantic: Modernity and Double Consciousness, Gilroy writes about black populations on both sides of the Atlantic. The double consciousness of migrant subjects is reflected by affiliating roots and routes as part of a complex cultural identification (19 and 190). As two sides of the same coin, roots refer to the stable and continuing elements of identities, while routes refer to disruption and change. Gilroy criticises those who are “more interested in the relationship of identity to roots and rootedness than in seeing identity as a process of movement and mediation which is more appropriately approached via the homonym routes” (19). He stresses the importance of not just focusing on one of either roots or routes but argues for an examination of their interplay. Forming a response to discrimination and exclusion, young migrants in online networks turn to more positive experiences such as identification with one’s heritage inspired by generational specific cultural affiliations. Here, we focus on two examples that cross two continents, showing routed online attachments to “be(com)ing Mocro”, and “be(coming) Nikkei”. Figure 1. “Leipe Mocro Flavour” music video (Ali B) The first example, being and becoming “Mocro”, refers to a local, bi-national consciousness. The term Mocro originated on the streets of the Netherlands during the late 1990s and is now commonly understood as a Dutch honorary nickname for youths with Moroccan roots living in the Netherlands and Belgium. A 2003 song, Leipe mocro flavour (“Crazy Mocro Flavour”) by Moroccan-Dutch rapper Ali B, familiarised a larger group of people with the label (see Figure 1). Ali B’s song is exemplary for a wider community of youngsters who have come to identify themselves as Mocros. One example is the Marokkanen met Brainz – Hyves (Mo), a community page within the Dutch social networking site Hyves. On this page, 2,200 youths who identify as Mocro get together to push against common stereotypes of Moroccan-Dutch boys as troublemakers and thieves and Islamic Moroccan-Dutch girls as veiled carriers of backward traditions (Leurs, forthcoming). Its description reads, “I assume that this Hyves will be the largest [Mocro community]. Because logically Moroccans have brains” (our translation): What can you find here? Discussions about politics, religion, current affairs, history, love and relationships. News about Moroccan/Arabic Parties. And whatever you want to tell others. Use your brains. Second, “Nikkei” directs our attention to Japanese migrants and their descendants. The Discover Nikkei website, set up by the Japanese American National Museum, provides a revealing description of being and becoming Nikkei: As Nikkei communities form in Japan and throughout the world, the process of community formation reveals the ongoing fluidity of Nikkei populations, the evasive nature of Nikkei identity, and the transnational dimensions of their community formations and what it means to be Nikkei. (Japanese American National Museum) This site was set up by the Japanese American National Museum for Nikkei in the global diaspora to connect and share stories. Nikkei youths of course also connect elsewhere. In her ethnographic online study, Shana Aoyama found that the social networking site Hi5 is taken up in Peru by young people of Japanese heritage as an avenue for identity exploration. She found group confirmation based on the performance of Nikkei-ness, as well as expressions of individuality. She writes, “instead of heading in one specific direction, the Internet use of Nikkei creates a starburst shape of identity construction and negotiation” (119). Mocro-ness and Nikkei-ness are common collective identification markers that are not just straightforward nationalisms. They refer back to different homelands, while simultaneously they also clearly mark one’s situation of being routed outside of this homeland. Mocro stems from postcolonial migratory flows from the Global South to the West. Nikkei-ness relates to the interesting case of the Japanese diaspora, which is little accounted for, although there are many Japanese communities present in North and South America from before the Second World War. The context of Peru is revealing, as it was the first South American country to accept Japanese migrants. It now hosts the second largest South American Japanese diaspora after Brazil (Lama), and Peru’s former president, Alberto Fujimoro, is also of Japanese origin. We can see how the importance of the nation-state gets blurred as diasporic youth, through cultural hybridisation of youth culture and ethnic ties, initiates subcultures and offers resistance to mainstream western cultural forms. Digital spaces are used to exert youthful diaspora branding. Networked branding includes expressing cultural identities that are communal and individual but also both local and global, illustrative of how “by virtue of being global the Internet can gift people back their sense of themselves as special and particular” (Miller and Slater 115). In the next section, we set out how youthful diaspora branding is part of a larger, more rhizomatic formation of multivocal hypertext aesthetics. Hypertext Aesthetics In this section, we set out how an in-between, or “liminal”, position, in postcolonial theory terms, can be a source of differential and multivocal cultural production. Appadurai, Bhabha, and Gilroy recognise that liminal positions increasingly leave their mark on the global and local flows of cultural objects, such as food, cinema, music, and fashion. Here, our focus is on how migrant youths turn to hypertextual forms of cultural production for a differential expression of digital diasporas. Hypertexts are textual fields made up of hyperlinks. Odin states that travelling through cyberspace by clicking and forging hypertext links is a form of multivocal digital diaspora aesthetics: The perpetual negotiation of difference that the border subject engages in creates a new space that demands its own aesthetic. This new aesthetic, which I term “hypertext” or “postcolonial,” represents the need to switch from the linear, univocal, closed, authoritative aesthetic involving passive encounters characterising the performance of the same to that of non-linear, multivocal, open, non-hierarchical aesthetic involving active encounters that are marked by repetition of the same with and in difference. (Cited in Landow 356-7) On their profile pages, migrant youth digitally author themselves in distinct ways by linking up to various sites. They craft their personal hypertext. These hypertexts display multivocal diaspora aesthetics which are personal and specific; they display personal intersections of affiliations that are not easily generalisable. In several Dutch-language online spaces, subjects from Dutch-Moroccan backgrounds have taken up the label Mocro as an identity marker. Across social networking sites such as Hyves and Facebook, the term gets included in nicknames and community pages. Think of nicknames such as “My own Mocro styly”, “Mocro-licious”, “Mocro-chick”. The term Mocro itself is often already multilayered, as it is often combined with age, gender, sexual preference, religion, sport, music, and generationally specific cultural affiliations. Furthermore, youths connect to a variety of groups ranging from feminist interests (“Women in Charge”), Dutch nationalism (“I Love Holland”), ethnic affiliations (“The Moroccan Kitchen”) to clothing (the brand H&M), and global junk food (McDonalds). These diverse affiliations—that are advertised online simultaneously—add nuance to the typical, one-dimensional stereotype about migrant youth, integration, and Islam in the context of Europe and Netherlands (Leurs, forthcoming). On the online social networking site Hi5, Nikkei youths in Peru, just like any other teenagers, express their individuality by decorating their personal profile page with texts, audio, photos, and videos. Besides personal information such as age, gender, and school information, Aoyama found that “a starburst” of diverse affiliations is published, including those that signal Japanese-ness such as the Hello Kitty brand, anime videos, Kanji writing, kimonos, and celebrities. Also Nikkei hyperlink to elements that can be identified as “Latino” and “Chino” (Chinese) (104-10). Furthermore, users can show their multiple affiliations by joining different “groups” (after which a hyperlink to the group community appears on the profile page). Aoyama writes “these groups stretch across a large and varied scope of topics, including that of national, racial/ethnic, and cultural identities” (2). These examples illustrate how digital diasporas encompass personalised multivocal hypertexts. With the widely accepted adagio “you are what you link” (Adamic and Adar), hypertextual webs can be understood as productions that reveal how diasporic youths choose to express themselves as individuals through complex sets of non-homogeneous identifications. Migrant youth connects to ethnic origin and global networks in eclectic and creative ways. The concept of “digital diaspora” therefore encapsulates both material and virtual (dis)connections that are identifiable through common traits, strategies, and aesthetics. Yet these hypertextual connections are also highly personalised and unique, offering a testimony to the fluid negotiations and intersections between the local and the global, the rooted and the diasporic. Conclusions In this article, we have argued that migrant youths render digital diasporas more complex by including branding and hypertextual aesthetics in transnational public spheres. Digital diasporas may no longer be understood simply in terms of their vertical relations to a homeland or place of origin or as horizontally connected to a clearly marked transnational community; rather, they must also be seen as engaging in rhizomatic digital practices, which reshuffle traditional understandings of origin and belonging. Contemporary youthful digital diasporas are therefore far more complex in their engagement with digital media than most existing theory allows: connections are hybridised, and affiliations are turned into practices of diasporic branding and becoming. There is a generational specificity to multivocal diaspora aesthetics; this specificity lies in the ways migrant youths show communal recognition and express their individuality through hypertext which combines affiliation to their national/ethnic “roots” with an embrace of other youth subcultures, many of them transnational. These two axes are constantly reshuffled and renegotiated online where, thanks to the technological possibilities of HTML hypertext, a whole range of identities and identifications may be brought together at any given time. We trust that these insights will be of interest in future discussion of online networks, transnational communities, identity formation, and hypertext aesthetics where much urgent and topical work remains to be done. References Adamic, Lada A., and Eytan Adar. “You Are What You Link.” 2001 Tenth International World Wide Web Conference, Hong Kong. 26 Apr. 2010. ‹http://www10.org/program/society/yawyl/YouAreWhatYouLink.htm›. Ali B. “Leipe Mocro Flavour.” ALIB.NL / SPEC Entertainment. 2007. 4 Oct. 2010 ‹http://www3.alib.nl/popupAlibtv.php?catId=42&contentId=544›. Alonso, Andoni, and Pedro J. Oiarzabal. Diasporas in the New Media Age. Reno: U of Nevada P, 2010. Anderson, Benedict. Imagined Communities: Reflections on the Origin and Spread of Nationalism. Rev. ed. 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Introduction Amidst ecological collapse and environmental catastrophe, humankind is surrounded by indications that our habitat is turning against us in monstrous ways. The very environments we live within now evoke existential terror, and this state of ecological monstrosity has permeated popular media, including video games. Such cultural manifestations of planetary catastrophe are particularly evident in video game monsters. These virtual figures continue monsters’ long-held role in reflecting the socio-cultural anxieties of their particular era. The horrific figures that monsters present play a culturally reflexive role, echoing the fears and anxieties of their social, political and cultural context. Media monsters closely reflect their surrounding cultural conditions (Cohen 47), representing “a symptom of or a metaphor for something bigger and more significant than the ostensible reality of the monster itself” (Hutchings 37). Society’s deepest anxieties culminate in these figures in forms that are “threatening and impure” (Carroll 28), “unnatural, transgressive, obscene, contradictory” (Kearney 4–5), and abject (Kristeva 4). In this article I ask how the appearance of the monstrous within contemporary video games reflects an era of climate change and ecological collapse, and how this could inform the engagement of players with discourse concerning climate change. Central to this inquiry is the literary practice of ecocriticism, which seeks to examine environmental rather than human representation in cultural artefacts, increasingly including accounts of contemporary ecological decay and disorder (Bulfin 144). I build on such perspectives to address play encounters that foreground figures of monstrosity borne of the escalating climate crisis, and summarise case studies of two recent video games undertaken as part of this project — The Legend of Zelda: Breath of the Wild (Nintendo EPD) and The Last of Us Part II (Naughty Dog). An ecocritical approach to the monsters that populate these case studies reveals the emergence of a ludic form of ecological monstrosity tied closely to our contemporary climatic conditions and taking two significant forms: one accentuating a visceral otherness and aberrance, and the other marked by the uncanny recognition of human authorship of climate change. Horrors from the Anthropocene A growing climate emergency surrounds us, enveloping us in the abject and aberrant conditions of what could be described as an ecological monstrosity. Monstrous threats to our environment and human survival are experienced on a planetary scale and research evidence plainly illustrates a compounding catastrophe. The United Nations Intergovernmental Panel on Climate Change (IPCC), a relatively cautious and conservative body (Parenti 5), reports that a human-made emergency has developed since the Industrial Revolution. The multitude of crises that confront us include: changes in the Earth’s atmosphere driving up global temperatures, ice sheets in retreat, sea levels rising, natural ecosystems and species in collapse, and an unprecedented frequency and magnitude of heatwaves, droughts, flooding, winter storms, hurricanes, and wildfires (United Nations Environment Programme). Further human activity, including a post-war addiction to the plastics that have now spread their way across our oceans like a “liquid smog” (Robles-Anderson and Liboiron 258), or short-sighted enthusiasm for pesticides, radiation energy, and industrial chemicals (Robles-Anderson and Liboiron 254), has ensured a damaging shift in the nature of the feedback loops that Earth’s ecosystems depend upon for stability (Parenti 6). Climatic equilibrium has been disrupted, and growing damage to the ecosystems that sustain human life suggests an inexorable, entropic path to decay. To understand Earth’s profound crisis requires thinking beyond just climate and to witness the interconnected “extraordinary burdens” placed on our planet by “toxic chemistry, mining, nuclear pollution, depletion of lakes and rivers under and above ground, ecosystem simplification, vast genocides of people” which will continue to lead to the recursive collapse of interlinked major systems (Haraway 100). To speak of climate change is really to speak of the ruin of ecologies, those “living systems composed of many moving parts” that make up the tapestry of organic life on Earth (Robles-Anderson and Liboiron 251). The emergency that presents itself, as Renata Tyszczuk observes, comprises a pervasiveness, uncertainty, and interdependency that together “affect every aspect of human lives, politics and culture” (47). The emergence of the term Anthropocene (or the Age of the Humans) to describe our current geological epoch (and to supersede the erstwhile and more stable Holocene) (Zalasiewicz et al. 1036–7; Chang 7) reflects a contemporary impossibility with talking about planet Earth without acknowledging the damaging impact of humankind on its ecosystems (Bulfin 142). This recognition of human complicity in the existential crisis engulfing our planet once again connects ecological monstrosity to the socio-cultural history of the monstrous. Monsters, Jeffrey Jerome Cohen points out, “are our children” and despite our repressive efforts, “always return” in order to “ask us why we have created them” (20). Ecological monstrosity declares to us that our relegation of greenhouse gases, rising sea levels, toxic waste, species extinction, and much more, to the discursive periphery has only been temporary. Monsters, when examined closely, start to look a lot like ourselves in terms of biological origins (Perron 357), as well as other abject cultural and social markers that signal these horrific figures as residing “too close to the borders of our [own] subjectivity for comfort” (Spittle 314). Isabel Pinedo sees this uncanny nature of the horror genre’s antagonists as a postmodern condition, a ghoulish reminder of the era’s breakdown of categories, blurring of boundaries, and collapse of master narratives that combine to ensure “mastery is lost … and the stable, unified, coherent self acquires the status of a fiction” (17–18). In standing in for anxiety, the other, and the aberrant, the figure of the monster deftly turns the mirror back on its human victims. Ecocritical Play The vast scale of ecological collapse has complicated effective public communication on the subject. The scope involved is unsettling, even paralysing, to its audiences: climate change might just be “too here, too there, too everywhere, too weird, too much, too big, too everything” to bring oneself to engage with (Tyszczuk 47). The detail involved has also been captured by scientific discourse, a detached communicative mode which too easily obviates the everyday human experience of the emergency (Bulfin 140; Abraham and Jayemanne 74–76). Considerable effort has been focussed upon producing higher-fidelity models of ecological catastrophe (Robles-Anderson and Liboiron 248), rather than addressing the more significant “trouble with representing largely intangible linkages” between micro-environmental actions and macro-environmental repercussions (Chang 86). Ecocriticism is, however, emerging as a cultural means by which the crisis, and restorative possibilities, may be rendered more legible to a wider audience. Representations of ecology and catastrophe not only sustain genres such as Eco-Disaster and Cli-Fi (Bulfin 140), but are also increasingly becoming a precondition for fiction centred upon human life (Tyszczuk 47). Media artefacts concerned with environment are able to illustrate the nature of the emergency alongside “a host of related environmental issues that the technocratic ‘facts and figures’ approach … is unlikely to touch” (Abraham and Jayemanne 76) and encourage in audiences a suprapersonal understanding of the environmental impact of individual actions (Chang 70). Popular culture offers a chance to foster ‘ecological thought’ wherein it becomes “frighteningly easy … to join the dots and see that everything is interconnected” (Morton, Ecological Thought 1) rather than founder before the inexplicability of the temporalities and spatialities involved in ecological collapse. An ecocritical approach is “one of the most crucial—yet under-researched—ways of looking into the possible cultural impact of the digital entertainment industry” upon public discourse relating to the environment crisis (Felczak 185). Video games demand this closer attention because, in a mirroring of the interconnectedness of Earth’s own ecosystems, “the world has also inevitably permeated into our technical artefacts, including games” (Chang 11), and recent scholarship has worked to investigate this very relationship. Benjamin Abraham has extended Morton’s arguments to outline a mode of ecological thought for games (What Is an Ecological Game?), Alenda Chang has closely examined how games model natural environments, and Benjamin Abraham and Darshana Jayemanne have outlined four modes in which games manifest players’ ecological relationships. Close analysis of texts and genres has addressed the capacity of game mechanics to persuade players about matters of sustainability (Kelly and Nardi); implicated Minecraft players in an ecological practice of writing upon landscapes (Bohunicky); argued that Final Fantasy VII’s plot fosters ecological responsibility (Milburn); and, identified in ARMA III’s ambient, visual backdrops of renewable power generation the potential to reimagine cultural futures (Abraham, Video Game Visions). Video games allow for a particular form of ecocriticism that has been overlooked in existing efforts to speak about ecological crisis: “a politics that includes what appears least political—laughter, the playful, even the silly” (Morton, Dark Ecology 113). Play is liminal, emergent, and necessarily incomplete, and this allows its various actors—players, developers, critics and texts themselves—to come together in non-authoritarian, imaginative and potentially radical ways. Through play, audiences are offered new and novel modes for envisioning ecological problems, solutions, and futures. To return, then, to encounters with ecological monstrosity, I next consider the visions of crisis that emerge through the video game monsters that draw upon the aberrant nature of ecological collapse, as well as those that foreground our own complicity as humans in the climate crisis, declaring that we players might ourselves be monstrous. The two case studies that follow are necessarily brief, but indicate the value of further research and textual analysis to more fully uncover the role of ecological monstrosity in contemporary video games. Breath of the Wild’s Corrupted Ecology The Legend of Zelda: Breath of the Wild (Nintendo EPD) is a fantasy action-adventure game in which players adopt the role of the games series’ long-running protagonist, Link, and explore the virtual landscapes of fictional Hyrule in unstructured and nonlinear ways. Landscape is immediately striking to players of Breath of the Wild, with the game using a distinctive, high-definition cel-shaded animation style to vividly render natural environments. Within the first ten minutes of play, lush green grass sways around the player’s avatar, densely treed forests interrupt rolling vistas, and finely detailed mountains tower over the player’s perspective. The player soon learns, however, that behind these inviting landscapes lies a catastrophic corruption of natural order, and that their virtual enemies will manifest a powerful monstrosity that seems to mirror Earth’s own ecological crises. The game’s backstory centres around the Zelda series’ persistent antagonist, Ganon, and his use of a primal form of evil to overwhelm a highly evolved and industrialised Hyrulian civilisation, in an event dubbed the Great Calamity. Hyrule’s dependency on mechanical technology in its defences is misjudged, and Ganon’s re-appearance causes widespread devastation. The parallel between Hyrule’s fate and humankind’s own unsustainable commitment to heavy industry and agriculture, and faith in technological approaches to mitigation in the face of looming catastrophe, are immediately recognisable. Visible, too, is the echo of the revenge of Earth’s climate in the organic and primal force of Ganon’s destructive power. Ganon leaves in his wake an array of impossible, aberrant creatures hostile to the player, including the deformed humanoid figure of the Bokoblin (bearing snouts, arrow-shaped tails, and a horn), the sand-swimming spike-covered whale known as a Molduga, and the Stone Talus, an anthropomorphic rock formation that bursts into life out of otherwise innocuous geological features. One particularly apposite monster, known simply as Malice, is a glowing black and purple substance that oozes its way through environments in Hyrule, spreading to cover and corrupt organic material. Malice is explained by in-game introductory text as “poisonous bogs formed by water that was sullied during the Great Calamity”—an environmental element thrown out of equilibrium by pollution. Monstrosity in Breath of the Wild is decidedly ecological, and its presentation of unstable biologies, poisoned waters, and a collapsed natural order offer a conspicuous display of our contemporary climate crisis. Breath of the Wild places players in a traditional position in relation to its virtual monsters: direct opposition (Taylor 31), with a clear mandate to eliminate the threat(s) and restore equilibrium (Krzywinska 12). The game communicates its collection of biological impossibilities and inexorable corruptions as clear aberrations of a once-balanced natural order, with Hyrule’s landscapes needing purification at the player’s hands. Video games are driven, according to Jaroslav Švelch, by a logic of informatic control when it comes to virtual monsters, where our previously “inscrutable and abject” antagonists can be analysed, defined and defeated as “the medium’s computational and procedural nature makes monstrosity fit into databases and algorithms” (194). In requiring Link, and players, to scrutinise and come to “know” monsters, the game suggests a particular ecocritical possibility. Ecological monstrosity becomes educative, placing the terrors of the climate crisis directly before players’ avatars, screens, and eyes and connecting, in visceral ways, mastery over these threats with pleasure and achievement. The monsters of Breath of the Wild offer the possibility of affectively preparing players for versions of the future by mediating such engagements with disaster and catastrophe. Recognising the Monstrosity Within Set in the aftermath of the outbreak of a mutant strain of the Cordyceps fungus (through exposure to which humans transform into aggressive, zombified ‘Infected’), The Last of Us Part II (Naughty Dog) is a post-apocalyptic action-adventure game. Players alternate between two playable human characters, Ellie and Abby, whose travels through the infection-ravaged states of Wyoming, Washington, and California overlap and intertwine. At first glance, The Last of Us Part II appears to construct similar forms of ecology and monstrosity as Breath of the Wild. Players are thrust into an experience of the sublime in the game’s presentation of natural environments that are vastly capacious and highly fidelitous in their detailing. Players begin the game scrambling across snowbound ranges and fleeing through thick forests, and later encounter lush grass, rushing rivers, and wild animals reclaiming once-urban environments. And, as in Breath of the Wild, monstrosity in this gameworld appears to embody impurity and corruption, whether through the horrific deformations of various types of zombie bodies, or the fungal masses that carpet many of the game’s abandoned buildings in a reclamation of human environments by nature. Closer analysis, however, demonstrates that the monstrosity that defines the play experience of The Last of Us Part II uncannily reflects the more uncomfortable truths of the Anthropocentric era. A key reason why zombies are traditionally frightening is because they are us. The semblance of human faces and bodies that remain etched into these monsters’ decaying forms act as portents for our own fates when faced with staggering hordes and overwhelmingly poor odds of survival. Impure biologies are presented to players in these zombies, but rather than represent a distant ‘other’ they stand as more-than-likely futures for the game’s avatars, just as Earth’s climate crisis is intimately bound up in human origins and inexorable futures. The Last of Us Part II further pursues its line of anthropocentric critique, as both Ellie and Abby interact during the game with different groupings of human survivors, including hubristic militia and violent religious cultists. The player comes to understand through these encounters that it is the distrust, dogmatism, and depravity of their fellow humans that pose immediate threats to avatarial survival, rather than the scrutable, reliable, and predictable horrors of the mindless zombies. In keeping with the appearance of monsters in both interactive and cinematic texts, monsters’ most important lessons emerge when the boundaries between reality and fiction, human and nonhuman, and normality and abnormality become blurred. The Last of Us Part II utilises this underlying ambiguity in monstrosity to suggest a confronting ecological claim: that monstrous culpability belongs to us—the inhabitants of Earth. For video game users in particular, this is a doubly pointed accusation. As Thomas Apperley and Darshana Jayemanne observe of digital games, “however much their digital virtuality is celebrated they are enacted and produced in strikingly visceral—ontologically virtual—ways”, and such a materialist consideration “demands that they are also understood as objects in the world” (15). The ecological consequences of the production of such digital objects are too often taken for granted, despite critical work examining the damaging impact of resource extraction, electronic waste, energy transfer, telecommunications transfer, and the logics of obsolescence involved (Dyer-Witheford and de Peuter; Newman; Chang 152). By foregrounding humanity’s own monstrosity, The Last of Us Part II illustrates what Timothy Morton describes as the “weirdly weird” consequences of human actions during the Anthropocene; those uncanny, unexpected, and planetarily destructive outcomes of the post-industrial myth of progress (Morton, Dark Ecology 7). The ecocritical work of video games could remind players that so many of our worst contemporary nightmares result from human hubris (Weinstock 286), a realisation played out in first-person perspective by Morton: “I am the criminal. And I discover this via scientific forensics … I’m the detective and the criminal!” (Dark Ecology 9). Playing with Ecological Monstrosity The Legend of Zelda: Breath of the Wild and The Last of Us Part II confront players with an ecological form of monstrosity, which is deeply recursive in its nature. Players encounter monsters that stand in for socio-political anxieties about ecological disaster as well as those that reflect humanity’s own monstrously destructive hubris. Attention is further drawn to the player’s own, lived role as a contributor to climate crisis, a consequence of not only the material characteristics of digital games, but also their broader participation in the unsustainable economics of the post-industrial age. To begin to make the connections between these recursive monsters and analogies is to engage in the type of ecological thought that lets us see the very interconnectedness that defines the ecosystems we have damaged so fatally. In understanding that video games are the “point of convergence for a whole array of technical, cultural, and promotional dynamics of which [players] are, at best, only partially aware” (Kline, Dyer-Witheford, and de Peuter 19), we see that the nested layering of anxieties, fears, fictions, and realities is fundamental to the very fabric of digital games. Recursion, Donna Haraway observes in relation to the interlinked failure of ecosystems, “can be a drag” (100), but I want to suggest that playing with ecological monstrosity instead turns recursion into opportunity. An ecocritical approach to the examination of contemporary videogame monsters demonstrates that these horrific figures, through their primordial aesthetic and affective impacts, are adept at foregrounding the ecosystemic nature of the relationship between games and our own world. Videogames play a role in representing both desirable and objectionable versions of the world, and such “utopian and dystopian projections of the future can shape our acts in the present” (Fordyce 295). By confronting players with viscerally accessible encounters with the horror of an aberrant and abjected near future (so near that it is, in fact, already the present), games such as Breath of the Wild and The Last of Us Part II can critically position players in relation to discourse and wider public debate about ecological issues and climate change (and further research could more closely examine players’ engagements with ecological monstrosity). Drawing attention to the symmetry between monstrosity and ecological catastrophe is a crucial way that contemporary games might encourage players to untangle the recursive environmental consequences of our anthropocentric era. 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