Journal articles on the topic 'Working class whites – united states – biography'

By the close of the nineteenth century, Hawai‘i had become a newly annexed territory of the United States and was tightly controlled by a cohesive oligarchy ofhaolesugar capitalists. The “enormous concentration of wealth and power” held by the Big Five sugar factors of Honolulu up until statehood was unparalleled elsewhere in the United States (Cooper and Daws 1985: 3–4). In contrast, native Hawai‘ians and immigrants recruited from China, Portugal, Japan, and the Philippines—in successive and overlapping waves—endured the low wages and poor working and living conditions characteristic of other agricultural export regions.

Recent research finds that there is a growing class gap in levels of civic engagement among young whites in the United States. Much of the literature on civic engagement focuses on individual– and family–level factors related to civic engagement. Our evidence suggests that it is critically important to consider variation and change in community–level factors as well, and that such factors may play a key role in facilitating or inhibiting civic engagement. To explore the puzzle of the growing class gap among young whites in civic engagement, we conducted two–generation in–depth qualitative interviews in white working class neighborhoods in Philadelphia and its inner suburbs, with companion interviews among Philadelphia–area youth living in middle class communities. We complement these interviews with quantitative measures of institutional and demographic changes in these neighborhoods over time. Our evidence suggests that a withdrawal of institutional investments in working class neighborhoods (and relative to middle class neighborhoods), along with an increase in population turnover and racial and ethnic heterogeneity, which has disproportionately impacted working class neighborhoods as well, may be important factors in understanding the growing class gap in civic engagement among white youth.

Body mass index (bmi) values reflect the net balance between nutrition, work effort, and calories consumed to fight disease. Nineteenth-century prison records in the United States demonstrate that the bmi values of blacks and whites were distributed symmetrically; neither underweight nor obese individuals were common among the working class. bmi values declined throughout the nineteenth century. By modern standards, however, nineteenth-century bmis were in healthy weight ranges, though the biological living standards in rural areas exceeded those in urban areas. The increase in bmis during the twentieth century did not have its origin in the nineteenth century.

Growing racial, ideological, and cultural polarization within the American electorate contributed to the shocking victory of Donald Trump in the 2016 presidential election. Using data from American National Election Studies surveys, we show that Trump’s unusually explicit appeals to racial and ethnic resentment attracted strong support from white working-class voters while repelling many college-educated whites along with the overwhelming majority of nonwhite voters. However, Trump’s campaign exploited divisions that have been growing within the electorate for decades because of demographic and cultural changes in American society. The 2016 presidential campaign also reinforced another longstanding trend in American electoral politics: the rise of negative partisanship, that is voting based on hostility toward the opposing party and its leaders. We conclude with a discussion of the consequences of deepening partisan and affective polarization for American democracy and the perceptions by both experts and the public of an erosion in its quality.

Popular and scholarly accounts of Trump’s ascendency to the presidency of the United States on the part of the American white working-class use different variables to define the sociodemographic group because there is no “working-class White” variable available in benchmark datasets for researchers to code. To address this need, the Author ran a multinomial regression to assess whether income, education and racial identity predict working-class membership among white Americans, finding that income and education are statistically significant predictors of working-class whiteness, while racial identity is not. Arriving at a robust definition of “white working-class” in light of these findings, the paper next turns to a review of the extant literature. By retrieving studies from searches of computerised databases, hand searches and authoritative texts, the review critically surmises the explanatory accounts of Trump’s victory. Discussion of the findings from the review is presented in three principal sections. The first section explains how working-class White communities, crippled by a dearth of social and geographic mobility, have been “left behind” by the political elites. The second section examines how white Americans, whose dominant group position is threatened by demographic change, voted for Trump because of resonance between his populist rhetoric and their latent “racist” attitudes. The third and final section explores the implications of a changing America for native-born whites, and how America’s increasing ethnoracial diversity is eroding relations between its dominant and nondominant groups. The Author surmises by arguing that these explanatory accounts must be understood in the context of this new empirical approximation of “working-class White”.

If, as a famous dead white European man once suggested, the point of studying racism is to change it, what can we learn about ending racism by studying it as whiteness? The first part of the paper summarizes some of the major issues and findings of recent studies of whiteness in the United States. It suggests that there is a hidden life at the heart of whiteness which is about preserving a set of specifically white constructions of masculinity and femininity, and that whites' lack of consciousness about this, and about white privilege in general, have undermined antiracist efforts. It summarizes some of the ways in which working-class white privilege is gendered, and how notions of masculinity and femininity are racial. Part II examines whiteness as ambivalence about the privileges and costs of whiteness as a useful entry point for understanding impulses to white antiracism.

(Title: Just Like Black, Only Better: Poor White in Antebellum South of America Depicted in Solomon Northup’s Novel “Twelve Years as A Slave”). Antebellum era, the period before the Civil War occured, or before the year 1861, in the United States is used to relate to the enslavement of black American. In fact, the era was not merely about black, but also poor white. This study is purposed to describe the poor whites’ life in antebellum America as reflected in Twelve Years As A Slave (1855), a narrative biography novel written by Solomon Northup. Set up the story in New York, Washingotn DC, and New Orleans, the author (and focalizer at once) told the story based on his own experience as a black who was captivated and sold into slavery for twelve years. Although the novel centered its story on black character, it also reflected the life of poor whites who were also being “enslaved” by their white counterparts. Through sociology of literature perspective, this study reveals that the character of poor white that represented through John M. Tibeats, Armsby, and James H. Burch came from Great Britain especially from Ireland. Mostly, they moved to America as incarcerated people. They lived under the poverty and some of them were the vagrants and petty criminals. Poor white during antebellum era in America was positioned in the lower social level. They were “enslaved” by their white master but more better compared to the black slaves. It can be noticed that poor white were positioned in low social level because of the socio-economic problem, while blacks were race and racism. Keywords: antebellum America, poor white, slavery, social class, American literature

Substantial racial/ethnic and gender disparities in COVID-19 mortality have been previously documented. However, few studies have investigated the impact of individual socioeconomic position (SEP) on these disparities. Objectives: To determine the joint effects of SEP, race/ethnicity, and gender on the burden of COVID-19 mortality. A secondary objective was to determine whether differences in opportunities for remote work were correlated with COVID-19 death rates for sociodemographic groups. Design: Annual mortality study which used a special government tabulation of 2020 COVID-19-related deaths stratified by decedents’ SEP (measured by educational attainment), gender, and race/ethnicity. Setting: United States in 2020. Participants: COVID-19 decedents aged 25 to 64 years old (n = 69,001). Exposures: Socioeconomic position (low, intermediate, and high), race/ethnicity (Hispanic, Black, Asian, Indigenous, multiracial, and non-Hispanic white), and gender (women and men). Detailed census data on occupations held by adults in 2020 in each of the 36 sociodemographic groups studied were used to quantify the possibility of remote work for each group. Main Outcomes and Measures: Age-adjusted COVID-19 death rates for 36 sociodemographic groups. Disparities were quantified by relative risks and 95% confidence intervals. High-SEP adults were the (low-risk) referent group for all relative risk calculations. Results: A higher proportion of Hispanics, Blacks, and Indigenous people were in a low SEP in 2020, compared with whites. COVID-19 mortality was five times higher for low vs. high-SEP adults (72.2 vs. 14.6 deaths per 100,000, RR = 4.94, 95% CI 4.82–5.05). The joint detriments of low SEP, Hispanic ethnicity, and male gender resulted in a COVID-19 death rate which was over 27 times higher (178.0 vs. 6.5 deaths/100,000, RR = 27.4, 95% CI 25.9–28.9) for low-SEP Hispanic men vs. high-SEP white women. In regression modeling, percent of the labor force in never remote jobs explained 72% of the variance in COVID-19 death rates. Conclusions and Relevance: SARS-CoV-2 infection control efforts should prioritize low-SEP adults (i.e., the working class), particularly the majority with “never remote” jobs characterized by inflexible and unsafe working conditions (i.e., blue collar, service, and retail sales workers).

This chapter examines the policy arguments advanced in Fisher v. University of Texas, an antiracial diversity in higher education case argued before the United States Supreme Court. The author contends that the arguments put forth by the petitioner are intended not only to frame White people as the expressed victims of opportunity-expanding policies, such as diversity, but also to construct people of color as undeserving of admissions to one of America's most preeminent public institutions of higher education. In addition to being ahistorical, the anti-diversity arguments in Fisher v. University of Texas purposely dismiss the structural arrangements and institutionalized practices responsible for the development of the University of Texas's diversity policy. The chapter concludes with a recommendation for a multidiscipline approach to education policy analysis in order to better understand and contextualize how race is operationalized in contemporary public policy debates. In 1942… segregation was considered fair. –Terry H. Anderson … the fact that special treatment for minority applicants upset working and middle-class whites so much more than preferences for applicants whose parents are faculty members, alumni, or major contributors cannot be explained solely by recent Supreme Court decisions holding that any racial classifications must be reviewed with utmost suspicion. –Derrick Bell

In 1945, American labor unions optimistically expected considerable growth in the coming decades. The New Deal policies continued their influence, and organized labor achieved its highest density rating (35 percent) ever recorded in the United States. By the mid-1950s, however, that figure began to decline, slowly at first and then, after 1970, swiftly. At the close of 2011, it had fallen to 11.8 percent. The cause of this reduction was not simply employer opposition, although that did occur. Rather, the American working class itself underwent a political and sociological sea change, propelled by southern migration of whites and blacks into the industrial North, sharp changes in political attitudes during and after the 1960s, and the economic transformation of the American and global economy that began in the 1970s. Some of these changes were beyond the scope of organized labor’s ability to alter; regarding others, labor proved to be slow, even hesitant, in its response. One consequence was the resurgence of a sharply conservative political vision among American working people that had a powerful impact on national elections and the policy choices followed.

This paper highlights the relationship between group identification and racialized emotions among white Americans when asked to think about slavery on U.S. soil. Previous scholarship focuses on the consequences of such emotions or stimuli that increase them; however, there is limited work focusing on threat as a racialized emotion, or more broadly who is likely to experience heightened emotions when asked to think about historical racial violence that implicates their group. Using Group Position Theory and Identity Theory, I elevate work on racial threat as an emotion, and demonstrate how it is linked to white Americans’ group identification with their racial, national, and class identities. Then I compare this relationship to other commonly studied emotions—guilt and shame—to demonstrate threat’s unique relationship with these identities. Using survey data collected from a Survey Sampling International panel ( n = 869), I find that feelings of threat are maximized among white Americans who strongly identify with their racial and national identities. In contrast, guilt is heightened among whites who strongly identify with their racial identity, but weakly identify with their national identity, while shame has no significant relationship with these identities. Feelings of threat are also more likely in respondents who self-identify as members of the lower or working class (in comparison to the middle class). The results highlight one way that threat is a distinct emotional experience for white Americans when compared to other emotions. I conclude by discussing how understanding emotions as an outcome of white Americans’ self-perceptions of their identities as group members stands to advance the study of intergroup relations and racism in the United States.

The Equal Employment Opportunity Commission (EEOC) was established in 1965 to implement Title VII of the Civil Rights Act of 1964, which made it illegal to discriminate against an individual in employment on the basis of race, color, religion, sex or national origin. Coming into the 1960s, the employment opportunity that privileged the white male was much more than a job. By the 1960s, growing numbers of white men had employment that gave them steadily rising real earnings, often with decades of tenure at one organization. The “career-with-one-company” (CWOC) that had become the employment norm by the beginning of the 1960s included health insurance and a defined-benefit pension, both funded by the employee’s business corporation or government agency. CWOC is what, in the decades immediately after World War II, turned much of white America into a growing and thriving middle class. This was a white middle class made up of, at the lower end, blue-collar workers with no more than a high-school education. Union representation in collective bargaining enforced the unions’ first-hired, last fired “seniority” principle while securing wage increases in step with productivity growth, with “cost-of-living allowances” that adjusted wages for inflation usually built into the contracts. Aided by government subsidies such as the federal GI Bill and tuition-free higher education at state “land grant” colleges, the male offspring of the white blue-collar worker had ample opportunity to transition to higher incomes, superior benefits, and even more employment security as a white-collar worker. In the 1950s, the white male who had recently ascended to the upper echelons of the middle class became known as “the organization man.” In the immediate aftermath of the 1964 Civil Rights Act, African Americans with no more than a high-school education gained access to CWOC employment at the blue-collar level. Owing to strong demand for production workers in the 1960s and 1970s and affirmative-action support under the EEOC, Blacks were making inroads into white-male privilege by gaining substantial access to well-paid and secure operative and craft occupations; big steps up from the common-laborer jobs into which they had previously been segregated. In the first Working Paper of this series https://www.ineteconomics.org/research/research-papers/how-the-disappearance-of-unionized-jobs-obliterated-an-emergent-black-middle-class, we outlined how the decline of unionized jobs from the beginning of the 1980s decimated an emergent African American blue-collar middle class. Over the decades it became clear, however, that, while African Americans were hit earlier and harder than whites, they were not the only ones to fall out of the middle class. Increasingly, white blue-collar workers with no more than a high-school education also lost their middle-class status as the ideology that companies should be run to “maximize shareholder value” put a permanent end to the CWOC norm. Over subsequent decades and up to the present, growing numbers of American workers with only a high-school education, regardless of race, have experienced stagnating incomes, downward socioeconomic mobility, and even, at certain times, declining life expectancy. In this, the second working paper of our Fifty Years After book manuscript, we provide a statistical overview of the changes in employment and earnings of Blacks since the mid-1960s. If Title VII of the Civil Rights Act of 1964, along with other anti-discrimination laws from that period, and the formation of the Equal Employment Opportunity Commission promised progress toward racial equality in employment and general well-being, the current situation shows a very troubling picture. Across all dimensions of economic well-being that are dependent on access to decent paying, secure jobs, Blacks fare worse than whites. We present the most recent available data on the occupations (for 2019) and the industries (for 2018) in which the different Black, white, Hispanic, and Asian members of the U.S. labor force are employed. Then, using the decennial censuses, we examine the distributions of Blacks across aggregate categories of occupations from 1960 to 2010 to see the changing pattern of jobs held by Blacks, in broad terms, from the time of the Civil Rights Act to the present. We then look at the differences in Black and white unemployment and wage rates, with and without accounting for differences in education. The racial gap in wages, after accounting for education level, has widened. Stable jobs that enable employees to share in productivity gains and hence increase their real earnings over time facilitate the accumulation of wealth. In its various forms, wealth influences the current and future well-being of families and their children by enabling investments in education and training, providing savings to offset unforeseen circumstances, and funding retirement. Although manifest progress has been made by a portion of better-educated Blacks, the overall picture for wealth accumulation by Blacks in comparison with whites is grim. A race-based wealth gap should be no surprise, as access of African Americans to stable, well-paid jobs has always been much less than for whites. Yet, the size of wealth disparities is extremely large and has worsened over the last fifty years. Currently the median family wealth for whites is ten times that of Blacks. We examine the wealth gap within separate categories, including housing equity, housing stability measured by delinquency on mortgages and foreclosure, retirement savings and liquid savings, corporate shareholding, and student-loan debt. We also look at health insurance coverage because it functions, in part, like savings that can be called upon to deal with unanticipated events. And lack of health insurance can wipe out one’s accumulated wealth should one require hospitalization and/or expensive drugs. In every one of these components of wealth, Blacks trail whites by large and increasing amounts. Each of these indicators reflects the persistent and even growing Black-white disparities in earnings, employment security, and career patterns over time. Which leaves us with the question that the “Fifty Years After” project seeks to answer: What happened to equal employment opportunity? For a quest for economic equality to become a reality, the pay and stability of employment for Blacks must be improved far more than for whites. But in view of the downward mobility of white workers, even a substantial closing of the Black-white income gap will not solve the problems of poverty and injustice in the United States. Contrary to the situation in the 1960s, in the presence of the impoverished and vulnerable American working class of the 2020s, “equal employment opportunity” will not yield the upward socioeconomic mobility for Blacks that was possible in the 1960s and 1970s. The Covid-19 crisis is having an especially devastating impact on people of color, but workers of every race and ethnicity are feeling immense pain. Even when the public-health crisis has abated, the gargantuan political task for the years and decades ahead will be the restoration of employment opportunity that will enable all Americans to live healthy, secure, and happy lives.

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

This article investigates the prosthesis of identity through the process of branding. It examines cross-cultural manifestations of this phenomena from sixth millennium BCE Syria to twelfth century Japan and Britain. From the Neolithic Era, humanity has sort to extend their identities using pictorial signs that were characteristically simple. Designed to be distinctive and instantly recognisable, the totemic symbols served to signal the origin of the bearer. Subsequently, the development of branding coincided with periods of increased in mobility both in respect to geography and social strata. This includes fifth millennium Mesopotamia, nineteenth century Britain, and America during the 1920s.There are fewer articles of greater influence on contemporary culture than A Theory of Human Motivation written by Abraham Maslow in 1943. Nearly seventy-five years later, his theories about the societal need for “belongingness” and “esteem” remain a mainstay of advertising campaigns (Maslow). Although the principles are used to sell a broad range of products from shampoo to breakfast cereal they are epitomised by apparel. This is with refence to garments and accessories bearing corporation logos. Whereas other purchased items, imbued with abstract products, are intended for personal consumption the public display of these symbols may be interpreted as a form of signalling. The intention of the wearers is to literally seek the fulfilment of the aforementioned social needs. This article investigates the use of brands as prosthesis.Coats and Crests: Identity Garnered on Garments in the Middle Ages and the Muromachi PeriodA logo, at its most basic, is a pictorial sign. In his essay, The Visual Language, Ernest Gombrich described the principle as reducing images to “distinctive features” (Gombrich 46). They represent a “simplification of code,” the meaning of which we are conditioned to recognise (Gombrich 46). Logos may also be interpreted as a manifestation of totemism. According to anthropologist Claude Levi-Strauss, the principle exists in all civilisations and reflects an effort to evoke the power of nature (71-127). Totemism is also a method of population distribution (Levi-Strauss 166).This principle, in a form garnered on garments, is manifested in Mon Kiri. The practice of cutting out family crests evolved into a form of corporate branding in Japan during the Meiji Period (1868-1912) (Christensen 14). During the Muromachi period (1336-1573) the crests provided an integral means of identification on the battlefield (Christensen 13). The adorning of crests on armour was also exercised in Europe during the twelfth century, when the faces of knights were similarly obscured by helmets (Family Crests of Japan 8). Both Mon Kiri and “Coat[s] of Arms” utilised totemic symbols (Family Crests of Japan 8; Elven 14; Christensen 13). The mon for the imperial family (figs. 1 & 2) during the Muromachi Period featured chrysanthemum and paulownia flowers (Goin’ Japaneque). “Coat[s] of Arms” in Britain featured a menagerie of animals including lions (fig. 3), horses and eagles (Elven).The prothesis of identity through garnering symbols on the battlefield provided “safety” through demonstrating “belongingness”. This constituted a conflation of two separate “needs” in the “hierarchy of prepotency” propositioned by Maslow. Fig. 1. The mon symbolising the Imperial Family during the Muromachi Period featured chrysanthemum and paulownia. "Kamon (Japanese Family Crests): Ancient Key to Samurai Culture." Goin' Japaneque! 15 Nov. 2015. 27 July 2019 <http://goinjapanesque.com/05983/>.Fig. 2. An example of the crest being utilised on a garment can be found in this portrait of samurai Oda Nobunaga. "Japan's 12 Most Famous Samurai." All About Japan. 27 Aug. 2018. 27 July 2019 <https://allabout-japan.com/en/article/5818/>.Fig. 3. A detail from the “Index of Subjects of Crests.” Elven, John Peter. The Book of Family Crests: Comprising Nearly Every Family Bearing, Properly Blazoned and Explained, Accompanied by Upwards of Four Thousand Engravings. Henry Washbourne, 1847.The Pursuit of Prestige: Prosthetic Pedigree from the Late Georgian to the Victorian Eras In 1817, the seal engraver to Prince Regent, Alexander Deuchar, described the function of family crests in British Crests: Containing The Crest and Mottos of The Families of Great Britain and Ireland; Together with Those of The Principal Cities and Heraldic Terms as follows: The first approach to civilization is the distinction of ranks. So necessary is this to the welfare and existence of society, that, without it, anarchy and confusion must prevail… In an early stage, heraldic emblems were characteristic of the bearer… Certain ordinances were made, regulating the mode of bearing arms, and who were entitled to bear them. (i-v)The partitioning of social classes in Britain had deteriorated by the time this compendium was published, with displays of “conspicuous consumption” displacing “heraldic emblems” as a primary method of status signalling (Deuchar 2; Han et al. 18). A consumerism born of newfound affluence, and the desire to signify this wealth through luxury goods, was as integral to the Industrial Revolution as technological development. In Rebels against the Future, published in 1996, Kirkpatrick Sale described the phenomenon:A substantial part of the new population, though still a distinct minority, was made modestly affluent, in some places quite wealthy, by privatization of of the countryside and the industrialization of the cities, and by the sorts of commercial and other services that this called forth. The new money stimulated the consumer demand… that allowed a market economy of a scope not known before. (40)This also reflected improvements in the provision of “health, food [and] education” (Maslow; Snow 25-28). With their “physiological needs” accommodated, this ”substantial part” of the population were able to prioritised their “esteem needs” including the pursuit for prestige (Sale 40; Maslow).In Britain during the Middle Ages laws “specified in minute detail” what each class was permitted to wear (Han et al. 15). A groom, for example, was not able to wear clothing that exceeded two marks in value (Han et al. 15). In a distinct departure during the Industrial Era, it was common for the “middling and lower classes” to “ape” the “fashionable vices of their superiors” (Sale 41). Although mon-like labels that were “simplified so as to be conspicuous and instantly recognisable” emerged in Europe during the nineteenth century their application on garments remained discrete up until the early twentieth century (Christensen 13-14; Moore and Reid 24). During the 1920s, the French companies Hermes and Coco Chanel were amongst the clothing manufacturers to pioneer this principle (Chaney; Icon).During the 1860s, Lincolnshire-born Charles Frederick Worth affixed gold stamped labels to the insides of his garments (Polan et al. 9; Press). Operating from Paris, the innovation was consistent with the introduction of trademark laws in France in 1857 (Lopes et al.). He would become known as the “Father of Haute Couture”, creating dresses for royalty and celebrities including Empress Eugene from Constantinople, French actress Sarah Bernhardt and Australian Opera Singer Nellie Melba (Lopes et al.; Krick). The clothing labels proved and ineffective deterrent to counterfeit, and by the 1890s the House of Worth implemented other measures to authenticate their products (Press). The legitimisation of the origin of a product is, arguably, the primary function of branding. This principle is also applicable to subjects. The prothesis of brands, as totemic symbols, assisted consumers to relocate themselves within a new system of population distribution (Levi-Strauss 166). It was one born of commerce as opposed to heraldry.Selling of Self: Conferring Identity from the Neolithic to Modern ErasIn his 1817 compendium on family crests, Deuchar elaborated on heraldry by writing:Ignoble birth was considered as a stain almost indelible… Illustrious parentage, on the other hand, constituted the very basis of honour: it communicated peculiar rights and privileges, to which the meaner born man might not aspire. (v-vi)The Twinings Logo (fig. 4) has remained unchanged since the design was commissioned by the grandson of the company founder Richard Twining in 1787 (Twining). In addition to reflecting the heritage of the family-owned company, the brand indicated the origin of the tea. This became pertinent during the nineteenth century. Plantations began to operate from Assam to Ceylon (Jones 267-269). Amidst the rampant diversification of tea sources in the Victorian era, concerns about the “unhygienic practices” of Chinese producers were proliferated (Wengrow 11). Subsequently, the brand also offered consumers assurance in quality. Fig. 4. The Twinings Logo reproduced from "History of Twinings." Twinings. 24 July 2019 <https://www.twinings.co.uk/about-twinings/history-of-twinings>.The term ‘brand’, adapted from the Norse “brandr”, was introduced into the English language during the sixteenth century (Starcevic 179). At its most literal, it translates as to “burn down” (Starcevic 179). Using hot elements to singe markings onto animals been recorded as early as 2700 BCE in Egypt (Starcevic 182). However, archaeologists concur that the modern principle of branding predates this practice. The implementation of carved seals or stamps to make indelible impressions of handcrafted objects dates back to Prehistoric Mesopotamia (Starcevic 183; Wengrow 13). Similar traditions developed during the Bronze Age in both China and the Indus Valley (Starcevic 185). In all three civilisations branding facilitated both commerce and aspects of Totemism. In the sixth millennium BCE in “Prehistoric” Mesopotamia, referred to as the Halaf period, stone seals were carved to emulate organic form such as animal teeth (Wengrow 13-14). They were used to safeguard objects by “confer[ring] part of the bearer’s personality” (Wengrow 14). They were concurrently applied to secure the contents of vessels containing “exotic goods” used in transactions (Wengrow 15). Worn as amulets (figs. 5 & 6) the seals, and the symbols they produced, were a physical extension of their owners (Wengrow 14).Fig. 5. Recreation of stamp seal amulets from Neolithic Mesopotamia during the sixth millennium BCE. Wengrow, David. "Prehistories of Commodity Branding." Current Anthropology 49.1 (2008): 14.Fig. 6. “Lot 25Y: Rare Syrian Steatite Amulet – Fertility God 5000 BCE.” The Salesroom. 27 July 2019 <https://www.the-saleroom.com/en-gb/auction-catalogues/artemis-gallery-ancient-art/catalogue-id-srartem10006/lot-a850d229-a303-4bae-b68c-a6130005c48a>. Fig. 7. Recreation of stamp seal designs from Mesopotamia from the late fifth to fourth millennium BCE. Wengrow, David. "Prehistories of Commodity Branding." Current Anthropology 49. 1 (2008): 16.In the following millennia, the seals would increase exponentially in application and aesthetic complexity (fig. 7) to support the development of household cum cottage industries (Wengrow 15). In addition to handcrafts, sealed vessels would transport consumables such as wine, aromatic oils and animal fats (Wengrow 18). The illustrations on the seals included depictions of rituals undertaken by human figures and/or allegories using animals. It can be ascertained that the transition in the Victorian Era from heraldry to commerce, from family to corporation, had precedence. By extension, consumers were able to participate in this process of value attribution using brands as signifiers. The principle remained prevalent during the modern and post-modern eras and can be respectively interpreted using structuralist and post-structuralist theory.Totemism to Simulacrum: The Evolution of Advertising from the Modern to Post-Modern Eras In 2011, Lisa Chaney wrote of the inception of the Coco Chanel logo (fig. 8) in her biography Chanel: An Intimate Life: A crucial element in the signature design of the Chanel No.5 bottle is the small black ‘C’ within a black circle set as the seal at the neck. On the top of the lid are two more ‘C’s, intertwined back to back… from at least 1924, the No5 bottles sported the unmistakable logo… these two ‘C’s referred to Gabrielle, – in other words Coco Chanel herself, and would become the logo for the House of Chanel. Chaney continued by describing Chanel’s fascination of totemic symbols as expressed through her use of tarot cards. She also “surrounded herself with objects ripe with meaning” such as representations of wheat and lions in reference prosperity and to her zodiac symbol ‘Leo’ respectively. Fig. 8. No5 Chanel Perfume, released in 1924, featured a seal-like logo attached to the bottle neck. “No5.” Chanel. 25 July 2019 <https://www.chanel.com/us/fragrance/p/120450/n5-parfum-grand-extrait/>.Fig. 9. This illustration of the bottle by Georges Goursat was published in a women’s magazine circa 1920s. “1921 Chanel No5.” Inside Chanel. 26 July 2019 <http://inside.chanel.com/en/timeline/1921_no5>; “La 4éme Fête de l’Histoire Samedi 16 et dimache 17 juin.” Ville de Perigueux. Musée d’art et d’archéologie du Périgord. 28 Mar. 2018. 26 July 2019 <https://www.perigueux-maap.fr/category/archives/page/5/>. This product was considered the “financial basis” of the Chanel “empire” which emerged during the second and third decades of the twentieth century (Tikkanen). Chanel is credited for revolutionising Haute Couture by introducing chic modern designs that emphasised “simplicity and comfort.” This was as opposed to the corseted highly embellished fashion that characterised the Victorian Era (Tikkanen). The lavish designs released by the House of Worth were, in and of themselves, “conspicuous” displays of “consumption” (Veblen 17). In contrast, the prestige and status associated with the “poor girl” look introduced by Chanel was invested in the story of the designer (Tikkanen). A primary example is her marinière or sailor’s blouse with a Breton stripe that epitomised her ascension from café singer to couturier (Tikkanen; Burstein 8). This signifier might have gone unobserved by less discerning consumers of fashion if it were not for branding. Not unlike the Prehistoric Mesopotamians, this iteration of branding is a process which “confer[s]” the “personality” of the designer into the garment (Wengrow 13 -14). The wearer of the garment is, in turn, is imbued by extension. Advertisers in the post-structuralist era embraced Levi-Strauss’s structuralist anthropological theories (Williamson 50). This is with particular reference to “bricolage” or the “preconditioning” of totemic symbols (Williamson 173; Pool 50). Subsequently, advertising creatives cum “bricoleur” employed his principles to imbue the brands with symbolic power. This symbolic capital was, arguably, transferable to the product and, ultimately, to its consumer (Williamson 173).Post-structuralist and semiotician Jean Baudrillard “exhaustively” critiqued brands and the advertising, or simulacrum, that embellished them between the late 1960s and early 1980s (Wengrow 10-11). In Simulacra and Simulation he wrote,it is the reflection of a profound reality; it masks and denatures a profound reality; it masks the absence of a profound reality; it has no relation to any reality whatsoever: it is its own pure simulacrum. (6)The symbolic power of the Chanel brand resonates in the ‘profound reality’ of her story. It is efficiently ‘denatured’ through becoming simplified, conspicuous and instantly recognisable. It is, as a logo, physically juxtaposed as simulacra onto apparel. This simulacrum, in turn, effects the ‘profound reality’ of the consumer. In 1899, economist Thorstein Veblen wrote in The Theory of the Leisure Class:Conspicuous consumption of valuable goods it the means of reputability to the gentleman of leisure… costly entertainments, such as potlatch or the ball, are peculiarly adapted to serve this end… he consumes vicariously for his host at the same time that he is witness to the consumption… he is also made to witness his host’s facility in etiquette. (47)Therefore, according to Veblen, it was the witnessing of “wasteful” consumption that “confers status” as opposed the primary conspicuous act (Han et al. 18). Despite television being in its experimental infancy advertising was at “the height of its powers” during the 1920s (Clark et al. 18; Hill 30). Post-World War I consumers, in America, experienced an unaccustomed level of prosperity and were unsuspecting of the motives of the newly formed advertising agencies (Clark et al. 18). Subsequently, the ‘witnessing’ of consumption could be constructed across a plethora of media from the newly emerged commercial radio to billboards (Hill viii–25). The resulting ‘status’ was ‘conferred’ onto brand logos. Women’s magazines, with a legacy dating back to 1828, were a primary locus (Hill 10).Belonging in a Post-Structuralist WorldIt is significant to note that, in a post-structuralist world, consumers do not exclusively seek upward mobility in their selection of brands. The establishment of counter-culture icon Levi-Strauss and Co. was concurrent to the emergence of both The House of Worth and Coco Chanel. The Bavarian-born Levi Strauss commenced selling apparel in San Francisco in 1853 (Levi’s). Two decades later, in partnership with Nevada born tailor Jacob Davis, he patented the “riveted-for-strength” workwear using blue denim (Levi’s). Although the ontology of ‘jeans’ is contested, references to “Jene Fustyan” date back the sixteenth century (Snyder 139). It involved the combining cotton, wool and linen to create “vestments” for Geonese sailors (Snyder 138). The Two Horse Logo (fig. 10), depicting them unable to pull apart a pair of jeans to symbolise strength, has been in continuous use by Levi Strauss & Co. company since its design in 1886 (Levi’s). Fig. 10. The Two Horse Logo by Levi Strauss & Co. has been in continuous use since 1886. Staff Unzipped. "Two Horses. One Message." Heritage. Levi Strauss & Co. 1 July 2011. 25 July 2019 <https://www.levistrauss.com/2011/07/01/two-horses-many-versions-one-message/>.The “rugged wear” would become the favoured apparel amongst miners at American Gold Rush (Muthu 6). Subsequently, between the 1930s – 1960s Hollywood films cultivated jeans as a symbol of “defiance” from Stage Coach staring John Wayne in 1939 to Rebel without A Cause staring James Dean in 1955 (Muthu 6; Edgar). Consequently, during the 1960s college students protesting in America (fig. 11) against the draft chose the attire to symbolise their solidarity with the working class (Hedarty). Notwithstanding a 1990s fashion revision of denim into a diversity of garments ranging from jackets to skirts, jeans have remained a wardrobe mainstay for the past half century (Hedarty; Muthu 10). Fig. 11. Although the brand label is not visible, jeans as initially introduced to the American Goldfields in the nineteenth century by Levi Strauss & Co. were cultivated as a symbol of defiance from the 1930s – 1960s. It documents an anti-war protest that occurred at the Pentagon in 1967. Cox, Savannah. "The Anti-Vietnam War Movement." ATI. 14 Dec. 2016. 16 July 2019 <https://allthatsinteresting.com/vietnam-war-protests#7>.In 2003, the journal Science published an article “Does Rejection Hurt? An Fmri Study of Social Exclusion” (Eisenberger et al.). The cross-institutional study demonstrated that the neurological reaction to rejection is indistinguishable to physical pain. Whereas during the 1940s Maslow classified the desire for “belonging” as secondary to “physiological needs,” early twenty-first century psychologists would suggest “[social] acceptance is a mechanism for survival” (Weir 50). In Simulacra and Simulation, Jean Baudrillard wrote: Today abstraction is no longer that of the map, the double, the mirror or the concept. Simulation is no longer that of a territory, a referential being or a substance. It is the generation by models of a real without origin or reality: a hyperreal… (1)In the intervening thirty-eight years since this document was published the artifice of our interactions has increased exponentially. In order to locate ‘belongness’ in this hyperreality, the identities of the seekers require a level of encoding. Brands, as signifiers, provide a vehicle.Whereas in Prehistoric Mesopotamia carved seals, worn as amulets, were used to extend the identity of a person, in post-digital China WeChat QR codes (fig. 12), stored in mobile phones, are used to facilitate transactions from exchanging contact details to commerce. Like other totems, they provide access to information such as locations, preferences, beliefs, marital status and financial circumstances. These individualised brands are the most recent incarnation of a technology that has developed over the past eight thousand years. The intermediary iteration, emblems affixed to garments, has remained prevalent since the twelfth century. Their continued salience is due to their visibility and, subsequent, accessibility as signifiers. Fig. 12. It may be posited that Wechat QR codes are a form individualised branding. Like other totems, they store information pertaining to the owner’s location, beliefs, preferences, marital status and financial circumstances. “Join Wechat groups using QR code on 2019.” Techwebsites. 26 July 2019 <https://techwebsites.net/join-wechat-group-qr-code/>.Fig. 13. Brands function effectively as signifiers is due to the international distribution of multinational corporations. This is the shopfront of Chanel in Dubai, which offers customers apparel bearing consistent insignia as the Parisian outlet at on Rue Cambon. Customers of Chanel can signify to each other with the confidence that their products will be recognised. “Chanel.” The Dubai Mall. 26 July 2019 <https://thedubaimall.com/en/shop/chanel>.Navigating a post-structuralist world of increasing mobility necessitates a rudimental understanding of these symbols. Whereas in the nineteenth century status was conveyed through consumption and witnessing consumption, from the twentieth century onwards the garnering of brands made this transaction immediate (Veblen 47; Han et al. 18). The bricolage of the brands is constructed by bricoleurs working in any number of contemporary creative fields such as advertising, filmmaking or song writing. They provide a system by which individuals can convey and recognise identities at prima facie. They enable the prosthesis of identity.ReferencesBaudrillard, Jean. Simulacra and Simulation. Trans. Sheila Faria Glaser. United States: University of Michigan Press, 1994.Burstein, Jessica. Cold Modernism: Literature, Fashion, Art. United States: Pennsylvania State University Press, 2012.Chaney, Lisa. Chanel: An Intimate Life. United Kingdom: Penguin Books Limited, 2011.Christensen, J.A. Cut-Art: An Introduction to Chung-Hua and Kiri-E. New York: Watson-Guptill Publications, 1989. Clark, Eddie M., Timothy C. Brock, David E. Stewart, David W. Stewart. Attention, Attitude, and Affect in Response to Advertising. United Kingdom: Taylor & Francis Group, 1994.Deuchar, Alexander. British Crests: Containing the Crests and Mottos of the Families of Great Britain and Ireland Together with Those of the Principal Cities – Primary So. London: Kirkwood & Sons, 1817.Ebert, Robert. “Great Movie: Stage Coach.” Robert Ebert.com. 1 Aug. 2011. 10 Mar. 2019 <https://www.rogerebert.com/reviews/great-movie-stagecoach-1939>.Elven, John Peter. The Book of Family Crests: Comprising Nearly Every Family Bearing, Properly Blazoned and Explained, Accompanied by Upwards of Four Thousand Engravings. London: Henry Washbourne, 1847.Eisenberger, Naomi I., Matthew D. Lieberman, and Kipling D. Williams. "Does Rejection Hurt? An Fmri Study of Social Exclusion." Science 302.5643 (2003): 290-92.Family Crests of Japan. California: Stone Bridge Press, 2007.Gombrich, Ernst. "The Visual Image: Its Place in Communication." Scientific American 272 (1972): 82-96.Hedarty, Stephanie. "How Jeans Conquered the World." BBC World Service. 28 Feb. 2012. 26 July 2019 <https://www.bbc.com/news/magazine-17101768>. Han, Young Jee, Joseph C. Nunes, and Xavier Drèze. "Signaling Status with Luxury Goods: The Role of Brand Prominence." Journal of Marketing 74.4 (2010): 15-30.Hill, Daniel Delis. Advertising to the American Woman, 1900-1999. United States of Ame: Ohio State University Press, 2002."History of Twinings." Twinings. 24 July 2019 <https://www.twinings.co.uk/about-twinings/history-of-twinings>. icon-icon: Telling You More about Icons. 18 Dec. 2016. 26 July 2019 <http://www.icon-icon.com/en/hermes-logo-the-horse-drawn-carriage/>. Jones, Geoffrey. Merchants to Multinationals: British Trading Companies in the 19th and 20th Centuries. Oxford: Oxford UP, 2002.Kamon (Japanese Family Crests): Ancient Key to Samurai Culture." Goin' Japaneque! 15 Nov. 2015. 27 July 2019 <http://goinjapanesque.com/05983/>. Krick, Jessa. "Charles Frederick Worth (1825-1895) and the House of Worth." Heilburnn Timeline of Art History. The Met. Oct. 2004. 23 July 2019 <https://www.metmuseum.org/toah/hd/wrth/hd_wrth.htm>. Levi’s. "About Levis Strauss & Co." 25 July 2019 <https://www.levis.com.au/about-us.html>. Lévi-Strauss, Claude. Totemism. London: Penguin, 1969.Lopes, Teresa de Silva, and Paul Duguid. Trademarks, Brands, and Competitiveness. Abingdon: Routledge, 2010.Maslow, Abraham. "A Theory of Human Motivation." British Journal of Psychiatry 208.4 (1942): 313-13.Moore, Karl, and Susan Reid. "The Birth of Brand: 4000 Years of Branding History." Business History 4.4 (2008).Muthu, Subramanian Senthikannan. Sustainability in Denim. Cambridge Woodhead Publishing, 2017.Polan, Brenda, and Roger Tredre. The Great Fashion Designers. Oxford: Bloomsbury Publishing, 2009.Pool, Roger C. Introduction. Totemism. New ed. Harmondsworth: Penguin, 1969.Press, Claire. Wardrobe Crisis: How We Went from Sunday Best to Fast Fashion. Melbourne: Schwartz Publishing, 2016.Sale, K. Rebels against the Future: The Luddites and Their War on the Industrial Revolution: Lessons for the Computer Age. Massachusetts: Addison-Wesley, 1996.Snow, C.P. The Two Cultures and the Scientific Revolution. Cambridge: Cambridge University Press, 1959. Snyder, Rachel Louise. Fugitive Denim: A Moving Story of People and Pants in the Borderless World of Global Trade. New York: W.W. Norton, 2008.Starcevic, Sladjana. "The Origin and Historical Development of Branding and Advertising in the Old Civilizations of Africa, Asia and Europe." Marketing 46.3 (2015): 179-96.Tikkanen, Amy. "Coco Chanel." Encyclopaedia Britannica. 19 Apr. 2019. 25 July 2019 <https://www.britannica.com/biography/Coco-Chanel>.Veblen, Thorstein. The Theory of the Leisure Class: An Economic Study in the Evolution of Institutions. London: Macmillan, 1975.Weir, Kirsten. "The Pain of Social Rejection." American Psychological Association 43.4 (2012): 50.Williamson, Judith. Decoding Advertisements: Ideology and Meaning in Advertising. Ideas in Progress. London: Boyars, 1978.

ExpositionPortland, Oregon (USA) has become known for an artisanal or ‘maker’ economy that relies on a resurgence of place specificity (Heying), primarily expressed and exported to a global audience in the notion of ‘Portland Made’ (Roy). Portland Made reveals a tension immanent in the notion of ‘place’: place is both here and not here, both real and imaginary. What emerges is a complicated picture of how place conceptually captures various intersections of materiality and mythology, aesthetics and economics. On the one hand, Portland Made represents the collective brand-identity used by Portland’s makers to signify a products’ material existence as handcrafted, place-embedded, and authentic. These characteristics lead to certain assumptions about the concept of ‘local’ (Marotta and Heying): what meaning does Portland Made convey, and how is such meaning distributed? On the other hand, the seemingly intentional embedding of place-specificity in objects meant for distribution far outside of Portland begs another type of question: how does Portland come to be discursively representative of these characteristics, and how are such representations distributed to global audiences? How does this global distribution and consumption of immaterial Portland feed back into the production of material Portland?To answer these questions we look to the realm of social media, specifically the popular image-based service Instagram. For the uninitiated, Instagram is a web-based social media service that allows pictures to be shared and seen by anyone that follows a person or business’ Instagram account. Actions include posting original photos (often taken and posted with a cell phone), ‘liking’ pictures, and ‘hash-tagging’ posts with trending terms that increase visibility. Instagram presents us with a complex view of place as both material and virtual, sometimes reifying and sometimes abstracting often-contradictory understandings of place specificity. Many makers use Instagram to promote their products to a broad audience and, in doing so, makers participate in the construction of Portland’s mythology. In this paper, we use empirical insights to theorise makers’ role in shaping and cultivating the virtual and material aspects of place. Additionally, we discuss how makers navigate the complex relationships tied to the importance of place in their specific cultural productions. In the first section, we develop the notion of a curated maker subjectivity. In the second section, we consider the relationship between subjectivity and place. Both sections emphasize how Instagram mediates the relationship between place and subjectivity. Through spotlighting particular literatures in each section, we attempt to fill a gap in the literature that addresses the relationship between subjectivity, place, and social media. Through this line of analysis, we attempt to better understand how and where Portland is made, along with the implications for Portland’s makers.ActionThe insights from this paper came to us inadvertently. While conducting fieldwork that interrogated ‘localism’ and how Portland makers conceptualise local, makers repeatedly discussed the importance of social media to their work. In our fieldwork, Instagram in particular has presented us with new opportunities to query the entanglements of real and virtual embedded in collective identifications with place. This paper draws from interviews conducted for two closely related research projects. The first examines maker ecosystems in three US cities, Portland, Chicago and New York (Doussard et. al.; Wolf-Powers and Levers). We drew from the Portland interviews (n=38) conducted for this project. The second research project is our multi-year examination of Portland’s maker community, where we have conducted interviews (n=48), two annual surveys of members of the Portland Made Collective (n=126 for 2014, n=338 for 2015) and numerous field observations. As will be evident below, our sample of makers includes small crafters and producers from a variety of ‘traditional’ sectors ranging from baking to carpentry to photography, all united by a common identification with the maker movement. Using insights from this trove of data as well as general observations of the changing artisan landscape of Portland, we address the question of how social media mediates the space between Portland as a material place and Portland as an imaginary place.Social Media, Subjectivity, and Authenticity In the post-Fordist era, creative self-enterprise and entrepreneurialism have been elevated to mythical status (Szeman), becoming especially important in the creative and digital industries. These industries have been characterized by contract based work (Neff, Wissinger, and Zukin; Storey, Salaman, and Platman), unstable employment (Hesmondhalgh and Baker), and the logic of flexible specialization (Duffy and Hund; Gill). In this context of hyper individualization and intense competition, creative workers and other entrepreneurs are increasingly pushed to strategically brand, curate, and project representational images of their subjectivity in order to secure new work (Gill), embody the values of the market (Banet-Weiser and Arzumanova), and take on commercial logics of authenticity (Duffy; Marwick and boyd). For example, Duffy and Hund explore how female fashion bloggers represent their branded persona, revealing three interrelated tropes typically used by bloggers: the destiny of passionate work; the presentation of a glam lifestyle; and carefully curated forms of social sharing. These curated tropes obscure the (unpaid) emotional and aesthetic labour (Hracs and Leslie), self-discipline, and capital required to run these blogs. Duffy and Hund also point out that this concealment is generative of particular mythologies about creative work, gender, race, and class. To this list we would add place; below, we will show the use of Instagram by Portland’s makers not only perpetuates particular mythologies about artisan labour and demands self-branding, but is also a spatial practice that is productive of place through the use of visual vernaculars that reflect a localized and globalized articulation of the social and physical milieu of Portland (Hjorth and Gu; Pike). Similar to many other artists and creative entrepreneurs (Pasquinelli and Sjöholm), Portland’s makers typically work long hours in order to produce high quality, unique goods at a volume that will afford them the ability to pay rent in Portland’s increasingly expensive central city neighbourhoods. Much of this work is done from the home: according to our survey of Portland Made Collective’s member firms, 40% consist of single entrepreneurs working from home. Despite being a part of a creative milieu that is constantly captured by the Portland ‘brand’, working long hours, alone, produces a sense of isolation, articulated well by this apparel maker:It’s very isolating working from home alone. [...] The other people I know are working from home, handmade people, I’ll post something, and it makes you realize we’re all sitting at home doing the exact same thing. We can’t all hang out because you gotta focus when you’re working, but when I’m like ugh, I just need a little break from the sewing machine for five minutes, I go on Instagram.This statement paints Instagram as a coping mechanism for the isolation of working alone from home, an important impetus for makers to use Instagram. This maker uses Instagram roughly two hours per workday to connect with other makers and to follow certain ‘trendsetters’ (many of whom also live in Portland). Following other makers allows the maker community to gauge where they are relative to other makers; one furniture maker told us that she was able to see where she should be going based on other makers that were slightly ahead of her, but she could also advise other makers that were slightly behind her. The effect is a sense of collaborative participation in the ‘scene’, which both alleviates the sense of isolation and helps makers gain legitimacy from others in their milieu. As we show below, this participation demands from makers a curative process of identity formation. Jacque Rancière’s intentional double meaning of the French term partage (the “distribution of the sensible”) creates space to frame curation in terms of the politics around “sharing in” and “sharing out” (Méchoulan). For Rancière, the curative aspect of communities (or scenes) reveals something inherently political about aesthetics: the politics of visibility on Instagram “revolve around what is seen and what can be said about it, who has the ability to see and the talent to speak, around the properties of space and the possibilities of time” (8-9). An integral part of the process of curating a particular identity to express over Instagram is reflected by who they follow or what they ‘like’ (a few makers mentioned the fact that they ‘like’ things strategically).Ultimately, makers need followers for their brand (product brand, self-brand, and place-brand), which requires makers to engage in a form of aesthetic labour through a curated articulation of who a maker is–their personal story, or what Duffy and Hund call “the destiny of passionate work”–and how that translates into what they make at the same time. These identities congeal over Instagram: one maker described this as a “circle of firms that are moving together.” Penetrating that circle by curating connections over Instagram is an important branding strategy.As a confections maker told us, strategically using hashtags and stylizing pictures to fit the trends is paramount. Doing these things effectively draws attention from other makers and trendsetters, and, as an apparel maker told us, getting even one influential trendsetter or blogger to follow them on Instagram can translate into huge influxes of attention (and sales) for their business. Furthermore, getting featured by an influential blogger or online magazine can yield instantaneous results. For instance, we spoke with an electronics accessories maker that had been featured in Gizmodo a few years prior, and the subsequent uptick in demand led him to hire over 20 new employees.The formulation of a ‘maker’ subjectivity reveals the underlying manner in which certain subjective characteristics are expressed while others remain hidden; expressing the wrong characteristics may subvert the ability for makers to establish themselves in the milieu. We asked a small Portland enterprise that documents the local maker scene about the process of curating an Instagram photo, especially curious about how they aesthetically frame ‘site visits’ at maker workspaces. We were somewhat surprised to hear that makers tend to “clean too much” ahead of a photo shoot; the photographer we spoke with told us that people want to see the space as it looks when it’s being worked in, when it’s a little messy. The photographer expressed an interest in accentuating the maker’s ‘individual understanding’ of the maker aesthetic; the framing and the lighting of each photo is meant to relay traces of the maker to potential consumers. The desire seems to be the expression and experience of ‘authenticity’, a desire that if captured correctly grants the maker a great deal of purchase in the field of Portland Made consumers. This is all to say that the curation of the workspaces is essential to the construction of the maker subjectivity and the Portland imaginary. Maker workshops are rendered as real places where real makers that belong to an authentic maker milieu produce authentic Portland goods that have a piece of Portland embedded within them (Molotch). Instagram is central in distributing that mythology to a global audience.At this point we can start to develop the relationship between maker subjectivity and place. Authenticity, in this context, appears to be tied to the product being both handmade and place-specific. As the curated imaginary of Portland matures, a growing dialogue emerges between makers and consumers of Portland Made (authentic) goods. This dialogue is a negotiated form of authority in which the maker claims authority while the consumer simultaneously confers authority. The aforementioned place-specificity signals a new layer of magic in regards to Portland’s distinctive position: would ‘making’ in any other place be generative of such authority? According to a number of our interviewees, being from Portland carries the assumption that Portland’s makers have a certain level of expertise that comes from being completely embedded in Portland’s creative scene. This complex interplay between real and virtual treats Portland’s imaginary as a concrete reality, preparing it for consumption by reinforcing the notion of an authoritative collective brand (Portland Made). One bicycle accessory maker claimed that the ability of Portland’s makers to access the Portland brand transmits credibility for makers of things associated with Portland, such as bikes, beer, and crafty goods. This perhaps explains why so many makers use Portland in the name of their company (e.g. Portland Razor Company) and why so many stamp their goods with ‘Made in Portland’.This, however, comes with an added set of expectations: the maker, again, is tasked with cultivating and performing a particular aesthetic in order to achieve legitimacy with their target audience, only this time it ends up being the dominant aesthetic associated with a specific place. For instance, the aforementioned bicycle accessory maker that we spoke with recalled an experience at a craft fair in which many of the consumers were less concerned with his prices than whether his goods were handmade in Portland. Without this legitimation, the good would not have the mysticism of Portland as a place locked within it. In this way, the authenticity of a place becomes metonymic (e.g. Portlandia), similar to how Detroit became known as ‘Motor City’. Portland’s particular authenticity is wrapped up in individuality, craftiness, creativity, and environmental conscientiousness, all things that makers in some way embed in their products (Molotch) and express in the photos on their Instagram feeds (Hjorth).(Social) Media, Place, and the Performance of Aesthetics In this section, we turn our attention to the relationship between subjectivity, place, and Instagram. Scholars have investigated how television production (Pramett), branding (Pike), and locative-based social media (Hjorth, Hjorth and Gu, Hjorth and Lim, Leszczynski) function as spatial practices. The practices affect and govern experiences and interactions with space, thereby generating spatial hybridity (de Souza e Silva). McQuire, for example, investigates the historical formation of the ‘media city’, demonstrating how various media technologies have become interconnected with the architectural structures of the city. Pramett expands on this analysis of media representations of cities by interrogating how media production acts as a spatial practice that produces and governs contested urban spaces, the people in those spaces, and the habitus of the place, forming what she dubs the “media neighbourhood.” The media neighbourhood becomes ordered by the constant opportunities for neighbourhood residents to be involved in media production; residents must navigate and interact with local space as though they may be captured on film or asked to work in the background production at any moment. These material (on site shooting and local hiring practices) and immaterial (textual, musical, and visual representations of a city) production practices become exploitative, extracting value from a place for media industries and developers that capitalize on a place’s popular imaginary.McQuire’s media city and Pramett’s media neighbourhood help us understand the embeddedness of (social) media in the material landscapes of Portland. Over the past few years, Portland has begun experiencing new flows of tourists and migrants–we should note that more than a few makers mentioned in interviews that they moved to Portland in order to become makers–expecting to find what they see on Instagram overlaid materially on the city itself. And indeed, they do: ‘vibrant’ neighbourhood districts such as Alberta Arts, Belmont, Mississippi, Hawthorne, Northwest 23rd, and downtown Portland’s rebranded ‘West End’ are all increasingly full of colourful boutiques that express maker aesthetics and sell local maker goods. Not only do the goods and boutiques need to exemplify these aesthetic qualities, but the makers and the workspaces from which these goods come from, need to fit that aesthetic.The maker subjectivity is developed through the navigation of both real and virtual experiences that contour the social performance of a ‘maker aesthetic’. This aesthetic has become increasingly socially consumed, a trend especially visible on Instagram: as a point of reference, there are at least four Portland-based ‘foodies’ that have over 80,000 followers on Instagram. One visible result of this curated and performed subjectivity and the place-brand it captures is the physical transformation of Portland: (material) space has become a surface onto which the (virtual) Instagram/maker aesthetic is being inscribed, a stage on which the maker aesthetic is performed. The material and immaterial are interwoven into a dramaturgy that gives space a certain set of meanings oriented toward creativity, quirkiness, and consumption. Meanings cultivated over Instagram, then, become productive of meaning in place. These meanings are consumed by thousands of tourists and newly minted Portlanders, as images of people posing in front of Portland’s hipster institutions (such as Salt & Straw or Voodoo Donuts) are captured on iPhones and redistributed back across Instagram for the world to experience. Perhaps this is why Tokyo now has an outpost of Portland’s Blue Star Donuts or why Red Hook (Brooklyn) has its own version of Portland’s Pok Pok. One designer/maker, who had recently relocated to Portland, captured the popular imaginary of Portland in this conversation:Maker: People in Brooklyn love the idea that it came from Portland. People in Seattle love it; people in the Midwest love that it came from Portland right now, because Portland’s like the thing.Interviewer: What does that mean, what does it embody?Maker: They know that it’s local, it like, they know that maker thing is there, it’s in Portland, that they know it’s organic to Portland, it’s local to Portland, there’s this crazy movement that you hear throughout the United States about–Interviewer: So people are getting a piece of that?Maker: Yeah.For us, the dialogical relationship between material and immaterial has never been more entangled. Instagram is one way that makers might control the gap between fragmentation and belonging (i.e. to a particular community or milieu), although in the process they are confronted with an aesthetic distribution that is productive of a mythological sense of place that social media seems to produce, distribute, and consume so effectively. In the era of social media, where sense of place is so quickly transmitted, cities can come to represent a sense of collective identity, and that identity might in turn be distributed across its material landscape.DenouementThrough every wrench turn, every stitching of fabric, every boutique opening, and every Instagram post, makers actively produce Portland as both a local and global place. Portland is constructed through the material and virtual interactions makers engage in, both cultivating and framing everyday interactions in space and ideas held about place. In the first section, we focused on the curation of a maker aesthetic and the development of the maker subjectivity mediated through Instagram. The second section attempted to better understand how those aesthetic performances on Instagram become imprinted on urban space and how these inscriptions feedback to global audiences. Taken together, these performances reveal the complex undertaking that makers adopt in branding their goods as Portland Made. In addition, we hope to have shown the complex entanglements between space and place, production and consumption, and ‘here’ and ‘not here’ that are enrolled in value production at the nexus of place-brand generation.Our investigation opens the door to another, perhaps more problematic set of interrogations which are beyond the scope of this paper. In particular, and especially in consideration of Portland’s gentrification crisis, we see two related sets of displacements as necessary of further interrogation. First, as we answer the question of where Portland is made, we acknowledge that the capturing of Portland Made as a brand perpetuates a process of displacement and “spatio-subjective” regulation that both reflects and reproduces spatial rationalizations (Williams and Dourish). This dis-place-ment renders particular neighbourhoods and populations within Portland, specifically ethnic minorities and the outer edges of the metropolitan area, invisible or superfluous to the city’s imaginary. Portland, as presented by makers through their Instagram accounts, conceals the city’s “power geometries” (Massey) and ignores the broader social context Portland exists in, while perpetuating the exclusion of ethnic minorities from the conversation about what else is made in Portland.Second, as Portland Made has become virtually representative of a deepening connection between makers and place, the performance of such aesthetic labour has left makers to navigate a process that increasingly leads to their own estrangement from the very place they have a hand in creating. This process reveals an absurdity: makers are making the very thing that displaces them. The cultivation of the maker milieu attracts companies, in-movers, and tourists to Portland, thus creating a tight real estate market and driving up property values. Living and working in Portland is increasingly difficult for makers, epitomized by the recent sale and eviction of approximately 500 makers from the Town Storage facility (Hammill). Additionally, industrial space in the city is increasingly coveted by tech firms, and competition over such space is being complicated by looming zoning changes in Portland’s new comprehensive plan.Our conclusions suggest additional research is needed to understand the relationship(s) between such aesthetic performance and various forms of displacement, but we also suggest attention to the global reach of such dynamics: how is Portland’s maker ecosystem connected to the global maker community over social media, and how is space shaped differentially in other places despite a seemingly homogenizing maker aesthetic? Additionally, we do not explore policy implications above, although there is significant space for such exploration with consideration to the attention that Portland and the maker movement in general are receiving from policymakers hungry for a post-Fordist magic bullet. ReferencesBanet-Weiser, Sarah, and Inna Arzumanova. “Creative Authorship, Self-Actualizing Women, and the Self-Brand.” Media Authorship. Eds. Cynthia Chris and David A. Gerstner. New York, NY: Routledge, 2012: 163-179. De Souza e Silva, Adriana. “From Cyber to Hybrid: Mobile Technologies as Interfaces of Hybrid Spaces.” Space and Culture 9.3 (2006): 261–278.Duffy, Brooke Erin, “The Romance of Work: Gender and Aspirational Labour in the Digital Culture Industries.” International Journal of Cultural Studies (2015): 1–17. Duffy, Brooke Erin, and Emily Hund. “‘Having It All’ on Social Media: Entrepreneurial Femininity and Self-Branding among Fashion Bloggers.” Social Media + Society 1.2 (2015): n. pag. Doussard, Marc, Charles Heying, Greg Schrock, and Laura Wolf-Powers. Metropolitan Maker Networks: The Role of Policy, Organization, and "Maker-Enabling Entrepreneurs" in Building the Maker Economy. Progress update to the Ewing Marion Kauffman Foundation. 2015. Gill, Rosalind. “‘Life Is a Pitch’: Managing the Self in New Media Work.” Managing Media Work (2010): n. pag. Hammill, Luke. "Sale of Towne Storage Building Sends Evicted Artists, Others Scrambling for Space." The Oregonian, 2016.Hesmondhalgh, David, and Sarah Baker. Creative Labour: Media Work in Three Cultural Industries. London, UK: Routledge, 2011. Heying, Charles. Brew to Bikes: Portland’s Artisan Economy. Portland, OR: Ooligan Press, 2010. Hjorth, Larissa. “The Place of the Emplaced Mobile: A Case Study into Gendered Locative Media Practices.” Mobile Media & Communication 1.1 (2013): 110–115. Hjorth, Larissa, and Kay Gu. “The Place of Emplaced Visualities: A Case Study of Smartphone Visuality and Location-Based Social Media in Shanghai, China.” Continuum: Journal of Media & Cultural Studies 26.5 (2012): 699–713. Hjorth, Larissa, and Sun Sun Lim. “Mobile Intimacy in an Age of Affective Mobile Media.” Feminist Media Studies 12.4 (2012): 477–484. Hracs, Brian J., and Deborah Leslie. “Aesthetic Labour in Creative Industries: The Case of Independent Musicians in Toronto, Canada.” Area 46.1 (2014): 66–73. Leszczynski, A. “Spatial Media/tion.” Progress in Human Geography 39.6 (2014): 729–751. Marotta, Stephen, and Charles Heying. “Interrogating Localism: What Does ‘Made in Portland’ Really Mean?” Craft Economies: Cultural Economies of the Handmade. Eds. Susan Luckman and Nicola Thomas. London, UK: Bloomsbury Academic: forthcoming. Marwick, Alice E., and danah boyd. “I Tweet Honestly, I Tweet Passionately: Twitter Users, Context Collapse, and the Imagined Audience.” New Media & Society 13.1 (2011): 114–133. Massey, Doreen. “A Global Sense of Place.” Space, Place, and Gender. Minneapolis, MN: University of Minnesota Press, 1994. McQuire, Scott. The Media City: Media, Architecture and Urban Space. Los Angeles, CA: Sage Publications Inc., 2008. Mechoulan, Eric. “Introduction: On the Edges of Jacques Ranciere.” SubStance 33.1 (2004): 3–9. Molotch, Harvey. “Place in Product.” International Journal of Urban and Regional Research 26.4 (2003): 665–688. Neff, Gina, Elizabeth Wissinger, and Sharon Zukin. “Entrepreneurial Labor among Cultural Producers: ‘Cool’ Jobs in ‘Hot’ Industries.” Social Semiotics 15.3 (2005): 307–334. Pasquinelli, Cecilia, and Jenny Sjöholm. “Art and Resilience: The Spatial Practices of Making a Resilient Artistic Career in London.” City, Culture and Society 6.3 (2015): 75–81. Pike, Andy. “Placing Brands and Branding: A Socio-Spatial Biography of Newcastle Brown Ale.” Transactions of the Institute of British Geographers 36.2 (2011): 206–222. ———. “Progress in Human Geography Geographies of Brands and Branding Geographies of Brands and Branding.” (2009): 1–27. Ranciere, Jacque. The Politics of Aesthetics. London: Bloomsbury Academic, 2004. Roy, Kelley. Portland Made. Portland, OR: Self-Published, 2015.

From the mid-twentieth century, state and public conceptions of deviance and crime control have turned increasingly punitive (Hallett 115; Hutchinson 138). In a Western context, criminal justice has long been retributive, prioritising punishment over rehabilitation (Wenzel et al. 26). Within that context, there has been an increase in punitiveness—understood here as a measure of a punishment’s severity—the intention of which has been to help restore the moral imbalance created by offending while also deterring future crime (Wenzel et al. 26). Entangled with the global spread of neoliberal capitalism, punitiveness has become internationally pervasive to a near-hegemonic degree (Sparks qtd. in Jennings et al. 463; Unnever and Cullen 100).The punitive turn has troubling characteristics. Punitive policies can be expensive, and increased incarceration stresses the criminal justice system and leads to prison overcrowding (Hutchinson 135). Further, punitiveness is not only applied unequally across categories such as class, race, and age (Unnever and Cullen 105-06; Wacquant 212) but the effectiveness of punitive policy relative to its costs is contested (Bouffard et al. 466, 477; Hutchinson 139). Despite this, evidence suggests public demand is driving punitive policymaking, but that demand is only weakly related to crime rates (Jennings et al. 463).While discussion of punitiveness in the public sphere often focuses on measures such as boot camps for young offenders, increased incarceration, and longer prison sentences, punitiveness also has a darker side. Our research analysing discussion taking place on a large, regional, crime-focused online forum reveals a startling degree and intensity of violence directed at offenders and related groups. Members of the discussion forum do propose unsurprising measures such as incarceration and boot camps, but also an array of violent alternatives, including beating, shooting, dismemberment, and conversion into animal food. This article draws on our research to explore why discussion of punitiveness can be so intensely violent.Our research applies thematic analysis to seven discussion threads posted to a large regional online forum focused on crime, made between September and November 2017. One discussion thread per week of the study period was purposively sampled based on relevance to the topic of punitiveness, ultimately yielding 1200 individual comments. Those comments were coded, and the data and codes were reiteratively analysed to produce categories, then basic, organising, and global themes. We intended to uncover themes in group discussion most salient to punitiveness to gain insight into how punitive social interactions unfold and how those who demand punitiveness understand their interactions and experiences of crime. We argue that, in this online forum, the global theme—the most salient concept related to punitiveness—is a “subaltern citizenship”. Here, a clear division emerges from the data, where the group members perceive themselves as “us”—legitimate citizens with all attendant rights—in opposition to an external “them”, a besieging group of diverse, marginalised Others who have illegitimately usurped certain rights and who victimise citizens. Group members often deride the state as too weak and untrustworthy to stop this victimisation. Ironically, the external Others perceived by the group to hold power are themselves genuinely marginalised, though the group does not recognise or see that form of marginalisation as legitimate. In this essay, to preserve the anonymity of the forum and its members, we refer to them only as “the Forum”, located in “the City”, and refrain from direct quotes except for commonly used words or phrases that do not identify individuals.It is also important to note that the research described here deliberately focused on a specific group in a specific space who were concerned about specific groups of offenders. Findings and discussion, and the views on punitiveness described, cannot be generalised to the broader community. Nor do we suggest these views can be considered representative of all Forum members as we present here only a limited analysis of some violent discourse emerging from our research. Likewise, while our discussion often centres on youth and other marginalised groups in the context of offending, we do not intend to imply that offending is a characteristic of these groups.Legitimate CitizenshipCommonly, citizenship is seen as a conferred status denoting full and equal community membership and the rights and responsibilities dictated by community values and norms (Lister 28-29). Western citizenship norms are informed by neoliberal capitalist values: individual responsibility, an obligation to be in paid employment, participation in economic consumption, the sanctity of ownership, and that the principal role of government is to defend the conditions under which these norms can freely thrive (Walsh 861-62). While norms are shaped by laws and policy frameworks, they are not imposed coercively or always deployed consciously. These norms exist as shared behavioural expectations reproduced through social interaction and embodied as “common sense” (Kotzian 59). As much as Western democracies tend to a universalist representation of one, undifferentiated citizenship, it is clear that gender, race, sexual orientation, religion, ethnicity, and migrant status all exist in different relationships to citizenship as an identity category. Glass ceilings, stolen generations, same-sex marriage debates, and Australian Government proposals to strip citizenship from certain types of criminal offender all demonstrate that the lived experience of norms surrounding citizenship is profoundly unequal for some (Staeheli et al. 629-30). An individual’s citizenship status, therefore, more accurately exists on a spectrum between legitimacy—full community membership, possessing all rights and living up to all associated responsibilities—and illegitimacy—diminished membership, with contested rights and questionable fulfilment of associated responsibilities—depending on the extent of their deviation from societal norms.Discussing punitiveness, Forum members position themselves as “us”, that is, legitimate citizens. Words such as “we” and “us” are used as synonyms for society and for those whose behaviours are “normal” or “acceptable”. Groups associated with offending are described as “they”, “them”, and their behaviours are “not normal”, “disgusting”, “feral”, and merit the removal of “them” from civilisation, usually to “the middle of nowhere” or “the Outback”. Possession of legitimate citizenship is implicit in assuming authority over what is normal and who should be exiled for failing the standard.Another implicit assumption discernible in the data is that Forum members perceive the “normal we” as good neoliberal citizens. “We” work hard, own homes and cars, and take individual responsibility. There is a strong imputation of welfare dependency among offenders, the poor, and other suspect groups. Offending is presented as something curable by stripping offenders or their parents of welfare payments. Members earn their status as legitimate citizens by adhering to the norms of neoliberal citizenship in opposition to potential offenders to whom the benefits of citizenship are simply doled out.Forum members also frame their citizenship as legitimate by asserting ownership over community spaces and resources. This can be seen in their talking as if they, their sympathetic audience, and “the City” are the same (for example, declaring that “the City” demands harsher punishments for juvenile offenders). There are also calls to “take back” the streets, the City, and Australia from groups associated with offending. That a space can and should be “taken back” implies a pre-existing state of control interrupted by those who have no right to ownership. At its most extreme, the assertion of ownership extends to a conviction that members have the right to position offenders as enemies of the state and request that the army, the ultimate tool of legitimate state violence, be turned against them if governments and the criminal justice system are too “weak” or “soft” to constrain them.The Illegitimate OtherThroughout the data, perceived offenders are spoken of with scorn and hatred. “Perceived offenders” may include offenders and their family, youths, Indigenous people, and people of low socioeconomic status, and these marginalised groups are referenced so interchangeably it can be difficult to determine which is being discussed.Commenting on four “atsi [sic] kids” who assaulted an elderly man, group members asserted “they” should be shot like dogs. The original text gives no antecedents to indicate whether “they” is meant to indicate youths, Indigenous youths, or offenders in general. However, Australia has a colonial history of conflating crime and indigeneity and shooting Indigenous people to preserve white social order (Hill and Dawes 310, 312), a consequence of the tendency of white people to imagine criminals as black (Unnever and Cullen 106). It must be noted that the racial identity of individual Forum members is unknown. This does constitute a limitation in the original study, as identity categories such as race and class intersect and manifest in social interactions in complex ways. However, that does not prevent analysis of the text itself.In the Forum’s discursive space, “they” is used to denote offenders, Indigenous youths, youths, or the poor interchangeably, as if they were all a homogeneous, mutually synonymous “Other”. Collectively, these groups are represented as so generally hopeless that they are imagined as choosing to offend so they will be sentenced to the comforts of “holiday camp” prisons where they can access luxuries otherwise beyond their reach: freedom from addicted parents, medical care, food, television, and computers. A common argument, that crime is an individual choice, is often based on the idea that prison is a better option for the poor than going home. As a result, offending by marginalised offenders is reconstructed as a rational choice or a failure of individual responsibility rather than a consequence of structural inequality.Further, parents of those in suspect populations are blamed for intergenerational maintenance of criminality. They are described as too drunk or drugged to care, too unskilled in parenting due to their presumed dreadful upbringing, or too busy enjoying their welfare payments to meet their responsibility to control their children or teach them the values and skills of citizenship. Comments imply parents probably participated in their children’s crimes even when no evidence suggests that possibility and that some groups simply cannot be trusted to raise disciplined children owing to their inherent moral and economic dissipation. That is, not just offenders but entire groups are deemed illegitimate, willing to enjoy benefits of citizenship such as welfare payments but unwilling or unable to earn them by engaging with the associated responsibilities. This is a frequent argument for why they deserve severely punitive punishment for deviance.However, the construction of the Other as illegitimate in Forum discussions reaches far beyond imagining them as lacking normative skills and values. The violence present on the Forum is startling in its intensity. Prevalent within the data is the reduction of people to insulting nicknames. Terms used to describe people range from the sarcastic— “little darlings”—through standard abusive language such as “bastards”, “shits”, “dickheads”, “lowlifes”, to dehumanising epithets such as “maggots”, “scum”, and “subhuman arsewipes”. Individually and collectively, “they” are relentlessly framed as less than human and even less than animals. They are “mongrels” and “vermin”. In groups, they are “packs”, and they deserve to be “hunted” or just shot from helicopters. They are unworthy of life. “Oxygen thieves” is a repeated epithet, as is the idea that they should be dropped out at sea to drown. Other suggestions for punishment include firing squads, lethal injections, and feeding them to animals.It is difficult to imagine a more definitive denial of legitimacy than discursively stripping individuals and groups of their humanity (their most fundamental status) and their right to existence (their most fundamental right as living beings). The Forum comes perilously close to casting the Other as Agamben’s homo sacer, humans who live in a “state of exception”, subject to the state’s power but excluded from the law’s protection and able to be killed without consequence (Lechte and Newman 524). While it would be hyperbole to push this comparison too far—given Agamben had concentration camps in mind—the state of exception as a means of both excluding a group from society and exercising control over its life does resonate here.Themes Underlying PunitivenessOur findings indicate the theme most salient to punitive discussion is citizenship, rooted in persistent concerns over who is perceived to have it, who is not, and what should be done about those Others whose deviance renders their citizenship less legitimate. Citizenship norms—real or aspirational—of society’s dominant groups constitute the standards by which Forum members judge their experiences of and with crime, perceived offenders, the criminal justice system, and the state. However, Forum members do not claim a straightforward belonging to and sharing in the maintenance of the polity. Analysis of the data suggests Forum members consider their legitimate citizenship tainted by external forces such as politics, untrustworthy authorities and institutions, and the unconstrained excess of the illegitimate Other. That is, they perceive their citizenship to be simultaneously legitimate and undeservedly subaltern.According to Gramsci, subaltern populations are subordinate to dominant groups in political and civil society, lulled by hegemonic norms to cooperate in their own oppression (Green 2). Civil society supports the authority of political society and, in return, political society uses the law and criminal justice system to safeguard civil society’s interests against unruly subalterns (Green 7). Rights and responsibilities of citizenship reside within the mutual relationship between political and civil society. Subalternity, by definition, exists outside this relationship, or with limited access to it.Forum members position themselves as citizens within civil society. They lay emphatic claim to fulfilling their responsibilities as neoliberal citizens. However, they perceive themselves to be denied the commensurate rights: they cannot rely on the criminal justice system to protect them from the illegitimate Other. The courts are “soft”, and prisons are “camps” with “revolving doors”. Authorities pamper offenders while doing nothing to stop them from hurting their victims. Human rights are viewed as an imposition by the UN or as policy flowing from a political sphere lacking integrity and dominated by “do gooders”. Rights are reserved only for offenders. Legitimate citizens no longer even have the right to defend themselves. The perceived result is a transfer of rights from legitimate to illegitimate, from deserving to undeserving. This process elides from view the actual subalterns of Australian society—here, most particularly Indigenous people and the socioeconomically vulnerable—and reconstructs them as oppressors of the dominant group, who are reframed as legitimate citizens unjustly made subaltern.The Violence in PunitivenessOn the Forum, as in the broader world, a sense of “white victimisation”—the view, unsupported by history or evidence, that whites are an oppressed people within a structure systematically doling out advantage to minorities (King 89)—is a recurrent legitimising argument for punitiveness and vigilantism. Amid the shrinking social safety nets and employment precarity of neoliberal capitalism, competitiveness increases, and white identity forms around perceived threats to power and status incurred by “losing out” to minorities (Sacks and Lindholm 131). One 2011 study finds a majority of white US citizens believe themselves subject to more racism than black people (King 89). However, these assumptions of whiteness tend to be spared critical examination because, in white-dominated societies, whiteness is the common-sense norm in opposition to which other racial categories are defined (Petray and Collin 2). When whiteness is made the focus of critical questioning, white identities gain salience and imaginings of the “dark other” and besieged white virtues intensify (Bonilla-Silva et al. 232).With respect to feelings of punitiveness, Unnever and Cullen (118-19) find that the social cause for punitiveness in the United States is hostility towards other races, that harsh punishments, including the death penalty, are demanded and accepted by the dominant group because they are perceived to mostly injure “people they do not like” (Unnever and Cullen 119). Moreover, perception that a racial group is inherently criminal amplifies more generalised prejudices against them and diminishes the capacity of the dominant group to feel empathy for suffering inflicted upon them by the criminal justice system (Unnever and Cullen 120).While our analysis of the Forum supports these findings where they touch on crimes committed by Indigenous people, they invite a question. Why, where race is not a factor, do youths and the socioeconomically disadvantaged also inspire intensely violent punitiveness as described above? We argue that the answer relates to status. From this perspective, race becomes one of several categories of differentiation from legitimate citizenship through an ascription of low status.Wenzel, Okimoto, and Cameron (29) contend punitiveness, with respect to specific offences, varies according to the symbolic meaning the offence holds for the observer. Crimes understood as a transgression against status or power inspire a need for “revenge, punishment, and stigmatisation” (Wenzel et al. 41) and justify an increase in the punitiveness required (Wenzel et al. 29, 34). This is particularly true where an offence is deemed to make someone unfit for community membership, such that severe punishment serves as a symbolic marker of exile and a reaffirmation for the community of the violated values and norms (Wenzel et al. 41). Indeed, as noted, Forum posts regularly call for offenders to be removed from society, exiled to the outback, or shipped beyond Australia’s territorial waters.Further, Forum members’ perception of subaltern citizenship, with its assumption of legitimate citizenship as being threatened by undeserving Others, makes them view crime as implicitly a matter of status transgression. This is intensified by perception that the political sphere and criminal justice system are failing legitimate citizens, refusing even to let them defend themselves. Virulent name-calling and comparisons to animals can be understood as attempts by the group to symbolically curtail the undeservedly higher status granted to offenders by weak governments and courts. More violent demands for punishment symbolically remove offenders from citizenship, reaffirm citizen values, and vent anger at a political and criminal justice system deemed complicit, through weakness, in reducing legitimate citizens to subaltern citizens.ConclusionsIn this essay, we highlight the extreme violence we found in our analysis of an extensive online crime forum in a regional Australian city. We explore some explanations for violent public punitiveness, highlighting how members identify themselves as subaltern citizens in a battle against undeserving Others, with no support from a weak state. This analysis centres community norms and a problematic conception of citizenship as drivers of both public punitiveness and dissatisfaction with crime control policy and the criminal justice system. We highlight a real dissonance between community needs and public policy that may undermine effective policymaking. That is, evidence-based crime control policies, successful crime prevention initiatives, and falling crime rates may not increase public satisfaction with how crime is dealt with if policymakers pursue those measures without regard for how citizens experience the process.While studies such as that by Wenzel, Okimoto, and Cameron identify differences in status between legitimate citizens and offenders as amplifiers of punitiveness, we suggest the amplification may be mediated by the status relationship between legitimate citizens and authority figures within legitimate society. The offender and their crime may not contribute as much to the public’s outrage as commonly assumed. Instead, public punitiveness may predominantly arise from the perception that the political sphere, media, and criminal justice system respond to citizens’ experience of crime in ways that devalue the status of legitimate citizens. At least in the context of this regional city, this points to something other than successful crime control being integral to building more effective and satisfactory crime control policy: in this case, the need to rebuild trust between citizens and authority groups.ReferencesBonilla-Silva, Eduardo, Carla Goar, and David G. Embrick. “When Whites Flock Together: The Social Psychology of White Habitus.” Critical Sociology 32.2-3 (2006): 229–253.Bouffard, Jeff, Maisha Cooper, and Kathleen Bergseth. “The Effectiveness of Various Restorative Justice Interventions on Recidivism Outcomes among Juvenile Offenders.” Youth Violence and Juvenile Justice 15.4 (2017): 465–480.Green, Marcus. “Gramsci Cannot Speak: Presentations and Interpretations of Gramsci’s Concept of the Subaltern.” Rethinking Marxism 14.3 (2002): 1–24.Hallett, Michael. “Imagining the Global Corporate Gulag: Lessons from History and Criminological Theory.” Contemporary Justice Review 12.2 (2009): 113–127.Hill, Richard, and Glenn Dawes. “The ‘Thin White Line’: Juvenile Crime, Racialised Narrative and Vigilantism—A North Queensland Study.” Current Issues in Criminal Justice 11.3 (2000): 308–326.Hutchinson, Terry. “‘A Slap on the Wrist’? The Conservative Agenda in Queensland, Australia.” Youth Justice 15.2 (2015): 134–147.Jennings, Will, Stephen Farrall, Emily Gray, and Colin Hay. “Penal Populism and the Public Thermostat: Crime, Public Punitiveness, and Public Policy.” Governance: An International Journal of Policy, Administration, and Institutions 30.3 (2017): 463–481.King, Mike. “The ‘Knockout Game’: Moral Panic and the Politics of White Victimhood.” Race & Class 56.4 (2015): 85–94.Kotzian, Peter. “Good Governance and Norms of Citizenship: An Investigation into the System- and Individual-Level Determinants of Attachment to Civic Norms.” American Journal of Economics and Sociology 73.1 (2014): 58–83.Lechte, John, and Saul Newman. “Agamben, Arendt and Human Rights: Bearing Witness to the Human.” European Journal of Social Theory 15.4 (2012): 522–536.Lister, Ruth. “Citizenship: Towards a Feminist Synthesis.” Feminist Review 57 (1997): 28–48.Petray, Theresa L., and Rowan Collin. “Your Privilege is Trending: Confronting Whiteness on Social Media.” Social Media + Society 3.2 (2017): 1–10.Sacks, Michael A., and Marika Lindholm. “A Room without a View: Social Distance and the Structuring of Privileged Identity.” Working through Whiteness: International Perspectives. Ed. Cynthia Levine-Rasky. Albany, NY: State U of New York P, 2002. 129-151.Staeheli, Lynn A., Patricia Ehrkamp, Helga Leitner, and Caroline R. Nagel. “Dreaming the Ordinary: Daily Life and the Complex Geographies of Citizenship.” Progress in Human Geography 36.5 (2012): 628–644.Unnever, James D., and Francis T. Cullen. “The Social Sources of Americans’ Punitiveness: A Test of Three Competing Models.” Criminology 48.1 (2010): 99–129.Wacquant, Loïc. “Crafting the Neoliberal State: Workfare, Prisonfare, and Social Insecurity.” Sociological Forum 25.2 (2010): 197–220.Walsh, James P. “Quantifying Citizens: Neoliberal Restructuring and Immigrant Selection in Canada and Australia.” Citizenship Studies 15.6-7 (2011): 861–879.Wenzel, Michael, Tyler Okimoto, and Kate Cameron. “Do Retributive and Restorative Justice Processes Address Different Symbolic Concerns?” Critical Criminology 20.1 (2012): 25–44.

Tiffany is running down a suburban street with headphones and a hoodie on. Her breath is clearly audible, rhythmic, steady, and in pace with her footsteps. The Tiffany’s Story video testimonial on the Be Smart. Be Well. website then cuts to Tiffany sitting at home describing her earlier experiences with asthma: “The hospital became like my second home... I couldn’t breathe on my own.” Dr. Wolf, who has been treating Tiffany since she was diagnosed with asthma at age 8, joins in, “At that time she had really severe asthma. It was very difficult to manage and remained very difficult to manage for many years” (Be Smart. Be Well). As a child, Tiffany could never run, with steady breath, as she did at the beginning of the video, titled The Right Meds Keep Her in the Ring (Be Smart. Be Well). But after figuring out a treatment regime that worked, Tiffany became a healthy teenager; the video features her in contexts where she is jogging, smiling radiantly with her mother, and holding up victory belts from her boxing matches. From a child unable to breathe on her own, to a teenager with dreams of going to the Olympics, Tiffany’s asthma story underscores some of the defining narratives of contemporary asthma care. Her experience moves from uncontrolled asthma that limited her activities to a well-managed condition where she is able to pursue her aspirations without interference. Her Olympic dreams fit perfectly, reproduce even, the iconic image of the asthmatic athlete. It’s an image that has been in circulation since the early years of the contemporary asthma epidemic, a moment in the 1990s when federal health agencies and advocacy organizations worked to give the growing population of child asthmatics hope and encouragement to overcome their asthma. Yet the figure of the athletic asthmatic, and other accomplished icons with well-controlled asthma, also promotes an idealized image of health: “you can be greater than you are,” when you take your medication. The messages, of course, are well intentioned, designed to educate and show kids that asthma does not equate with disability. Yet these messages frequently work on logic where drugs control symptoms to enable you to do better in life. In some corners of asthma care, concern with symptoms is subsumed by narratives of activity and accomplishment. This article sketches shifts in the meaning of health and disease in the context of asthma treatment, moving from a time when treatments were not disease-specific and illness was seen as debilitating, to the contemporary moment where pharmaceutical companies market disease and promote health through direct-to-consumer advertising (DTCA). It’s a move situated within a broader, biomedicalized context where health isn’t just achieved, it’s augmented. Tiffany’s story is typical of someone with severe or even moderate asthma: uncontrolled symptoms, use of emergency care, unresponsive to medications, and an inability to live life as fully as desired. Symptoms and the threat of symptoms prevent people from undertaking routine activities (such as exercise, visiting friends, or attending work or school) and going into spaces that might trigger an attack. Asthma, in other words, can prevent people from living a “normal” life. But it can also be more than a chronic inconvenience that shapes behaviors; in the U.S., asthma still kills more than 3,000 people each year (Moorman et al. 20). Medical practitioners, researchers, and patients persistently search for insight into asthma’s causes and possible cures (Whitmarsh). Both cause and cure still allude, but preventative measures have improved dramatically in the last thirty years, through both pharmaceutical advancements and better public health approaches. Whereas a century ago, or even 30 years ago, severe asthmatics would have lead quite restricted lives—confined to their homes and unable to be active—today’s asthmatics are not limited by their condition to the degree they were decades before. We see this in asthma research that shows improved morbidity, decreased hospitalizations, and better quality of life (Moorman et al. 1-67). We also see this in DTCA, asthma advocacy campaigns, and even public health messages that actively combat the historic image of the weak, invalid asthmatic with stories of famous athletes, entertainers, or politicians who overcame asthma to achieve great things. It moves the discourse from an overly negative image—as one asthmatic interlocutor conveyed, “there was a stereotype in the 80s, in the movies, where the nerdy wimpy kid always had asthma, and the inhaler was associated with that”—to an extraordinarily positive image of high achieving asthmatics. Inhalers, formerly a sign of weakness, are now common in competitive sport contexts (Arie 344). The contrast between these representations—the 1980s nerdy wimp and the 21st century athlete—is stark. The latter image participates in the shift towards augmented health, where active bodies have become the new idealized norm. The shifting representations of asthmatics, even over the last twenty years, makes sense in the context of biomedicalization (Clarke et al. 172), where treatment regimes moved from a focus on “attaining control over the body” under medicalization, to “enabling the transformation of bodies to include desired new properties and identities” (Clarke et al. 183). The right treatment will allow you to do things that your body wouldn’t let you do otherwise. The question is: should treatment be sold on this premise? What would have been considered a return to health a hundred years ago wouldn’t be considered doing enough to manage your asthma today. A hundred years ago, the absence of symptoms would have been a success; today, the focus is on the degree to which one feels limited and how much you can accomplish in the span of 24-hours. Missed school and work days are a key measure in asthma epidemiology and care; these public health measures not only signal uncontrolled asthma, but do so by counting absence in the context of labor. The discursive shift can also be seen in the change from the urge to “breathe easy” (language from the Centers for Disease Control) to suggestions in pharmaceutical ads that you can “breathe better.” What new selves are being created by emergent health rhetorics, as Metzel asks (6), rhetorics which seem to be consumerist and neoliberal as much as they are biomedical? Role Reversal Historically, those with severe asthma led their lives carefully, or in reclusion. French novelist Marcel Proust, in addition to his literary accomplishments, spent much of his life confined to his home. Despite searching through medical texts and experimenting with various treatments, Proust’s asthma “dominated” his daily life, in the words of Mark Jackson (6). Writing of asthma’s history, Jackson continues, Proust constitutes the archetypal asthmatic, whose breathlessness and discomfort echo across space and time. Proust’s intimate descriptions of his symptoms—‘an asthmatic never knows if he will be able to breathe’ he wrote to the novelist Andre Gide in 1919—bear striking similarities both to Greek and medieval accounts of asthma many centuries earlier and to recent surveys suggesting that, at the turn of the millennium, many asthmatics continue to suffer from severe attacks that prevent them from speaking or make them fear for their lives. (8) In Proust’s time, advertisements for asthma and other respiratory treatments focused on providing symptom relief; some even purported to cure respiratory woes. These advertisements were rarely asthma specific, in part, because manufacturers sought the widest possible customer base, but also because it was difficult to distinguish one respiratory illness from another (Jackson 201). Asthmatics like Proust tried a range of remedies, including asthma cigarettes, the Carbolic Smoke Ball, and various forms of early inhalers. Most of these early asthma remedies instructed customers to use their product when in need of relief. Some ads stated that more regular use could stave off symptoms as well remedy them in the moment, but prevention wasn’t the primary message. The principle focus was addressing symptoms at hand. Just about a hundred years later, at the beginning of the U.S. asthma epidemic, symptoms were still center stage. National attention turned towards the asthmatic condition as the public health effects of severe asthma became visible—asthma-related deaths and hospitalizations had increased, along with rising prevalence rates. Asthma—formerly kept hidden in homes and in low-income communities—emerged as a major public health issue (Mitman 245). Advocacy campaigns were created on the heels of the epidemic’s emergence; they aimed to make asthma visible and show kids that their condition didn’t have to get in the way of life. Elite athletes became central figures in these campaigns. The Asthma All-Stars program, which featured Olympic medalists Jackie Joyner-Kersee and Amy Van Dyken, as well as Pittsburgh Steeler Jerome Bettis, worked to educate the public through acknowledgement of the condition as well as treatment advocacy. The National Library of Medicine’s exhibit on asthma, “Breath of Life” (1999), exemplifies this period with a showcase of famous asthmatics. In the exhibit, more than half the profiles of contemporary asthmatics feature Olympic or all-star athletes; entertainers, politicians, and scientists round out the exhibit. The legacy of the asthmatic athlete persists today; it’s still common to see sports figures speaking at fundraisers or spearheading events. These images are important, particularly for patient populations who truly feel limited and unable to do things because of their asthma. Athletes who speak about their condition are always clear: well-controlled asthma comes from adherence to treatment. The importance of these images also stems from the use of the image of the All-Star asthmatic to counter the historical stereotype of the weak, invalid asthmatic, who, like Proust, could not even leave the house. The man who recalled the stereotyped asthmatic from the 1980s, stated “I think I mapped myself onto that [stereotype], like, this is a disability, right, the media tells me this is a disability cause it’s always the kids who can’t do anything who are puffing their puffers.” In step with emergent 21st century health rhetoric, and increasing asthma prevalence, the image of the asthmatic was revised, falling in line with newly normalized health ideals (Clarke et al. 181; Metzel 2; Sinding 262). Active Asthmatics If 19th and early 20th century inhaler advertisements declared their products could relieve if not cure respiratory symptoms, at the beginning of the 21st century asthma treatment went beyond simply relieving symptoms; advertisements and medical discourse emphasized preventative symptom control, improved lung function, and better breathing. With the development of long-term controller medications, many asthmatics could reliably prevent symptoms a majority of the time. When combination inhalers hit the market in the early 2000s, the mood of advertisements could be summed up by a line from a GlaxoSmithKline commercial, “Coping is not the same as controlling” (GlaxoSmithKline). Prevention rather than symptom relief was the order of the new century. And yet just in the last ten years, pharmaceutical messages have shifted yet again, moving from an emphasis on controlling symptoms to living a better life: don’t let asthma slow you down, or stop you from living the life you want to live. It’s a message predicated on a particular view of what a normal life should look like, one characterized as augmented health. A 2012 Advair commercial reflects the tone of augmented health, “Asthma can hold you back, but it doesn’t always have to. Advair is clinically proven to significantly increase symptom free days, to help you do more of the things you like to do, more of the things you have to do, and more of what you want to do” (Advair). Strategically placed throughout the commercial, a voice chimes in “GO!” as the hero of the commercial, a middle aged asthmatic man, bikes down a wooded trail; moves through a busy hallway where he greets one person after the next, all of whom hand him file folders or blue prints; dances at a nightclub; and walks down bleachers to join a group of friends at a ballgame. The commercial ends with the man arriving home well after dark, comfortably settling into bed, and then energetically waking up to do it all over again the next day. Marked by words like increase, more, and go, the Advair commercial depicts a life full of activity. Not only that, the commercial leverages contexts that are commonly problematic for asthmatics: being outside and in foliage rich areas; biking and dancing, or other physical activities that could leave one breathless; and sleeping comfortably—nighttime attacks are common among asthmatics. The message is clear: look at all the things asthmatics can do when their condition is well controlled—with Advair, of course. It’s a message that builds on an earlier trend in asthma advocacy, during the 1990s, when well-known asthmatic athletes were used to bring visibility to asthma. If asthma control in the 1990s emphasized that asthmatics didn’t need to be held back, 21st century ads suggest that one could do more. By augmenting your health, asthma control can transform your life by allowing you to do more.Today, DTCA for asthma drugs are just as likely to emphasize improved lung function as they are symptom control, and, as advertised in the Advair commercial, improved lung function enables one to do more. A man featured in a 2012 Symbicort commercial explains, “Symbicort helps significantly improve my lung function, starting within five minutes… With Symbicort, today I’m breathing better” (Symbicort). The man’s renewed capacity to go on fishing trips with loved ones is the example in this commercial. Control, relief, and cure are nowhere to be found in these DTC advertisements; symptoms have been dropped from the frame. Rather than work off illness, or the older stereotype of the weak, homebound asthmatic, the new wave of DTCA champions augmented health: a higher quality of life, where patient-consumers can “do” whatever they like. What would have been considered a return to normal a hundred years ago, in Proust’s time, wouldn’t be considered doing enough to manage your asthma today. A hundred years ago, getting out of the house would have been enough; today, it’s a question of how much can you accomplish in the span of 24-hours. The portrayal of health in these DTCA calls to mind Lauren Berlant’s description of OTC cold medicine, which claim to make you feel better, but are really more concerned with making sure people can stay productive (28). Conclusion Had Proust lived a century later, he may have, like Tiffany, led a less restricted life. Or as Dr. Wolf put it, “A normal life. Busy and as active as she’d like to be. But she needs to take medication to do it” (Be Well. Be Smart). Symptom-free doesn’t seem to be enough anymore. Contemporary images of asthmatics—as an all-star athlete, an aspiring boxer, and a hyper-busy city dweller—are shaped by an imagined healthy norm. Advocacy campaigns originally intended to combat long-standing negative representations partake in the promotion of augmented health. Increasingly, health is no longer defined by the absence of symptoms, but by how active you are and how much you do. Busy and productive is a gold standard of the idealized norm, a norm that circulates—to a greater or lesser extent—in direct-to-consumer advertising, asthma advocacy campaigns, and public health messages (Sinding 262). Without doubt, the pharmaceutical industry plays a tremendous role in shaping contemporary health norms. Yet, as Joseph Dumit describes it, "the pharmaceutical industry is a massive elephant. Like the blind men of the famous parable, we each catch a hold of a tiny piece of it -- leg, tail, trunk -- and think we have a handle on it" (18). A powerful force with influence on many aspects of contemporary life, the pharmaceutical industry could be understood through the lens of biomedicalization: Biomedicalization imposes new mandates and performances that become incorporated into one’s sense of self. The subjectivities that arise out of these performances of what it is to be healthy (e.g., proactive, prevention-conscious, neo-rational) suggest how biomedical technoscience indicates a type of governmentality that can enact itself at the level of subjective identities and social relations. (Clarke et al. 182) Disease marketing—prevalent in the 1990s—is no longer needed or effective; health marketing has taken over and pharmaceutical companies are not at the table alone (Elliott 97). Instead of working through disease difference, health marketing attempts to level ground through images and standards that everyone can work towards, asthmatics included. Of course, pharmaceutical marketing simultaneously renders invisible socioeconomic conditions that contribute to asthma incidence, and marginalized populations that struggle to access medication and medical care in the first place. Augmented health works to flatten difference across social, economic, political, and ecological scales, as if these inequalities didn’t matter for disease management. Scholars writing about emergent modes of health—how health is imagined, constructed, studied, and sold—have documented how new health regimes work off potential risk categories, race, class, and gendered ideologies, or hoped-for modes of living. Some are literally “against health” (the title of Metzel and Kirkland’s edited volume). But to be against health, as Metzel writes is not to be against needed treatment (9). To examine the ways in which DTCA or advocacy campaigns promote specific, idealized images of health—images where people are athletic, outgoing, and busy—and question whether these drugs go above and beyond the restoration of health, should not be equated with a statement about whether medication is necessary. Epidemiological evidence and clinical studies are clear that contemporary treatments help reduce the burden of asthma in various ways: through reduced hospitalizations, lower death rates, and better-controlled asthma. Drugs keep many asthmatics relatively symptom-free. The point, rather, is that health is complex, structured by various institutions, actors, politics, and materials. One of the valences of the new health regime is augmented health, seen in the context of this paper at work in DTCA and possibly emerging in other corners of the asthma care arena as well. To date, most writing on augmentation has focused on how advancements in science and technology extend the capacity of human bodies—from prosthetics and fertility drugs, to steroids and life support (Hogle 696). Less has been written on the ways in which chronic conditions like diabetes, heart disease, and asthma—conditions where life hinges on medications, but are common enough that they are deemed unexceptional—produce a rhetoric of augmentation; where the new healthy is augmented living. It’s not the drugs for life rhetoric that works off new risk categories, as Dumit has shown (201); asthmatics are symptomatic, always at risk anyways, and often already on drugs for life. Drugs for chronic conditions like asthma may simply control symptoms, but they’re increasingly sold on the promise of enhancing life capacities as well. As Elliott has observed, it’s part of a move from disease marketing to health marketing (97). The discursive shift in asthma care, and perhaps other chronic disease contexts as well, doesn’t register as enhancement or augmentation because it mirrors the new health norm that is part of the broader context of biomedicalization. As the frame of health shifts, questions about bodies, ethics, and enhancement technologies might need to shift as well. Linda Hogle’s question is apt here: “what is necessary to sustain health? At which point does repair become something more than restorative, and for which (and whose) purposes are interventions defined as 'therapeutic'” (697). Since health norms have become augmented in the last ten years, this question becomes all the more difficult to answer. Within these new health regimes, potential has not only become open-ended, it also seems to be a therapeutic goal. References Arie, Sophie. “What Can We Learn from Asthma in Elite Athletes?” British Medical Journal 344 (2012). Be Smart. Be Well. “The Right Meds Keep Her in the Ring.” Be Smart. Be Well. 14 Aug. 2013. 1 Dec. 2013 ‹http://www.besmartbewell.com/childhood-asthma/tiffany.htm›. Clarke, Adele, Janet Shim, Laura Mamo, Jennifer Fosket, and Jennifer Fishman. “Biomedicalization: Technoscientific Transformations of Health, Illness, and U.S. Biomedicine.” American Sociological Review 68 (2003): 161-194. Dumit, Joseph. Drugs for Life: How Pharmaceutical Companies Define Our Health. Durham: Duke University Press, 2012. Elliott, Carl. Better than Well: American Medicine Meets the American Dream. New York: W.W. Norton & Company, 2012. GlaxoSmithKline. “Advair Commercial – 2012.” 14 Sep. 2013. 1 Dec. 2013 ‹http://www.youtube.com/watch?v=OZ4hgIfU4AI›. GlaxoSmithKline. “GlaxoSmithKline (GSK) Commercial – Asthma.com.” 1 Aug. 2013. 14 Sep. 2013. ‹http://www.youtube.com/watch?v=bvyxbX3Jnp4›. Hogle, Linda. “Enhancement Technologies and the Body.” Annual Review of Anthropology 34 (2005): 695-716. Jackson, Mark. Asthma: A Biography. Oxford: Oxford University Press, 2009. Metzl, Jonathan M., and Anna Kirkland. Against Health: How Health Became the New Morality. New York: New York University Press, 2010. Moorman, J.E., L.J. Akinbami, C.M. Bailey, et al. “National Surveillance of Asthma: United States, 2001–2010. National Center for Health Statistics.” Vital Health Stat 3.35 (2012). Mitman, Gregg. Breathing Space: How Allergies Shape Our Lives and Landscapes. New Haven: Yale University Press, 2007. National Library of Medicine. “Breath of Life.” National Library of Medicine Archives, 1999. 31 Aug. 2013. 1 Dec. 2013 ‹http://www.nlm.nih.gov/archive/20120918/hmd/breath/breathhome.html›.Sinding, Christiane. “The Power of Norms: Georges Canguilhem, Michel Foucault, and the History of Medicine.” In Locating Medical History: Their Stories and Meanings, eds. Frank Huisman and John Harley Warner. Baltimore: Johns Hopkins University Press, 2004. Symbicort. “Symbicort Fishing Video.” 1 Jan. 2013. 13 Sep. 2013 ‹http://www.youtube.com/watch?v=oG9MxLwnapE› . Whitmarsh, Ian. Biomedical Ambiguity: Race, Asthma, and the Contested Meaning of Genetic Research in the Caribbean. Ithaca: Cornell University Press, 2008.