Artículos de revistas sobre el tema "English language – united states – composition and exercises"

The goal of this work consists in determination of similarities and differences in value characteristics of freedom expressed in the speech of senior age politicians of the United States, United Kingdom and Russia. The subject of this research is the semantics of English and Russian aphorisms that represent value understanding of freedom in the speech of aging politicians of the listed countries. The speech of senior people was selected due to the lack of studies on the matter within comparative linguistics. Based on the material of aphorisms of the famous aging politicians of the United States, United Kingdom and Russia, the author defines the composition of topical units and groups that reflect value understanding of freedom in the English and Russian languages. The scientific novelty lies in the establishment of similarities and differences in value characteristics of freedom in the speech of English-language and Russian-language aging politicians. As a result of the conducted analysis, it was revealed that in the speech of English-language and Russian-language aging politicians, freedom is rarely the topic of discussion, they rather create the own aphorisms and at times utilize aphorisms from the corresponding English and Russian glossaries. Most often, aging politicians discuss the questions related to practical manifestation of freedom, as well as touch upon reflection of the value of freedom as a phenomenon or a process. Comparison of the composition of aphorisms in Russian and English languages demonstrates that they differ for the most part. The author concludes on the specificity of topical units. The acquired results can be applied in the university lectures on comparative lexicology of English and Russian languages.

The English composition is an important indicator of English learners’ overall language skills and is asked in large-scale English examinations, both in China’s college entrance examinations and graduate examinations and in the TOEFL, GRE, and IELTS examinations in Europe and the United States. Some automatic scoring systems for English writing have been created in the United States and internationally, however the systems still have issues with generalization, accuracy, and error correction. In this paper, we present a method to improve the accuracy of existing automatic composition scoring systems through deep learning techniques in a wireless network environment. Experiments reveal that the method can accurately assess the quality of English learners’ writings, paving the way for the creation of an automated composition scoring system for large-scale machine testing and web-based self-learning platforms.

By 1900, composition as a university subject was already a century old. Writing instruction and the writing of regular “themes” were part of the university curriculum in the United States throughout the nineteenth century, with goals and methods perhaps best represented in Blair's Lectures on Rhetoric and Belles Lettres (1783), Newman's A Practical System of Rhetoric (1827), Parker's Aids to English Composition (1844), Boyd's Elements of Rhetoric and Literary Criticism (1844), and Quackenbos's Advanced Course of Rhetoric and English Composition (1855). Composition courses, usually required, are among the most distinguishing features of the North American version of university education. They represent a distinctively democratic ideal, that writing belongs to everyone, and a contract between the institution and the public—a bargain that, over time, made English departments large and central to the American university and to the American idea of an undergraduate education.

The author suggests that English-only classrooms are not only the implicit goal of much language policy in the United States, but also assumed to be already the case, an ironic situation in light of composition’s historical role as “containing” language differences in U.S. higher education. He suggests that the myth of linguistic homogeneity has serious implications not only for international second-language writers in U.S. classrooms but also for resident second-language writers and for native speakers of unprivileged varieties of English, and that rather than simply abandon the placement practices that have worked to contain—but also to support—multilingual writers, composition teachers need to reimagine the composition classroom as the multilingual space that it is, where the presence of language differences is the default.

Tracing the effects of the “laissez-faire” postcolonial politics of language in the United States, which in fact enabled English to become the dominant language through cultural rather than institutional means, the essay then suggests how the linguistic memory that emerges from decolonization and nation building continues, often in unsuspected ways, to influence the language policy of the modern U.S. university and U.S. college composition. The author argues for a national language policy that moves beyond the notion of language as a right, with its lingering assumptions of English monolingualism as an ultimate goal, and instead fosters a linguistic culture where being multilingual is both normal and desirable.

Keeping in mind the Chinese character-combination yuyan, with its multiple meanings of language, parts of language, the processes of language, and the products of those processes, the author depicts English as kept alive by many people and by many different ways of using it in a wide range of personal, social, and historical contexts. She proposes four lines of inquiry “against the grain” of English-only instruction—that living-English users weigh what English can do for them against what it has done to them; that they weigh what English can do against what it cannot do; that they understand English as being in the hands of all its users; and that they focus energy on how to tinker with the very standardized usages they are pressured to “imitate”—and discusses the implications of those lines of inquiry for composition in the United States.

One Nation – One Language? The English-Only Movement in the United StatesSpeaking English is perceived as essential to American identity. The English language does not, however, have an official status in the United States. As a consequence of the change in the racial and ethnic composition of the US population, in particular the growth of the Hispanic/Latino minority, since the 1980s the country has witnessed the birth and growth of the English-Only movement. The aim of the movement is to give English an official status. Even though no federal regulations have yet been passed, Official English measures have been adopted by many American states.This article presents the English-Only movement within the context of earlier attempts to restrict the use of foreign languages in the US. It also briefly discusses some of the federal, state and local regulations.

The article begins with the presentation of students with special educational needs based on the Regulation of the Minister of National Education. Then, it discusses the general principles of working with such students, giving specific tips for English teachers. Subsequently, it presents the results of the occurrence of the phenomenon based on various studies on the territory of the United States and selected European countries. In addition, it focuses on the three main characteristic symptoms of students with ADHD (attention deficit, impulsiveness, hyperactivity) and explains the subtypes of ADHD. The author also adds characteristics of students with ADD. Particular attention is paid to presenting ways of adapting the English language teaching environment in the primary school to the needs of students with ADHD and the most effective rules of cooperation with them. Finally, it describes selected practical tips for working with students with ADHD at the second educational level of the primary school, giving examples of exercises developing various language skills.

This article provides a historical case study of the Sentinelle Affair, a conflict between French language rights and the English Only educational policies of the Catholic Church in New England in the 1920s. An analysis of this conflict reveals a correspondence between programs of language centralization and the production of language differences in the United States. The article explores the possibility that such language histories of white ethnic groups might provide grounds for creating what Malea Powell calls “a rhetoric and composition alliance.”

Mirella Rizzo regularly used children's books to give her second graders meaningful contexts for mathematical ideas. The composition of her class reflected its urban setting: culturally and ethnically diverse, including several students who had recently immigrated to the United States. As a naturalized citizen herself, Mirella was especially sensitive to the needs of her English Language Learner (ELL) students. She believed that reading, discussing, and extending math–related books gave her students opportunities to build both English and mathematical proficiency.

This article presents a new model describing a language competition situation between a local majority language and a migrant minority language. Migrants enter the society, form families, and produce offspring. Adults raise their children in either one of the two languages or both. Children then attend school, learn additional languages as adults, and produce a new cohort with its own linguistic repertoire. Families and adults are utility maximizing actors, who take into account instrumental aspects of languages, such as their communicative range, as well as identity-related aspects. A general macro-level model describes how the linguistic composition of a population facing migration changes over time. Furthermore, a specific functional form of the general model is proposed and steady states are analyzed. Finally, for illustrative purposes, the model is applied to the case of Spanish and English in the United States.

AbstractThe remarkable increase in immigration from Asia and Latin America requires a rethinking of multiracial analyses of neighborhood racial-composition preferences. This research addresses two interrelated questions: (1) since spatial mobility is so central to social mobility, how do recent Asian and Latino/a immigrants develop ideas about the racial and ethnic composition of the neighborhoods in which they want to live; and (2) what are the implications of processes of immigrant adaptation for the likely dynamics of race and ethnic relations in increasingly diverse communities? Guided by Massey's spatial assimilation model and previous studies of neighborhood racial-composition preferences, this research underscores the critical importance of immigration and assimilation as influences on preferences for same-race, White, and Black neighbors. Data are from the 1993–1994 Los Angeles Survey of Urban Inequality (N = 1921). Results point to the critical role of acculturation—the accumulation of time in the United States and English-language proficiency/use, as well as racial attitudes—in understanding what motivates preferences for these diverse groups, and to the complexities of accurately modeling preferences among largely foreign-born populations. Preferences for both same-race and White neighbors vary by the length of time that immigrants have accumulated in the United States and their ability to communicate effectively in English. English-language fluency is a particularly salient predictor of preferences among recent immigrants. Consistent with prior research on preferences, racial stereotypes stand out as particularly potent predictors of preferences; however, their influence is weakest among the most recent immigrants, coming to resemble those of the native-born with increasing years of U.S. residence.

Changes in the demographic composition of the United States relative to the increase in English language learners (ELLs) in newcomer and refugee populations generate the need for cultural brokers, particularly in the ranks of educators and teacher candidates. Applied learning, especially as used in service-learning opportunities in teacher candidate preparation programs, can produce educators with greater cultural understanding and skills in best practices for literacy instruction. Examples of service-learning for this purpose are highlighted, as well as emerging strategies in professional development for educators who work with ELLs and their families.

Background The #MeToo movement sparked an international debate on the sexual harassment, abuse, and assault and has taken many directions since its inception in October of 2017. Much of the early conversation took place on public social media sites such as Twitter, where the hashtag movement began. Objective The aim of this study is to document, characterize, and quantify early public discourse and conversation of the #MeToo movement from Twitter data in the United States. We focus on posts with public first-person revelations of sexual assault/abuse and early life experiences of such events. Methods We purchased full tweets and associated metadata from the Twitter Premium application programming interface between October 14 and 21, 2017 (ie, the first week of the movement). We examined the content of novel English language tweets with the phrase “MeToo” from within the United States (N=11,935). We used machine learning methods, least absolute shrinkage and selection operator regression, and support vector machine models to summarize and classify the content of individual tweets with revelations of sexual assault and abuse and early life experiences of sexual assault and abuse. Results We found that the most predictive words created a vivid archetype of the revelations of sexual assault and abuse. We then estimated that in the first week of the movement, 11% of novel English language tweets with the words “MeToo” revealed details about the poster’s experience of sexual assault or abuse and 5.8% revealed early life experiences of such events. We examined the demographic composition of posters of sexual assault and abuse and found that white women aged 25-50 years were overrepresented in terms of their representation on Twitter. Furthermore, we found that the mass sharing of personal experiences of sexual assault and abuse had a large reach, where 6 to 34 million Twitter users may have seen such first-person revelations from someone they followed in the first week of the movement. Conclusions These data illustrate that revelations shared went beyond acknowledgement of having experienced sexual harassment and often included vivid and traumatic descriptions of early life experiences of assault and abuse. These findings and methods underscore the value of content analysis, supported by novel machine learning methods, to improve our understanding of how widespread the revelations were, which likely amplified the spread and saliency of the #MeToo movement.

Differences in student performance were analyzed for Black males in Connecticut, Florida, Maryland, Massachusetts, and Texas on the Advanced Placement English Language and Composition, Calculus AB, Biology, and United States History examinations from the 2001 through the 2012 exam years. All analyses included in the comparisons of overall examination scores and U.S. History examination scores were statistically significant. Of the 48 individual examination comparisons, 26 yielded evidence of a statistically significant difference among the Black male students from the selected states. Massachusetts was the state with the highest percentages of Black male students who achieved an AP score of 4 or 5. Conversely, Texas was the state with the highest percentages of Black male students who failed to achieve an AP score of 4 or 5. Implications for policy regarding advanced placement testing as an avenue for preparing students for college and recommendations for future research are discussed.

The ability to listen attentively is of utmost importance for individuals who are learning a language, as it serves as the bedrock for effective communication and mastery of the language. Nonetheless, conventional methods employed in teaching listening tend to concentrate on passive listening exercises, resulting in limited engagement and insufficient development of this skill. To overcome these constraints, the integration of information and communication technology (ICT) tools alongside learner-centric teaching strategies has proven to be highly beneficial. This review will look at the current level of research and innovations in the use of ICT and learner-centered teaching techniques to improve EFL teachers' listening instruction from 2012 to 2023. On March 15th, 2023, 232 papers were collected from the Scopus database and a bibliometric analysis was performed to examine the publishing trend and geographic distribution, the contribution and collaboration of various nations, the most influential authors and publications, the most frequently used author keywords, and under-explored issues. From 2012 to 2023, the data revealed a rising trend in overall publication production, with 51 countries contributing to the research on EFL instructors' use of ICT and learner-centered teaching practices to improve listening instruction. The United States, Australia, and Iran were the top three contributors among these countries. The most commonly used author keywords were EFL, ICT, learner-centered teaching strategies, listening instruction, and teaching methods, indicating that these were the major themes of study in this area over the preceding decade.

The article deals with the issues of future German language teachers training in higher educational institutions of the United States of America. It is determined that the training of future German language teachers is carried out according to educational programs that consist of several compulsory courses (German, English, methods of teaching foreign languages) and a wide range of elective courses. The generalization of the content of German language teacher training programs is presented. Three main blocks of courses that are offered for study within these educational programs are identified. To improve the acquired language skills, a separate German language course is provided, which is detailed in various topics. In general, much attention is paid to the development of free speech through systematic conversations on civilization and various topical issues. At the same time, it is worth noting the individualization of training, as for this purpose morphological and phonetic exercises are often developed according to the needs and level of knowledge of each individual student. The methodological block of the program contains empirical studies of teaching foreign languages to children and adults. At the same time, theoretical foundations of foreign language teaching: approaches, methods, techniques are also mastered. Pedagogical practice is obligatory. Students can implement the acquired knowledge of German language teaching methods through practical application, including lesson planning, classroom observation, materials development and technology integration. The combination of the above mentioned blocks of the program is special topics in German, which include literature or literary criticism, linguistics, linguistic pedagogy. Elective courses are aimed not only at improving the level of German language proficiency, but also cover the study of literature, history and culture of German-speaking countries, as well as familiarization with their media. The importance of compulsory practice in teaching German and the possibility of studying and internships abroad is stated. It is found that the vast majority of future German language teachers in the United States have a bachelor's degree and only about a third – a master's degree. It is established that special attention is paid to the formation and development of speech skills and intercultural communication skills. Keywords: future teachers training; program; university; students; higher education institutions; German language.

Background: Much of the previous research in teacher attrition and retention focuses on teachers in general, without regard to specific types of teachers. We focus on English language arts (ELA) and English as a second language (ESL) teachers because the United States has stubbornly low achievement in reading, and reading is critical to the success of learning other subjects, and because these are the two groups of teachers most responsible for teaching both native and non-native English speakers to read. Purpose: Our goal is to understand how the demographics and qualifications of ELA and ESL teachers have changed over time, changes in the student characteristics and school conditions in which they teach, their attrition rate, and the factors that are associated with their attrition behaviors. We also pay close attention to teachers in economically disadvantaged schools. Research Design: We use nationally representative data from seven waves of the Schools and Staffing Survey from 1987–1988 to 2011–2012, as well as the 2015–2016 National Teacher and Principal Survey to examine ELA and ESL teachers and their turnover behaviors. We employ sampling weights to make the results nationally representative. We use both descriptive and regression analyses to examine these teachers. Data Analysis: We first describe how characteristics of ELA and ESL teachers and the schools in which they teach have changed from 1988 to 2016. We then examine how these characteristics vary systematically across high- and low-poverty schools and compare the attrition rate for ELA and ESL teachers relative to other teachers. We also examine the factors that are associated with various forms of turnover and how organizational supports may be leveraged to increase retention. Findings: We find the composition of ELA and ESL teachers has changed substantially over time, with more teachers attending selective schools, being certified to teach, and more likely to teach in high-poverty schools. Relatedly, teacher characteristics in high- and low-poverty schools are consistently different across time, and school working conditions play an enhanced role in high-poverty schools rather than in more affluent schools. Conclusions: Although we find ELA teachers turn over at similar rates compared to non-ELA teachers, we find ESL teachers are more likely to leave both their current school and the profession. This is particularly concerning given that the ESL population is increasing while at the same time there is a shortage of trained-ESL teachers.

Composition theorists concerned with students’ academic writing ability have long questioned the application of voice as a standard for writing competence, and second language compositionists have suggested that English language learners may be disadvantaged by the practice of emphasizing voice in the evaluation of student writing. Despite these criticisms, however, voice continues to frequently appear as a goal in guidelines for teaching writing and on high-stakes writing assessment rubrics in the United States. Given the apparent lack of alignment between theory and practice regarding its use, more empirical research is needed to understand how teachers apply voice as a criterion in the evaluation of student writing. Researchers have used sociocultural and functionalist frameworks to analyze voice-related discursive patterns, yet we do not know how readers evaluate written texts for voice. To address this gap in research the present study asked: 1) What language features do secondary English teachers associate with voice in secondary students’ writing and how do they explain their associations? 2) How do such identified features vary across genres as well as among readers? Nineteen teachers were interviewed using a think-aloud protocol designed to illuminate their perceptions of voice in narrative and expository samples of secondary students’ writing. Results from an inductive analysis of interview transcripts suggest that participating teachers associated voice with appraisal features, such as amplified expressions of affect and judgment, that are characteristic of literary genres.

The following case study was conducted in 2014 in the Department of Didactics of the Institute for English Language and Literature at the Freie Universität Berlin. It was conceived as a preliminary investigation for an ongoing qualitative research project called The Experience of Theatrical Performance in EFL Teacher Education. The purpose of this larger project is to study the effects of the experience of theatrical performance (i.e. live performance before an audience) on EFL teachers-in-training. For this preliminary study, qualitative data were obtained from a group of seven undergraduate English Education students in conjunction with a course focused on the use of creative writing in the EFL classroom. As part of the course work, the students produced a small number of original creative texts in traditional literary genres: a personal essay, two short stories (using 1st and 3rd person point-of-view), a poem and a short play. Each student also kept a Course Journal, in which he or she wrote daily in-class creative writing exercises as well as critical and personal reflections. The course ended with a Public Reading: the students presented their creative work before an audience comprised of peers, faculty, and members of the general public. The following paper considers in particular the students' personal reflections both before and after this Public Reading. What emerges is a coherent emotional and cognitive trajectory, determined in all of its moments by the theatrical event (as future, present, and past experience) of performing original creative work before a live audience. Because the investigation was conducted by a participant in the course (i.e. the teacher himself, a native English speaker born in the United States), the report also includes thick description of the intersubjective and intercultural contexts of the study, as well as ethnographic reflections on its limitations.

This paper (1) reviews the literature related to the educational needs of the professional accountant, including several major studies done in the United States, and the accreditation standards of the American Assembly of Collegiate Schools of Business (A.A.C.S.B.) and (2) investigates empirically the perceptions of Canadian accounting educators and practitioners of the educational needs of professional accountants to determine the extent to which these needs are being fulfilled by the current university undergraduate programs in Canada. The literature review confirms the theme that accountants should be broadly educated as well as being technically competent. A calendar review of eleven major Canadian universities provides an indication of the current structure of undergraduate accounting programs in Canada. An opinion survey of educators and practitioners suggests a rather different structure. Among other results, respondents of the survey suggested a higher percentage of general education be included in undergraduate accounting programs especially for certain Ontario and Quebec universities. A greater emphasis should be placed on English language and composition than currently prevails in many major universities. It is hoped that the analysis will prove useful to those involved in curriculum design at the baccalaureate level.

ObjectiveEvaluate the evidence for effects of inpatient antimicrobial stewardship programs (ASPs) on patient, prescribing, and microbial outcomes.DesignSystematic review.MethodsSearch of MEDLINE (2000 through November 2013), Cochrane Library, and reference lists of relevant studies. We included English language studies with patient populations relevant to the United States (ie, infectious conditions and prescriptions required for antimicrobials) that evaluated ASP interventions and reported outcomes of interest. Study characteristics and outcomes data were extracted and reviewed by investigators and trained research personnel.ResultsFew intervention types (eg, audit and feedback, guideline implementation, and decision support) substantially impacted patient outcomes, including mortality, length of stay, readmission, or incidence of Clostridium difficile infection. However, most interventions were not powered adequately to demonstrate impacts on patient outcomes. Most interventions were associated with improved prescribing patterns as measured by decreased antimicrobial use or increased appropriate use. Where reported, ASPs were generally associated with improvements in microbial outcomes, including institutional resistance patterns or resistance in the study population. Few data were provided on harms, sustainability, or key intervention components. Studies were typically of short duration, low in methodological quality, and varied in study design, populations enrolled, hospital setting, ASP intent, intervention composition and implementation, comparison group, and outcomes assessed.ConclusionsNumerous studies suggest that ASPs can improve prescribing and microbial outcomes. Strength of evidence was low, and most studies were not designed adequately to detect improvements in mortality or other patient outcomes, but obvious adverse effects on patient outcomes were not reported.

ObjectiveEvaluate the evidence for effects of inpatient antimicrobial stewardship programs (ASPs) on patient, prescribing, and microbial outcomes.DesignSystematic review.MethodsSearch of MEDLINE (2000 through November 2013), Cochrane Library, and reference lists of relevant studies. We included English language studies with patient populations relevant to the United States (ie, infectious conditions and prescriptions required for antimicrobials) that evaluated ASP interventions and reported outcomes of interest. Study characteristics and outcomes data were extracted and reviewed by investigators and trained research personnel.ResultsFew intervention types (eg, audit and feedback, guideline implementation, and decision support) substantially impacted patient outcomes, including mortality, length of stay, readmission, or incidence ofClostridium difficileinfection. However, most interventions were not powered adequately to demonstrate impacts on patient outcomes. Most interventions were associated with improved prescribing patterns as measured by decreased antimicrobial use or increased appropriate use. Where reported, ASPs were generally associated with improvements in microbial outcomes, including institutional resistance patterns or resistance in the study population. Few data were provided on harms, sustainability, or key intervention components. Studies were typically of short duration, low in methodological quality, and varied in study design, populations enrolled, hospital setting, ASP intent, intervention composition and implementation, comparison group, and outcomes assessed.ConclusionsNumerous studies suggest that ASPs can improve prescribing and microbial outcomes. Strength of evidence was low, and most studies were not designed adequately to detect improvements in mortality or other patient outcomes, but obvious adverse effects on patient outcomes were not reported.

ImportancePrior investigations in social determinants of health (SDoH) in pediatric head and neck cancer (HNC) have only considered a narrow scope of HNCs, SDoH, and geography while lacking inquiry into the interrelational association of SDoH with disparities in clinical pediatric HNC.ObjectivesTo evaluate the association of SDoH with disparities in HNC among children and adolescents and to assess which specific aspects of SDoH are most associated with disparities in dynamic and regional sociodemographic contexts.Design, Setting, and ParticipantsThis retrospective cohort study included data about patients (aged ≤19 years) with pediatric HNC who were diagnosed from 1975 to 2017 from the Surveillance, Epidemiology, and End Results Program (SEER) database. Data were analyzed from October 2021 to October 2022.ExposuresOverall social vulnerability and its subcomponent contributions from 15 SDoH variables, grouped into socioeconomic status (SES; poverty, unemployment, income level, and high school diploma status), minority and language status (ML; minoritized racial and ethnic group and proficiency with English), household composition (HH; household members aged ≥65 and ≤17 years, disability status, single-parent status), and housing and transportation (HT; multiunit structure, mobile homes, crowding, no vehicle, group quarters). These were ranked and scored across all US counties.Main Outcomes and MeasuresRegression trends were performed in continuous measures of surveillance and survival period and in discrete measures of advanced staging and surgery receipt.ResultsA total of 37 043 patients (20 729 [55.9%] aged 10-19 years; 18 603 [50.2%] male patients; 22 430 [60.6%] White patients) with 30 different HNCs in SEER had significant relative decreases in the surveillance period, ranging from 23.9% for malignant melanomas (mean [SD] duration, lowest vs highest vulnerability: 170 [128] months to 129 [88] months) to 41.9% for non-Hodgkin lymphomas (mean [SD] duration, lowest vs highest vulnerability: 216 [142] months vs 127 [94] months). SES followed by ML and HT vulnerabilities were associated with these overall trends per relative-difference magnitudes (eg, SES for ependymomas and choroid plexus tumors: mean [SD] duration, lowest vs highest vulnerability: 114 [113] months vs 86 [84] months; P < .001). Differences in mean survival time were observed with increasing social vulnerability, ranging from 11.3% for ependymomas and choroid plexus tumors (mean [SD] survival, lowest vs highest vulnerability: 46 [46] months to 41 [48] months; P = .43) to 61.4% for gliomas not otherwise specified (NOS) (mean [SD] survival, lowest vs highest vulnerability: 44 [84] months to 17 [28] months; P < .001), with ML vulnerability followed by SES, HH, and HT being significantly associated with decreased survival (eg, ML for gliomas NOS: mean [SD] survival, lowest vs highest vulnerability: 42 [84] months vs 19 [35] months; P < .001). Increased odds of advanced staging with non-Hodgkin lymphoma (OR, 1.21; 95% CI, 1.02-1.45) and retinoblastomas (OR, 1.31; 95% CI, 1.14-1.50) and decreased odds of surgery receipt for melanomas (OR, 0.79; 95% CI, 0.69-0.91) and rhabdomyosarcomas (OR, 0.90; 95% CI, 0.83-0.98) were associated with increasing overall social vulnerability.Conclusions and RelevanceIn this cohort study of patients with pediatric HNC, significant decreases in receipt of care and survival time were observed with increasing SDoH vulnerability.

The article deals with a collection of hymns by the famous church composer and regent B. M. Ledkovsky, a representative of the Russian musical diaspora, whose creative path during the last almost twenty-five years of his life was connected with the United States of America. The verbal basis of the collection was made up of the liturgical texts of the Great Vespers service translated from Church Slavonic into English. Without making a detailed excursion into the historical past of America and without having the intention to create a picture of the formation and establishment of Orthodoxy on American soil (this topic, multi-level and multi-valued, is worthy, in our opinion, of more than one special study), the author touches only on individual events and facts of this history. Referring to the modern church-singing practice, which is accepted today in the Russian Orthodox Church Abroad (ROCOR) only partially, and focusing mainly on some features of the services of the Orthodox Church in America (OCA), the author considers "Great Vespers" as a collection that generally corresponds to one of the rites of the Russian Orthodox Church, along with the All – Night Vigil written by B. M. Ledkovsky. The English-language verbal basis used in “Great Vespers” is seen as specific to the liturgical work of B. M. Ledkovsky, who always belonged to the Russian Orthodox Church – both in Russia and abroad after the revolution, but at the same time very consonant with the liturgical practice of the OCA, which gradually switched to the national, English language. Published in 1976 St. Vladimir's Seminary Press (SVS Press), one of the leading theological educational institutions of the Orthodox Church in America, where B. M. Ledkovsky worked as a teacher of church music for a number of years, "Great Vespers", composed by the composer on the order of the Seminary, was published after his death. The final revision and preparation of the collection for publication was made by D. Drillock, a student and junior colleague of B. M. Ledkovsky, E. and J. Erikson, R. Evich. They also, as indicated in the publication, carried out an English-language adaptation of the liturgical texts. It is characteristic that the musical component of most of the Great Vespers chants is the material of Obikhod Ledkovsky (All-Night Vigil), published in 1959 in Jordanville in the printing house of St. Job of Pochaevsky Holy Trinity Monastery. Individual hymns of this collection (litanies, Sunday troparia, and others) were later included in the editions of St. Vladimir Seminary in 1980 and 1982 in English ("Holy Week"; "Divine Liturgy", “The Liturgy of the Presanctified Gifts”). The proposed article examines the composition of the collection, with its features, based on the material of several hymns, shows the confirming statements of the composer and the approaches to harmonization that are fundamentally important for him, which he uses here and in other works. Some attention is also paid to the analysis of musical and linguistic parameters of harmonizations, the issues of vocalization of the chanted liturgical text.

BackgroundIndividual-level measures of acculturation (e.g. age of immigration) have a complex relationship with psychiatric disorders. Fine-grained analyses that tap various acculturation dimensions and population subgroups are needed to generate hypotheses regarding the mechanisms of action for the association between acculturation and mental health.MethodStudy participants were US Latinos (N = 6359) from Wave 2 of the 2004–2005 National Epidemiologic Survey of Alcohol and Related Conditions (N = 34 653). We used linear χ2 tests and logistic regression models to analyze the association between five acculturation dimensions and presence of 12-month DSM-IV mood/anxiety disorders across Latino subgroups (Mexican, Puerto Rican, Cuban, ‘Other Latinos’).ResultsAcculturation dimensions associated linearly with past-year presence of mood/anxiety disorders among Mexicans were: (1) younger age of immigration (linear χ21 = 11.04, p < 0.001), (2) longer time in the United States (linear χ21 = 10.52, p < 0.01), (3) greater English-language orientation (linear χ21 = 14.57, p < 0.001), (4) lower Latino composition of social network (linear χ21 = 15.03, p < 0.001), and (5) lower Latino ethnic identification (linear χ21 = 7.29, p < 0.01). However, the associations were less consistent among Cubans and Other Latinos, and no associations with acculturation were found among Puerto Ricans.ConclusionsThe relationship between different acculturation dimensions and 12-month mood/anxiety disorder varies across ethnic subgroups characterized by cultural and historical differences. The association between acculturation measures and disorder may depend on the extent to which they index protective or pathogenic adaptation pathways (e.g. loss of family support) across population subgroups preceding and/or following immigration. Future research should incorporate direct measures of maladaptive pathways and their relationship to various acculturation dimensions.

Since its inception in 2010, the Uningá Review Journal (henceforth, URJ) has undergone adaptations as part of the consolidation/internationalization process and, as a result, the journal was able to add to its development actions related to access, dissemination/distribution and visibility of publications in the environment of the scientific society, aligned with Open Science practices. The first important aspect for the internationalization of a journal is its indexing in databases/directories. The URJ is currently indexed on the following platforms: EBSCO host – Academic Source, Latindex, Diadorim, Google Scholar, Capes Journal Portal and Directory of Open Access Journals (DOAJ). These databases define quality criteria for indexing journals, so being indexed implies certification of notoriety recognized by the international community (Fleury, 2022). The indexation of a journal enhances its visibility and, consequently, leads to an increase in the number of citations of published scientific articles. Based on the amount of citations that the articles receive in a period, the impact factor is obtained, a fundamental criterion of quality in a scientific publication. To date, the URJ does not have JCR (Journal Citation Report) and SJR (Scientific Journal Rankings). In the four-year period 2013-2016, the journal obtained B4 stratification by the Qualis Periodics system. Currently presents Academic Google h5 index – 9 and City Factor – 1.04 (2020-2021). Another essential step is to fit the internationalization standards, because the largest indexers are already in this format and, with this, they further expand access to knowledge and information from secure sources. As an example, the Journal Portal created by Capes in 2000, which has already become one of the largest collections of journals and offer internationally produced scientific and technological publications. Thus, in January 2021, the URJ adopted bilingual publication (in Portuguese and in English), once, in an increasingly globalized world, the addition of the foreign language brings down another barrier to access. Publishing articles in English is considered one of the most relevant measures in the internationalization process and is part of the strategy to enhance the dissemination and distribution of these works both in Brazil and abroad (Antunes, Barros & Minayo, 2019). Fiorin (2011) states that one of the factors pointed out as a gauge of excellence in scientific production is its level of internationalization. With this in mind, in order to internationalize it, in January 2022, the journal adhered to the standards of the American Psychological Association (from now on, APA), in search of greater scope for publications. The APA is an organization founded in July 1892 by a group of professionals interested in what they called “the new psychology”. In its beginning, it had 31 participants, however, it grew rapidly after World War II. Today, it is the largest scientific organization of Psychology in the United States, with more than 121,000 professionals, including consultants, educators, researchers, clinicians, students, in addition to the members themselves (American Psychological Association, 2008). These norms appeared in 1929, published in manuscript format, entitled “Instructions in regard to preparation of manuscript”. This manual was produced by business managers, anthropologists and psychologists in order to compose a guide to help in the structuring of scientific articles and also to standardize tables, figures and references, with the intention of assisting in the composition of these (Bentley et al., 1929). After this first material, these guidelines had additions and updates, being in its seventh edition. These modifications needed to be made because of the refinement of analyses caused by the implementation of new technologies and the propagation of these in various media on the internet (American Psychological Association, 2012). With the “new” standardization adopted, it seeks to reach more researchers, so that there is greater dissemination of scientific knowledge, consonant to thought aligned with “Open Science”. Packer and Santos (2019) describe that the adoption of Open Science “pleads a considerable transformation […] of the traditional modus operandi of fostering, designing, realizing and, particularly, to communicate research”, since “the objective is to privilege the collaborative nature of research and democratize the access and use of scientific knowledge”. Furthermore, there are different challenges to those found so far for the URJ, because there is the intention of fully achieving its internationalization. This is expected to bring new opportunities. Faria (2017) reports that the great challenge of internationalization, in addition to the use of English language, is the quality of the published articles, the partnership of natives with English-speaking authors as their mother language, as well as the composition of an international editorial board. In view of these important achievements, such as internationalization and Open Science adhering, the URJ invites all researchers to submit their manuscripts. It is a multidisciplinary journal, which publishes original articles, case/experience reports and literature reviews, in the following sections: a) Agrarian Sciences and Environment, b) Exact and Earth Sciences, and Engineerings, c) Social and Human Sciences. REFERENCES American Psychological Association. (2008). APA History. Recuperado de: https://www.apa.org/about/apa/archives/apa-history American Psychological Association. (2012). Manual de Publicação da APA; tradução: Daniel Bueno; revisão técnica: Maria Lucia Tiellet Nunes. 6. ed. – Porto Alegre: Penso. Antunes, J. L. F., Barros, A. J. D., & Minayo, M. C. S. (2019). Caminhos da internacionalização dos periódicos de saúde coletiva. Saúde em Debate, 43(122), p. 878. Bentley, M., Peerenboom, C. A., Hodge, F. W., Passano, E. B., Warren, H. C., & Washburn, M. F. (1929). Instructions in regard to preparation of manuscript. Psychological Bulletin, 26(2), pp. 57–63. Capes. (2007). A importância de se adaptar às normas de internacionalização. Recuperado de: https://www.gov.br/capes/pt-br/assuntos/noticias/blank-35496251 Farias, S. A. (2017). Internacionalização dos periódicos brasileiros. RAE, 57(4), pp. 401-404. doi: https://doi.org/10.1590/S0034-759020170409 Fleury, H. J. (2022). Internacionalização do psicodrama brasileiro. Rev. Bras. Psicodrama, 30(e0522), pp. 1-3. doi: https://doi.org/10.1590/psicodrama.v30.555_PT Fiorin, J. L. (2011). Internacionalização da produção científica: a publicação de trabalhos de Ciências Humanas e Sociais em periódicos internacionais. Revista Brasileira de Pós-Graduação, 4(8), pp. 263-281. Packer, A. L., & Santos, S. (2019). Ciência aberta e o novo modus operandi de comunicar pesquisa – Parte I [on-line]. Scielo em Perspectiva. 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In Celebration of the Appearance of the New Journal Ichiro Kato Ex-President, Robotics Society of Japan., Professor, Waseda University It is a great honor for me to extend my congratulations on the occasion of the foundation of this new journal of robotics and mechatronics. Although several academic societies and industrial associations in Japan publish periodicals dealing with robotics and mechatronics, there is no English edition in these fields. It is thus a breakthrough for such an English journal to be published in this country. Since I believe that the development of robotics and mechatronics will be best attained by close international cooperation, I hope this journal will contribute to the promotion of cooperation in these fields. H ere, let me introduce my commitment to robotics. I started a study on artificial hands in 1963. But as a matter of fact, I did not know then that the first industrial robots had appeared in the United States in 1962. Just after the first symposium on robotics held in Tokyo in 1967, certain kinds of robots for industrial use developed in the United States were exhibited in the Harumi Trade Centre in Tokyo. These matters ignited the research and development of robots in Japan. Robots are based on the combined technology of mechanisms and electronics, and robotics has come to play a leading role in the present industrialized world. Industrial robots now have an important place in industrial fields. I forecast that robots will coexist with mankind and assist us not only in industrial fields but also in almost all situations such as welfare and our personal lives. As is well known, Japan is one of the centers in the world for robotics and mechatronics. That is the reason why I celebrate the new publication of this journal in Japan. It will be of significance to achieve greater international exchange of information and ideas by overcoming the barrier of the Japanese language. For the prospects of future robots - my robot, a personal or domestic robot - which will appear in the 21st century, I expect that this journal will play an important role. In Celebration of the Foundation of the ""Journal of Robotics and Mechatronics"" Makoto Kajitani Professor, The University of Electro-Communications It goes without saying that most manufactured products sustammg the recent Japanese industrial growth depend on mechatronics-based technology. Born in Japan in the middle of the 1970's, ""Mechatronics"" has now become a common word in the world, attaining the concept of a central or leading technology in today's industries with its progress. To our regret, however, no mechatronics-professed journal was found either in Japan or worldwide. It is a feat of planning in order to meet the expectations of engineers and researchers engaged in the study of mechatronics in all countries that the first international journal is being published for the world in Japan from which mechatronics originated. As one of the researchers looking forward to the development of mechatronics, I wish to express my gratitude and pleasure. Mechatronics is a technology contriving to create value added through composition and fusion. Mechatronics-like conception is seen in the recent trends of industrial fields to search for new germs of alternation and fusion among different technologies or industries. We are in a time of creating new value through international fusion not only in the branch of technology but also in the spheres of politics and economy. The ultimate aim of developing mechatronics is to be of help to people's mental sufficiency and serenity. For this purpose, grounds are wanted for spiritual fusion among mechatronics engineers or researchers. I hope that this journal will not only be destined for the scientific phase but carry out an interphasic role for international intercourse among engineers and researchers. It is an undeserved honor for me to be favored on the occasion of the foundation of this journal with the opportunity to offer my congratulations. I express my heartfelt wish that this journal will play a pivotal role in interchanging information related to robotics and mechatronics. Congratulatory Messages Russell H. Taylor Editor, IEEE Transactions on Robotics and Automation Congratulations on the establishment of the International Journal of Robotics and Mechatronics. I am confident that your new journal will make a significant contribution to the wider dissemination of the considerable body of excellent research that has hitherto been published in Japanese. I am looking forward to reading it.

Language skills are essential for early childhood, being able to speak clearly and process speech sounds, understand others, express ideas, and interact with others are the building blocks for a child's development. Therefore, this study will examine the effect of the Inside Outside Circle (IOC) instructional strategies with media images on children's language skills. This research is a quasi-experimental design with a posttest only and using a control group. The sample in this study were children in two kindergartens in the village of Banjar Tegal. Data analysis in this study was carried out by quantitative descriptive methods using t-test analysis techniques. The results of this study in kindergarten students in Banjar Tegal Village show that there is an influence of the IOC learning model with picture media on children's language skills (tcount = 6.28> ttable = 2.00). This shows that language skills achieved by groups of children participating in learning with the IOC model with drawing media are better than groups of children who attend learning without the IOC model. The implication is that further research is expected to develop other aspects of child devel- opment through the IOC model. Keywords: Children Language skills, Image media, Inside-Outside Circle Instructional Strategies Reference: Afrida, Ni., & Mahriza, R. (2019). Visual and Cognitive Media : The Language Acquisition of Children With Dyslexia in Aceh. IJLRES - International Journal on Language , Research and Education Studies, 3(1), 112–126. https://doi.org/10.30575/2017/IJLRES-2019010409 Al Otaiba, S., & Fuchs, D. (2006). Who are the young children for whom best practices in reading are ineffective? An experimental and longitudinal study. Journal of Learning Disabilities, 39(5), 414–431. https://doi.org/10.1177/00222194060390050401 Asrifan, A. (2015). 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Introduction: A leading cause of death worldwide is heart disease, and in the United States alone, 6.2 million individuals live with heart failure. The recent ability to recreate the vascular network of cardiac Extracellular Matrix (ECM) suggests the feasibility of engineering whole heart constructs. Tissue engineering method such as perfusion decellularization allows for effective removal of nearly all cellular composition of a heart while maintaining the native mechanical integrity of the scaffold. This scaffold can be reseeded with stem cells in the hopes of generating a functional heart. The goal of this systematic review was to assess the various perfusion decellularization methods and its effects upon the biologic scaffold. Methodology: A comprehensive systematic literature review search was carried out through Pubmed, MEDLINE and Google Scholar using the search terms “whole heart decellularization”, “whole organ decellularization” and “perfusion decellularization”. The inclusion criteria for this research were as follows: scholarly or peer-reviewed studies, published within the last 20 years in the English language, and primary studies in which whole cardiac organ decellularization was performed. Chosen articles were those examining the various decellularization methods and its effects upon the biologic scaffold. Excluded were studies regarding heart valve decellularization, tissue decellularization, cardiac patch, tissue recellularization, articles in foreign languages, articles dated prior to 2001, literature reviews, systematic reviews, and duplicate articles. Results: Chemical agents such as acid and bases cause hydrolytic degradation of biomolecules which could reduce ECM strength and eliminate growth factors from the matrix. Compared to other detergents such as Triton X-100, sodium dodecyl sulfate yields a more complete removal of nuclear material. A combination of these various approaches has shown an increased efficacy of the decellularization process. The decellularization of a large solid organ such as the heart requires several sophisticated steps. Perfusion decellularization is achieved via anterograde or retrograde perfusion of the intrinsic vascular network of the heart by utilizing decellularizing agents (i.e., chemicals and/or enzymes). Hodgson et al., 2017 demonstrates a combined strategy in which the decellularization of porcine hearts is accomplished in 24 hours and results in 98% DNA removal with only 6 hours of detergent exposure. Conclusion: There have been significant advances to address the heart disease epidemic. A promising approach is perfusion decellularization which allows for complete DNA content removal while maintaining the ECM scaffold integrity. This scaffold is then re-cellularized with stem cells in the hopes of creating an artificial heart. There are several challenges that need to be surpassed before bio-artificial hearts can be used to replace in vivo function. Future research is directed towards optimizing types of cells and cell sources used to repopulate decellularized hearts, seeding strategies and bioreactor systems to provide in vitro conditions required for organ maturation.

This paper describes the usage of Instagram (the social networking platform) in sophomore English classes at a private Japanese university. Instagram was used to help students prepare for their study abroad semester. Students created private Instagram accounts and used this platform for group exercises with a mixed group of students and staff at potential study abroad sites in the United States of America. The participants posted images and video of their daily lives and routines at their schools, and created posts based on tasks set by the instructor. Group members were then encouraged to ask each other questions and communicate through Instagram. The study found that Instagram usage has the potential to help students prepare linguistically and culturally for study abroad semesters. The paper recommends follow-up studies that use Instagram and other social networking sites to help students prepare culturally and linguistically for study abroad semesters. This has implications for language teachers who are teaching prospective study abroad students or are interested in incorporating technology into their classes, as well as coordinators of study abroad programs interested in modernizing their study abroad orientation programs. この論文では、日本の私立大学の 2 年生の英語クラスでの Instagram（SNS）の使 用法について説明します。 Instagram は、学生が留学の準備をするのを助けるため に使用されました。学生はプライベート Instagram アカウントを作成し、このプラ ットフォームを使用して、米国の潜在的な留学サイトで学生とスタッフの混合グル ープとのグループ演習を行いました。参加者は、学校での日常生活の画像や動画を 投稿し、講師が設定したタスクに基づいて投稿を作成しました。その後、グループ のメンバーはお互いに質問し、Instagram を介してコミュニケーションすることが 奨励されました。調査では、Instagram の使用により、学生が留学学期に向けて言 語的および文化的に準備するのに役立つ可能性があることがわかりました。この論 文では、Instagram やその他の SNS を使用して、学生が留学に向けて文化的および 言語的に準備するのに役立つ追跡調査を推奨しています。これは、将来の留学学生 を教えている、またはクラスにテクノロジーを組み込むことに関心のある語学教 師、および留学オリエンテーションプログラムの近代化に関心のある留学プログラ ムのコーディネーターに影響を及ぼします。

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Michael Hall ,Tourism in South and Southeast Asia; Issues and cases. Oxford: Butterworth-Heinemann, 2000, xiv + 293 pp., Stephen Page (eds) -John McCarthy, Bernard Sellato, Forest, resources and people in Bulungan; Elements for a history of settlement, trade and social dynamics in Borneo, 1880-2000. Jakarta: Center for international forestry research (CIFOR), 2001, ix + 183 pp. -Naomi M. McPherson, Michael French Smith, Village on the edge; Changing times in Papua New Guinea. Honolulu: University of Hawai'i Press, 2002, xviii + 214 pp. -Gert J. Oostindie, Peter van Wiechen, Vademecum van de Oost- en West-Indische Compagnie Historisch-geografisch overzicht van de Nederlandse aanwezigheid in Afrika, Amerika, Azië en West-Australië vanaf 1602 tot heden. Utrecht: Bestebreurtje, 2002, 381 pp. -Gert J. Oostindie, C.L. Temminck Groll, The Dutch overseas; Architectural Survey; Mutual heritage of four centuries in three continents. (in cooperation with W. van Alphen and with contributions from H.C.A. de Kat, H.C. van Nederveen Meerkerk and L.B. Wevers), Zwolle: Waanders/[Zeist]: Netherlands Department for Conservation, [2002]. 479 pp. -Gert J. Oostindie, M.H. Bartels ,Hollanders uit en thuis; Archeologie, geschiedenis en bouwhistorie gedurende de VOC-tijd in de Oost, de West en thuis; Cultuurhistorie van de Nederlandse expansie. Hilversum: Verloren, 2002, 190 pp. [SCHI-reeks 2.], E.H.P. Cordfunke, H. Sarfatij (eds) -Henk Schulte Nordholt, Tony Day, Fluid iron; State formation in Southeast Asia. Honolulu: University of Hawai'i Press, 2002, xii + 339 pp. -Nick Stanley, Nicholas Thomas ,Double vision; Art histories and colonial histories in the Pacific. Cambridge: Cambridge University Press, 1999, xii + 289 pp., Diane Losche, Jennifer Newell (eds) -Heather Sutherland, David Henley, Jealousy and justice; The indigenous roots of colonial rule in northern Sulawesi. Amsterdam: VU Uitgeverij, 2002, 106 pp. -Gerard Termorshuizen, Piet Hagen, Journalisten in Nederland; Een persgeschiedenis in portretten 1850-2000. Amsterdam: Arbeiderspers, 2002, 600 pp. -Amy E. Wassing, Bart de Prins, Voor keizer en koning; Leonard du Bus de Gisignies 1780-1849; Commissaris-Generaal van Nederlands-Indië. Amsterdam: Balans, 2002, 288 pp. -Robert Wessing, Michaela Appel, Hajatan in Pekayon; Feste bei Heirat und Beschneidung in einem westjavanischen Dorf. München: Verlag des Staatlichen Museums für Völkerkunde, 2001, 160 pp. [Münchner Beiträge zur Völkerkunde, Beiheft I.] -Nicholas J. White, Matthew Jones, Conflict and confrontation in South East Asia, 1961-1965; Britain, the United States, Indonesia and the creation of Malaysia. Cambridge: Cambridge University Press, 2002, xv + 325 pp. -Edwin Wieringa, Peter Riddell, Islam and the Malay-Indonesian world; Transmission and responses. London: Hurst, 2001, xvii + 349 pp. -Edwin Wieringa, Stuart Robson ,Javanese-English dictionary. (With the assistance of Yacinta Kurniasih), Singapore: Periplus, 2002, 821 pp., Singgih Wibisono (eds) -Henk Schulte Nordholt, Edward Aspinall ,Local power and politics in Indonesia; Decentralisation and democracy. Sin gapore: Institute of Southeast Asian studies, 2003, 296 pp. [Indonesia Assessment.], Greg Fealy (eds) -Henke Schulte Nordholt, Coen Holtzappel ,Riding a tiger; Dilemmas of integration and decentralization in Indonesia. Amsterdam: Rozenburg, 2002, 320 pp., Martin Sanders, Milan Titus (eds) -Henk Schulte Nordholt, Minako Sakai, Beyond Jakarta; Regional autonomy and local society in Indonesia. Adelaide: Crawford House, 2002, xvi + 354 pp. -Henk Schulte Nordholt, Damien Kingsbury ,Autonomy and disintegration in Indonesia. London; RoutledgeCurzon, 2003, xiv + 219 pp., Harry Aveling (eds)

Background. Today, jazz transcriptions of works by George Gershwin can be heard around the world. Works such as “The Man I Love”, “I Got Rhythm”, “Summertime”, “Liza”, “Fascinating Rhythm”, “Somebody Loves Me”, “Swanee”, included in the collection “Gershwin songs”, and also “Seven virtuoso etudes on the themes of G. Gershwin” by E. Wilde are performed by modern academic musicians. Thus, widely known performance versions of piano transcriptions “Gershwin songs” by M.-A. Hamelin, the song “The Man I Love” performed by A. Tharaud, P. Barton, and others famous performers. The evidence of growing interest of classical performers in the music of the American composer is the successful holding of the IV G. Gershvin International Music Competition in New York (on November 7–10, 2019). Director and main organizer of the competition, Michael Bulychev-Okser, is the American pianist, the main winner of many international competitions in the United States, Italy, Andorra, Spain and Mexico. How does a musician of academic direction, whose inner professional intentions and way of thinking are brought up on the classical repertoire, perceive Gershwin’s jazz compositions? What is the specificity of modern reading of his music? In which cultural traditions should we look for the key to understanding Gershwin’s musical language, its rhythmic and intonational specifics? Finally, can a jazz pianist consider himself completely free from the culture of the academic tradition by playing Gershwin? The search for answers to all these questions has identified the problematic perspective of this article. The purpose of the article is to reveal the characteristic features of the performance of G. Gershwin’s transcriptions by modern academic pianists using specific examples and to determine the interpretational tasks of the performer. The research methodology is based on a comprehensive genre andstyle approach to the study of musical material, and also includes a comparative method used for concidering different performance versions of the same work. The main results of the study. Jazz and the culture of academic music work closely together in the style of G. Gershwin. Indicative in this sense was the idea of a concert eloquently called “Reunion of Classics and Jazz” (1924), for which the “Rhapsody in Blue” was created and where it was first performed by the author with the orchestra of Paul Whiteman. G. Gershwin, more than any other composer of his time, communicated with African-American musicians: he knew Will Voderi, Lucky Roberts, Duke Ellington; heard New York pianists play downtown and often visited the “Cotton Club” and other places in Harlem to hear the bands of Duke Ellington, Cab Calloway and other jazz musicians. But not only jazz was the area of interest and creative acquaintances of Gershwin. Along with jazz culture, there were many other musical styles. In the works of G. Gershwin, Ch. Ives, A. Copland in the early 1920s – mid 1940s there is an original combination of deep folk intonation with the composer’s technique of the XX century, up to the use of dodecaphonic-serial technique (Copland). The fusion of jazz and academic branches in Gershwin’s music, above all, takes place at the level of form. “I took the blues and put it in a larger and more serious form”, said the composer (as quoted by Schneider, 1999: 67). As a pianist, Gershwin did not receive a systematic professional education as a child, although he later had enough teachers. But that didn’t stop him from becoming a real pianist-virtuoso and a brilliant improviser. One should listen to archival recordings of Gershwin’s performance to get an idea of his performance style. Samples of his piano performances have been partially preserved: some acoustic and electric recordings, radio recordings, two sound films and a large number of piano videos (Gibbons, 2002). The studio recording of “Rhapsody in Blue” demonstrates Gershwin’s completely “academic” pianism – with clear, well-founded articulation, bright sonic fullness, thoughtful agogics of expressive declamation, which is only emphasized by the well-organized metric pulsation and dynamics by active rhythmic movement – and his true virtuoso skill. Should a modern pianist, performing Gershwin’s works, follow the example of a balanced and rather “academic” performance, as in his studio recording “Rhapsody in Blue”, or follow Gershvin’s interpretation, which can be observed in the transcription “I Got Rhythm”, where he clearly prefers the jazz element? It makes sense to compare different examples of Gershwin’s popular piano transcription of “The Man I Love”. The performance version of the English pianist Paul Barton is an attempt to imitate the specifics of the freedom of sound of instrumental jazz styles, however, as one can hear, the musical intonation is not always convincing, the breath is a bit torn, the agogics of chord melodic constructions performance the agogics of chord melodic constructions (upper layers of texture) is greatly exaggerated and the performing is practically “released” from calculation and feeling of time. As an undoubted plus of this version it is necessary to note huge attention to harmony as such, to vertical and balance within a chord – Barton’s harmony “breathes” and moves. This approach can be justified, because the harmony of Gershwin’s songs is always diverse, bright and inventive. The record of Gershwin’s 1959 “Songbook” by Ella Fitzgerald is available today. The composition “The Man I Love” in her performance can be one of the possible orienting points in the intonation of the main melodic voice, the calculation of its unfolding in time, the display of interval “tensions” and melodic intentions in Gershwin’s music. E. Fitzgerald’s vocal-jazz style presupposes a different temporal organization of the melody, different from the one suggested by P. Barton – the movement of its vocal recitation-intonation and improvisational vocals is accelerated, then somewhat slowed down, thus creating “compensated time” of a musical work, and it is with soft, relaxed, naturally light breathing. The modern media space presents the album of French pianist Alexandre Tharaud “Swing in Paris”, which includes two compositions by Gershwin: “The Man I Love” and “Do it Again!”. Three different interpretations of “The Man I Love” are popular on the You Tube website, where each video is original in its own way. These performings are variants, but the concept of details – melodic constructions, organization of rhythmic accents, as well as a sense of Gershwin’s style, is preserved. The sophistication of the Parisian salon is what distinguishes the game of Tharaud. The musician has a sense of proportion and uses the full range of expressive means of academic pianism. At the same time, the development of the melodic line takes place organically and effortlessly, alluding to vocal genre examples, to free breathing and “blues” articulation of jazz vocalists; rhythmic accentuation is unobtrusive but clearly felt. Summing up, we note that the “Tharaud approach” is certainly the closest to the reference. Conclusions. Proceeding from the synthetic nature of G. Gershwin’s music, comprehension of its stylistic and cultural origins, analysis of listened musical samples, let us single out the interpretation constants that must be taken into account by the performer of his compositions. Among them – the inheritance of agogics, articulation, “light” breathing, inherent in the vocal jazz manner, in the intonation of the melody; “Breathing” harmony with a colorful timbre filling of chords and subvoices united into a movable vertical-horizontal complex; understanding of rhythm as an independent expressive sphere that has ethnic roots in the music of the African American tradition.

The worsening trend of childhood obesity is a global public health issue. Digital technology evolution is a contributing factor towards physical inactivity and obesity among children. In order to overcome this growing problem, exercise games have been introduced in early eighties to ameliorate this obesogenic environment. Exercise games utilize innovative technologies that provide an interactive environment, requiring gestures and body movements to simulate on-screen gameplay. The objective of this review is to assess the effectiveness of exercise gaming intervention in managing childhood obesity. A systematic review was performed. Six articles examining exercise video games impact on weight management among children published between January 2013 and December 2017 in the English language were selected from a total of 54 articles identified through five major search engines. Majority of the research was conducted in developed countries particularly in the United States whereby some developing countries had started with small-scale researches in this area. The result indicated that there was a significant increase in physical activity level, reduction of BMI, reduced adipose tissue composition and a positive psychological impact after the intervention of exercise games. However, the impact of exercise games on physiological and metabolic parameters were inconclusive and requires further study. In conclusion, exercise games are the effective way to combat childhood obesity, along with other modules of lifestyle.

Abstract Background Patient satisfaction is considered as a product of two psychological processes, a cognitive one, including expectations and perceptions, and an emotional one resulting from the congruence between expectation and subjective perception of the user. The objective was to identify the factors associated with the level of perceived satisfaction in patients treated in 36 nonprofit health clinics that offer comprehensive health care services in four counties in the state of California, United States. Methods Cross-sectional analytical study in 14 clinics in four California counties. It consisted of the application of a 30-item questionnaire to determine the degree of patient satisfaction with the clinic. The factorial composition of the quality of care and clinic quality components was analyzed and two factors with an Eigen value greater than 1 were obtained. Results A total of 846 responses were registered. Factor analysis identified two underlying dimensions: Physician Attitude and Empathy. It was found that the discordance in language between the physician and the patient generates a difference in the perception of satisfaction. Patients who prefer to speak English have better satisfaction than those who speak Spanish. Spanish speakers who do not have interpreter have lower satisfaction than those who do (p < 0,01). Conclusions The most important sociodemographic cofactor was language. Satisfaction decreased in Spanish-speaking patients who were not proficient in the use of English since they expressed fewer comments and doubts.

Understanding all sorts of factors that play into social and moral dilemmas such as the prisoner’s dilemma is necessary to understand decision making on all fronts. These dilemmas are manifestations of many decisions from every day (deciding what to eat for dinner) to life-changing (a nuclear war treaty). To identify if there is a link between gender identity and levels of cooperation and the expectations of a partner in the prisoner’s dilemma, this study uses quantitative data collected from high school students taking the AP English Language and Composition course at a small high school in the midwestern United States. Using a game-like replication of the prisoner’s dilemma using point values instead of jail time, this study examines the relationship between gender and the decision of an individual to either “share the points” (cooperate) or “steal the points” (defect) in two environments, one with face-to-face interaction with partners and another with total anonymity. This study also tests the relationship between the gender of the assigned partner and the decision of an individual to “share” or “steal” in the environment of face-to-face interaction. The study shows that females have significantly higher rates of cooperation in both environments (with interaction and without) and that players have a significantly higher rate of cooperation when partnered with a female player.

SummaryThe escalating demand for ultra‐processed foods poses a growing concern due to its potential adverse effects on human health. This study conducts a comprehensive bibliometric analysis of research and review articles investigating the intricate relationship between ultra‐processed foods and the gut microbiota. Employing rigorous search strategies across Scopus and Web of Science databases, we identified 211 English‐language articles. Utilizing Biblioshiny and R‐tool Bibliometrix, we analysed publication and citation trends, prominent contributors, collaborative networks, and influential journals. Our investigation reveals a consistent upward trajectory in both publications and citations over the past 42 years. Notably, the articles by Chassaing et al. (2015) and Thomas et al. (2011) stand out with the highest citation counts, highlighting their impact in research and review domains. The United States emerges as a key player, leading in both citations and productivity. "Nutrients" emerges as a dominant journal in disseminating knowledge in this field. Importantly, our analysis extends beyond bibliometrics to glean insights into the actual impact of ultra‐processed foods on the gut microbiota. Synthesizing findings from the reviewed articles, we observe a nuanced relationship between ultra‐processed food consumption and alterations in the gut microbiota composition. While the specific "dry" impact remains a focal point, our results underscore the need for targeted research to elucidate the molecular and functional implications of these dietary patterns on gut microbial communities. This 42‐year bibliometric journey underscores the increasing awareness and concern surrounding the impact of ultra‐processed foods on the gut microbiota. The rising trend in publications and citations, coupled with our nuanced insights, emphasizes the continued significance of this field. Researchers, policymakers, and health professionals will find our study valuable for understanding the evolving landscape and addressing the broader implications of modern dietary trends on human health.

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

Introduction I am a transmigrant who has moved back and forth between the West and the Rest. I was born and raised in a Muslim family in a predominantly Muslim country, Bangladesh, but I spent several years of my childhood in Pakistan. After my marriage, I lived in the United States for a year and a half, the Middle East for 5 years, Australia for three years, back to the Middle East for another 5 years, then, finally, in Australia for the last 12 years. I speak Bengali (my mother tongue), Urdu (which I learnt in Pakistan), a bit of Arabic (learnt in the Middle East); but English has always been my medium of instruction. So where is home? Is it my place of origin, the Muslim umma, or my land of settlement? Or is it my ‘root’ or my ‘route’ (Blunt and Dowling)? Blunt and Dowling (199) observe that the lives of transmigrants are often interpreted in terms of their ‘roots’ and ‘routes’, which are two frameworks for thinking about home, homeland and diaspora. Whereas ‘roots’ might imply an original homeland from which people have scattered, and to which they might seek to return, ‘routes’ focuses on mobile, multiple and transcultural geographies of home. However, both ‘roots’ and ‘routes’ are attached to emotion and identity, and both invoke a sense of place, belonging or alienation that is intrinsically tied to a sense of self (Blunt and Dowling 196-219). In this paper, I equate home with my root (place of birth) and route (transnational homing) within the context of the ‘diaspora and belonging’. First I define the diaspora and possible criteria of belonging. Next I describe my transnational homing within the framework of diaspora and belonging. Finally, I consider how Australia can be a ‘home’ for me and other Muslim Australians. The Diaspora and Belonging Blunt and Dowling (199) define diaspora as “scattering of people over space and transnational connections between people and the places”. Cohen emphasised the ethno-cultural aspects of the diaspora setting; that is, how migrants identify and position themselves in other nations in terms of their (different) ethnic and cultural orientation. Hall argues that the diasporic subjects form a cultural identity through transformation and difference. Speaking of the Hindu diaspora in the UK and Caribbean, Vertovec (21-23) contends that the migrants’ contact with their original ‘home’ or diaspora depends on four factors: migration processes and factors of settlement, cultural composition, structural and political power, and community development. With regard to the first factor, migration processes and factors of settlement, Vertovec explains that if the migrants are political or economic refugees, or on a temporary visa, they are likely to live in a ‘myth of return’. In the cultural composition context, Vertovec argues that religion, language, region of origin, caste, and degree of cultural homogenisation are factors in which migrants are bound to their homeland. Concerning the social structure and political power issue, Vertovec suggests that the extent and nature of racial and ethnic pluralism or social stigma, class composition, degree of institutionalised racism, involvement in party politics (or active citizenship) determine migrants’ connection to their new or old home. Finally, community development, including membership in organisations (political, union, religious, cultural, leisure), leadership qualities, and ethnic convergence or conflict (trends towards intra-communal or inter-ethnic/inter-religious co-operation) would also affect the migrants’ sense of belonging. Using these scholarly ideas as triggers, I will examine my home and belonging over the last few decades. My Home In an initial stage of my transmigrant history, my home was my root (place of birth, Dhaka, Bangladesh). Subsequently, my routes (settlement in different countries) reshaped my homes. In all respects, the ethno-cultural factors have played a big part in my definition of ‘home’. But on some occasions my ethnic identification has been overridden by my religious identification and vice versa. By ethnic identity, I mean my language (mother tongue) and my connection to my people (Bangladeshi). By my religious identity, I mean my Muslim religion, and my spiritual connection to the umma, a Muslim nation transcending all boundaries. Umma refers to the Muslim identity and unity within a larger Muslim group across national boundaries. The only thing the members of the umma have in common is their Islamic belief (Spencer and Wollman 169-170). In my childhood my father, a banker, was relocated to Karachi, Pakistan (then West Pakistan). Although I lived in Pakistan for much of my childhood, I have never considered it to be my home, even though it is predominantly a Muslim country. In this case, my home was my root (Bangladesh) where my grandparents and extended family lived. Every year I used to visit my grandparents who resided in a small town in Bangladesh (then East Pakistan). Thus my connection with my home was sustained through my extended family, ethnic traditions, language (Bengali/Bangla), and the occasional visits to the landscape of Bangladesh. Smith (9-11) notes that people build their connection or identity to their homeland through their historic land, common historical memories, myths, symbols and traditions. Though Pakistan and Bangladesh had common histories, their traditions of language, dress and ethnic culture were very different. For example, the celebration of the Bengali New Year (Pohela Baishakh), folk dance, folk music and folk tales, drama, poetry, lyrics of poets Rabindranath Tagore (Rabindra Sangeet) and Nazrul Islam (Nazrul Geeti) are distinct in the cultural heritage of Bangladesh. Special musical instruments such as the banshi (a bamboo flute), dhol (drums), ektara (a single-stringed instrument) and dotara (a four-stringed instrument) are unique to Bangladeshi culture. The Bangladeshi cuisine (rice and freshwater fish) is also different from Pakistan where people mainly eat flat round bread (roti) and meat (gosh). However, my bonding factor to Bangladesh was my relatives, particularly my grandparents as they made me feel one of ‘us’. Their affection for me was irreplaceable. The train journey from Dhaka (capital city) to their town, Noakhali, was captivating. The hustle and bustle at the train station and the lush green paddy fields along the train journey reminded me that this was my ‘home’. Though I spoke the official language (Urdu) in Pakistan and had a few Pakistani friends in Karachi, they could never replace my feelings for my friends, extended relatives and cousins who lived in Bangladesh. I could not relate to the landscape or dry weather of Pakistan. More importantly, some Pakistani women (our neighbours) were critical of my mother’s traditional dress (saree), and described it as revealing because it showed a bit of her back. They took pride in their traditional dress (shalwar, kameez, dopatta), which they considered to be more covered and ‘Islamic’. So, because of our traditional dress (saree) and perhaps other differences, we were regarded as the ‘Other’. In 1970 my father was relocated back to Dhaka, Bangladesh, and I was glad to go home. It should be noted that both Pakistan and Bangladesh were separated from India in 1947 – first as one nation; then, in 1971, Bangladesh became independent from Pakistan. The conflict between Bangladesh (then East Pakistan) and Pakistan (then West Pakistan) originated for economic and political reasons. At this time I was a high school student and witnessed acts of genocide committed by the Pakistani regime against the Bangladeshis (March-December 1971). My memories of these acts are vivid and still very painful. After my marriage, I moved from Bangladesh to the United States. In this instance, my new route (Austin, Texas, USA), as it happened, did not become my home. Here the ethno-cultural and Islamic cultural factors took precedence. I spoke the English language, made some American friends, and studied history at the University of Texas. I appreciated the warm friendship extended to me in the US, but experienced a degree of culture shock. I did not appreciate the pub life, alcohol consumption, and what I perceived to be the lack of family bonds (children moving out at the age of 18, families only meeting occasionally on birthdays and Christmas). Furthermore, I could not relate to de facto relationships and acceptance of sex before marriage. However, to me ‘home’ meant a family orientation and living in close contact with family. Besides the cultural divide, my husband and I were living in the US on student visas and, as Vertovec (21-23) noted, temporary visa status can deter people from their sense of belonging to the host country. In retrospect I can see that we lived in the ‘myth of return’. However, our next move for a better life was not to our root (Bangladesh), but another route to the Muslim world of Dhahran in Saudi Arabia. My husband moved to Dhahran not because it was a Muslim world but because it gave him better economic opportunities. However, I thought this new destination would become my home – the home that was coined by Anderson as the imagined nation, or my Muslim umma. Anderson argues that the imagined communities are “to be distinguished, not by their falsity/genuineness, but by the style in which they are imagined” (6; Wood 61). Hall (122) asserts: identity is actually formed through unconscious processes over time, rather than being innate in consciousness at birth. There is always something ‘imaginary’ or fantasized about its unity. It always remains incomplete, is always ‘in process’, always ‘being formed’. As discussed above, when I had returned home to Bangladesh from Pakistan – both Muslim countries – my primary connection to my home country was my ethnic identity, language and traditions. My ethnic identity overshadowed the religious identity. But when I moved to Saudi Arabia, where my ethnic identity differed from that of the mainstream Arabs and Bedouin/nomadic Arabs, my connection to this new land was through my Islamic cultural and religious identity. Admittedly, this connection to the umma was more psychological than physical, but I was now in close proximity to Mecca, and to my home of Dhaka, Bangladesh. Mecca is an important city in Saudi Arabia for Muslims because it is the holy city of Islam, the home to the Ka’aba (the religious centre of Islam), and the birthplace of Prophet Muhammad [Peace Be Upon Him]. It is also the destination of the Hajj, one of the five pillars of Islamic faith. Therefore, Mecca is home to significant events in Islamic history, as well as being an important present day centre for the Islamic faith. We lived in Dhahran, Saudi Arabia for 5 years. Though it was a 2.5 hours flight away, I treasured Mecca’s proximity and regarded Dhahran as my second and spiritual home. Saudi Arabia had a restricted lifestyle for women, but I liked it because it was a Muslim country that gave me the opportunity to perform umrah Hajj (pilgrimage). However, Saudi Arabia did not allow citizenship to expatriates. Saudi Arabia’s government was keen to protect the status quo and did not want to compromise its cultural values or standard of living by allowing foreigners to become a permanent part of society. In exceptional circumstances only, the King granted citizenship to a foreigner for outstanding service to the state over a number of years. Children of foreigners born in Saudi Arabia did not have rights of local citizenship; they automatically assumed the nationality of their parents. If it was available, Saudi citizenship would assure expatriates a secure and permanent living in Saudi Arabia; as it was, there was a fear among the non-Saudis that they would have to leave the country once their job contract expired. Under the circumstances, though my spiritual connection to Mecca was strong, my husband was convinced that Saudi Arabia did not provide any job security. So, in 1987 when Australia offered migration to highly skilled people, my husband decided to migrate to Australia for a better and more secure economic life. I agreed to his decision, but quite reluctantly because we were again moving to a non-Muslim part of the world, which would be culturally different and far away from my original homeland (Bangladesh). In Australia, we lived first in Brisbane, then Adelaide, and after three years we took our Australian citizenship. At that stage I loved the Barossa Valley and Victor Harbour in South Australia, and the Gold Coast and Sunshine Coast in Queensland, but did not feel at home in Australia. We bought a house in Adelaide and I was a full time home-maker but was always apprehensive that my children (two boys) would lose their culture in this non-Muslim world. In 1990 we once again moved back to the Muslim world, this time to Muscat, Sultanate of Oman. My connection to this route was again spiritual. I valued the fact that we would live in a Muslim country and our children would be brought up in a Muslim environment. But my husband’s move was purely financial as he got a lucrative job offer in Muscat. We had another son in Oman. We enjoyed the luxurious lifestyle provided by my husband’s workplace and the service provided by the housemaid. I loved the beaches and freedom to drive my car, and I appreciated the friendly Omani people. I also enjoyed our frequent trips (4 hours flight) to my root, Dhaka, Bangladesh. So our children were raised within our ethnic and Islamic culture, remained close to my root (family in Dhaka), though they attended a British school in Muscat. But by the time I started considering Oman to be my second home, we had to leave once again for a place that could provide us with a more secure future. Oman was like Saudi Arabia; it employed expatriates only on a contract basis, and did not give them citizenship (not even fellow Muslims). So after 5 years it was time to move back to Australia. It was with great reluctance that I moved with my husband to Brisbane in 1995 because once again we were to face a different cultural context. As mentioned earlier, we lived in Brisbane in the late 1980s; I liked the weather, the landscape, but did not consider it home for cultural reasons. Our boys started attending expensive private schools and we bought a house in a prestigious Western suburb in Brisbane. Soon after arriving I started my tertiary education at the University of Queensland, and finished an MA in Historical Studies in Indian History in 1998. Still Australia was not my home. I kept thinking that we would return to my previous routes or the ‘imagined’ homeland somewhere in the Middle East, in close proximity to my root (Bangladesh), where we could remain economically secure in a Muslim country. But gradually I began to feel that Australia was becoming my ‘home’. I had gradually become involved in professional and community activities (with university colleagues, the Bangladeshi community and Muslim women’s organisations), and in retrospect I could see that this was an early stage of my ‘self-actualisation’ (Maslow). Through my involvement with diverse people, I felt emotionally connected with the concerns, hopes and dreams of my Muslim-Australian friends. Subsequently, I also felt connected with my mainstream Australian friends whose emotions and fears (9/11 incident, Bali bombing and 7/7 tragedy) were similar to mine. In late 1998 I started my PhD studies on the immigration history of Australia, with a particular focus on the historical settlement of Muslims in Australia. This entailed retrieving archival files and interviewing people, mostly Muslims and some mainstream Australians, and enquiring into relevant migration issues. I also became more active in community issues, and was not constrained by my circumstances. By circumstances, I mean that even though I belonged to a patriarchally structured Muslim family, where my husband was the main breadwinner, main decision-maker, my independence and research activities (entailing frequent interstate trips for data collection, and public speaking) were not frowned upon or forbidden (Khan 14-15); fortunately, my husband appreciated my passion for research and gave me his trust and support. This, along with the Muslim community’s support (interviews), and the wider community’s recognition (for example, the publication of my letters in Australian newspapers, interviews on radio and television) enabled me to develop my self-esteem and built up my bicultural identity as a Muslim in a predominantly Christian country and as a Bangladeshi-Australian. In 2005, for the sake of a better job opportunity, my husband moved to the UK, but this time I asserted that I would not move again. I felt that here in Australia (now in Perth) I had a job, an identity and a home. This time my husband was able to secure a good job back in Australia and was only away for a year. I no longer dream of finding a home in the Middle East. Through my bicultural identity here in Australia I feel connected to the wider community and to the Muslim umma. However, my attachment to the umma has become ambivalent. I feel proud of my Australian-Muslim identity but I am concerned about the jihadi ideology of militant Muslims. By jihadi ideology, I mean the extremist ideology of the al-Qaeda terrorist group (Farrar 2007). The Muslim umma now incorporates both moderate and radical Muslims. The radical Muslims (though only a tiny minority of 1.4 billion Muslims worldwide) pose a threat to their moderate counterparts as well as to non-Muslims. In the UK, some second- and third-generation Muslims identify themselves with the umma rather than their parents’ homelands or their country of birth (Husain). It should not be a matter of concern if these young Muslims adopt a ‘pure’ Muslim identity, providing at the same time they are loyal to their country of residence. But when they resort to terrorism with their ‘pure’ Muslim identity (e.g., the 7/7 London bombers) they defame my religion Islam, and undermine my spiritual connection to the umma. As a 1st generation immigrant, the defining criteria of my ‘homeliness’ in Australia are my ethno-cultural and religious identity (which includes my family), my active citizenship, and my community development/contribution through my research work – all of which allow me a sense of efficacy in my life. My ethnic and religious identities generally co-exist equally, but when I see some Muslims kill my fellow Australians (such as the Bali bombings in 2002 and 2005) my Australian identity takes precedence. I feel for the victims and condemn the perpetrators. On the other hand, when I see politics play a role over the human rights issues (e.g., the Tampa incident), my religious identity begs me to comment on it (see Kabir, Muslims in Australia 295-305). Problematising ‘Home’ for Muslim Australians In the European context, Grillo (863) and Werbner (904), and in the Australian context, Kabir (Muslims in Australia) and Poynting and Mason, have identified the diversity within Islam (national, ethnic, religious etc). Werbner (904) notes that in spite of the “wishful talk of the emergence of a ‘British Islam’, even today there are Pakistani, Bangladeshi and Arab mosques, as well as Turkish and Shia’a mosques”; thus British Muslims retain their separate identities. Similarly, in Australia, the existence of separate mosques for the Bangladeshi, Pakistani, Arab and Shia’a peoples indicates that Australian Muslims have also kept their ethnic identities discrete (Saeed 64-77). However, in times of crisis, such as the Salman Rushdie affair in 1989, and the 1990-1991 Gulf crises, both British and Australian Muslims were quick to unite and express their Islamic identity by way of resistance (Kabir, Muslims in Australia 160-162; Poynting and Mason 68-70). In both British and Australian contexts, I argue that a peaceful rally or resistance is indicative of active citizenship of Muslims as it reveals their sense of belonging (also Werbner 905). So when a transmigrant Muslim wants to make a peaceful demonstration, the Western world should be encouraged, not threatened – as long as the transmigrant’s allegiances lie also with the host country. In the European context, Grillo (868) writes: when I asked Mehmet if he was planning to stay in Germany he answered without hesitation: ‘Yes, of course’. And then, after a little break, he added ‘as long as we can live here as Muslims’. In this context, I support Mehmet’s desire to live as a Muslim in a non-Muslim world as long as this is peaceful. Paradoxically, living a Muslim life through ijtihad can be either socially progressive or destructive. The Canadian Muslim feminist Irshad Manji relies on ijtihad, but so does Osama bin Laden! Manji emphasises that ijtihad can be, on the one hand, the adaptation of Islam using independent reasoning, hybridity and the contesting of ‘traditional’ family values (c.f. Doogue and Kirkwood 275-276, 314); and, on the other, ijtihad can take the form of conservative, patriarchal and militant Islamic values. The al-Qaeda terrorist Osama bin Laden espouses the jihadi ideology of Sayyid Qutb (1906-1966), an Egyptian who early in his career might have been described as a Muslim modernist who believed that Islam and Western secular ideals could be reconciled. But he discarded that idea after going to the US in 1948-50; there he was treated as ‘different’ and that treatment turned him against the West. He came back to Egypt and embraced a much more rigid and militaristic form of Islam (Esposito 136). Other scholars, such as Cesari, have identified a third orientation – a ‘secularised Islam’, which stresses general beliefs in the values of Islam and an Islamic identity, without too much concern for practices. Grillo (871) observed Islam in the West emphasised diversity. He stressed that, “some [Muslims were] more quietest, some more secular, some more clamorous, some more negotiatory”, while some were exclusively characterised by Islamic identity, such as wearing the burqa (elaborate veils), hijabs (headscarves), beards by men and total abstinence from drinking alcohol. So Mehmet, cited above, could be living a Muslim life within the spectrum of these possibilities, ranging from an integrating mode to a strict, militant Muslim manner. In the UK context, Zubaida (96) contends that marginalised, culturally-impoverished youth are the people for whom radical, militant Islamism may have an appeal, though it must be noted that the 7/7 bombers belonged to affluent families (O’Sullivan 14; Husain). In Australia, Muslim Australians are facing three challenges. First, the Muslim unemployment rate: it was three times higher than the national total in 1996 and 2001 (Kabir, Muslims in Australia 266-278; Kabir, “What Does It Mean” 63). Second, some spiritual leaders have used extreme rhetoric to appeal to marginalised youth; in January 2007, the Australian-born imam of Lebanese background, Sheikh Feiz Mohammad, was alleged to have employed a DVD format to urge children to kill the enemies of Islam and to have praised martyrs with a violent interpretation of jihad (Chulov 2). Third, the proposed citizenship test has the potential to make new migrants’ – particularly Muslims’ – settlement in Australia stressful (Kabir, “What Does It Mean” 62-79); in May 2007, fuelled by perceptions that some migrants – especially Muslims – were not integrating quickly enough, the Howard government introduced a citizenship test bill that proposes to test applicants on their English language skills and knowledge of Australian history and ‘values’. I contend that being able to demonstrate knowledge of history and having English language skills is no guarantee that a migrant will be a good citizen. Through my transmigrant history, I have learnt that developing a bond with a new place takes time, acceptance and a gradual change of identity, which are less likely to happen when facing assimilationist constraints. I spoke English and studied history in the United States, but I did not consider it my home. I did not speak the Arabic language, and did not study Middle Eastern history while I was in the Middle East, but I felt connected to it for cultural and religious reasons. Through my knowledge of history and English language proficiency I did not make Australia my home when I first migrated to Australia. Australia became my home when I started interacting with other Australians, which was made possible by having the time at my disposal and by fortunate circumstances, which included a fairly high level of efficacy and affluence. If I had been rejected because of my lack of knowledge of ‘Australian values’, or had encountered discrimination in the job market, I would have been much less willing to embrace my host country and call it home. I believe a stringent citizenship test is more likely to alienate would-be citizens than to induce their adoption of values and loyalty to their new home. Conclusion Blunt (5) observes that current studies of home often investigate mobile geographies of dwelling and how it shapes one’s identity and belonging. Such geographies of home negotiate from the domestic to the global context, thus mobilising the home beyond a fixed, bounded and confining location. Similarly, in this paper I have discussed how my mobile geography, from the domestic (root) to global (route), has shaped my identity. Though I received a degree of culture shock in the United States, loved the Middle East, and was at first quite resistant to the idea of making Australia my second home, the confidence I acquired in residing in these ‘several homes’ were cumulative and eventually enabled me to regard Australia as my ‘home’. I loved the Middle East, but I did not pursue an active involvement with the Arab community because I was a busy mother. Also I lacked the communication skill (fluency in Arabic) with the local residents who lived outside the expatriates’ campus. I am no longer a cultural freak. I am no longer the same Bangladeshi woman who saw her ethnic and Islamic culture as superior to all other cultures. I have learnt to appreciate Australian values, such as tolerance, ‘a fair go’ and multiculturalism (see Kabir, “What Does It Mean” 62-79). My bicultural identity is my strength. With my ethnic and religious identity, I can relate to the concerns of the Muslim community and other Australian ethnic and religious minorities. And with my Australian identity I have developed ‘a voice’ to pursue active citizenship. Thus my biculturalism has enabled me to retain and merge my former home with my present and permanent home of Australia. References Anderson, Benedict. Imagined Communities: Reflections on the Origin and Spread of Nationalism. London, New York: Verso, 1983. Australian Bureau of Statistics: Census of Housing and Population, 1996 and 2001. Blunt, Alison. Domicile and Diaspora: Anglo-Indian Women and the Spatial Politics of Home. Oxford: Blackwell, 2005. Blunt, Alison, and Robyn Dowling. Home. London and New York: Routledge, 2006. Cesari, Jocelyne. “Muslim Minorities in Europe: The Silent Revolution.” In John L. Esposito and Burgat, eds., Modernising Islam: Religion in the Public Sphere in Europe and the Middle East. London: Hurst, 2003. 251-269. Chulov, Martin. “Treatment Has Sheik Wary of Returning Home.” Weekend Australian 6-7 Jan. 2007: 2. Cohen, Robin. Global Diasporas: An Introduction. Seattle: University of Washington, 1997. Doogue, Geraldine, and Peter Kirkwood. Tomorrow’s Islam: Uniting Old-Age Beliefs and a Modern World. Sydney: ABC Books, 2005. Esposito, John. The Islamic Threat: Myth or Reality? 3rd ed. New York, Oxford: Oxford UP, 1999. Farrar, Max. “When the Bombs Go Off: Rethinking and Managing Diversity Strategies in Leeds, UK.” International Journal of Diversity in Organisations, Communities and Nations 6.5 (2007): 63-68. Grillo, Ralph. “Islam and Transnationalism.” Journal of Ethnic and Migration Studies 30.5 (Sep. 2004): 861-878. Hall, Stuart. Polity Reader in Cultural Theory. Cambridge: Polity Press, 1994. Huntington, Samuel, P. The Clash of Civilisation and the Remaking of World Order. London: Touchstone, 1998. Husain, Ed. The Islamist: Why I Joined Radical Islam in Britain, What I Saw inside and Why I Left. London: Penguin, 2007. Kabir, Nahid. Muslims in Australia: Immigration, Race Relations and Cultural History. London: Kegan Paul, 2005. ———. “What Does It Mean to Be Un-Australian: Views of Australian Muslim Students in 2006.” People and Place 15.1 (2007): 62-79. Khan, Shahnaz. Aversion and Desire: Negotiating Muslim Female Identity in the Diaspora. Toronto: Women’s Press, 2002. Manji, Irshad. The Trouble with Islam Today. Canada:Vintage, 2005. Maslow, Abraham. Motivation and Personality. New York: Harper, 1954. O’Sullivan, J. “The Real British Disease.” Quadrant (Jan.-Feb. 2006): 14-20. 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Citation reference for this article MLA Style Kabir, Nahid. "Why I Call Australia ‘Home’?: A Transmigrant’s Perspective." M/C Journal 10.4 (2007). echo date('d M. Y'); ?> <http://journal.media-culture.org.au/0708/15-kabir.php>. APA Style Kabir, N. (Aug. 2007) "Why I Call Australia ‘Home’?: A Transmigrant’s Perspective," M/C Journal, 10(4). Retrieved echo date('d M. Y'); ?> from <http://journal.media-culture.org.au/0708/15-kabir.php>.

Introduction: Google Autocomplete Algorithms Despite recent attention to the impact of social media platforms on political discourse and public opinion, most people locate their news on search engines (Robertson et al.). When a user conducts a search, millions of outputs, in the form of videos, images, articles, and Websites are sorted to present the most relevant search predictions. Google, the most dominant search engine in the world, expanded its search index in 2009 to include the autocomplete function, which provides suggestions for query inputs (Dörr and Stephan). Google’s autocomplete function also allows users to “search smarter” by reducing typing time by 25 percent (Baker and Potts 189). Google’s complex algorithm is impacted upon by factors like search history, location, and keyword searches (Karapapa and Borghi), and there are policies to ensure the autocomplete function does not contain harmful content. In 2017, Google implemented a feedback tool to allow human evaluators to assess the quality of search results; however, the algorithm still provides misleading results that frame far-right actors as neutral. In this article, we use reverse engineering to understand the nature of these algorithms in relation to the descriptive outcome, to illustrate how autocomplete subtitles label conspiracists in three countries. According to Google, these “subtitles are generated automatically”, further stating that the “systems might determine that someone could be called an actor, director, or writer. Only one of these can appear as the subtitle” and that Google “cannot accept or create custom subtitles” (Google). We focused our attention on well-known conspiracy theorists because of their influence and audience outreach. In this article we argue that these subtitles are problematic because they can mislead the public and amplify extremist views. Google’s autocomplete feature is misleading because it does not highlight what is publicly known about these actors. The labels are neutral or positive but never negative, reflecting primary jobs and/or the actor’s preferred descriptions. This is harmful to the public because Google’s search rankings can influence a user’s knowledge and information preferences through the search engine manipulation effect (Epstein and Robertson). Users’ preferences and understanding of information can be manipulated based upon their trust in Google search results, thus allowing these labels to be widely accepted instead of providing a full picture of the harm their ideologies and belief cause. Algorithms That Mainstream Conspiracies Search engines establish order and visibility to Web pages that operationalise and stabilise meaning to particular queries (Gillespie). Google’s subtitles and blackbox operate as a complex algorithm for its search index and offer a mediated visibility to aspects of social and political life (Gillespie). Algorithms are designed to perform computational tasks through an operational sequence that computer systems must follow (Broussard), but they are also “invisible infrastructures” that Internet users consciously or unconsciously follow (Gran et al. 1779). The way algorithms rank, classify, sort, predict, and process data is political because it presents the world through a predetermined lens (Bucher 3) decided by proprietary knowledge – a “secret sauce” (O’Neil 29) – that is not disclosed to the general public (Christin). Technology titans, like Google, Facebook, and Amazon (Webb), rigorously protect and defend intellectual property for these algorithms, which are worth billions of dollars (O’Neil). As a result, algorithms are commonly defined as opaque, secret “black boxes” that conceal the decisions that are already made “behind corporate walls and layers of code” (Pasquale 899). The opacity of algorithms is related to layers of intentional secrecy, technical illiteracy, the size of algorithmic systems, and the ability of machine learning algorithms to evolve and become unintelligible to humans, even to those trained in programming languages (Christin 898-899). The opaque nature of algorithms alongside the perceived neutrality of algorithmic systems is problematic. Search engines are increasingly normalised and this leads to a socialisation where suppositions are made that “these artifacts are credible and provide accurate information that is fundamentally depoliticized and neutral” (Noble 25). Google’s autocomplete and PageRank algorithms exist outside of the veil of neutrality. In 2015, Google’s photos app, which uses machine learning techniques to help users collect, search, and categorise images, labelled two black people as ‘gorillas’ (O’Neil). Safiya Noble illustrates how media and technology are rooted in systems of white supremacy, and how these long-standing social biases surface in algorithms, illustrating how racial and gendered inequities embed into algorithmic systems. Google actively fixes algorithmic biases with band-aid-like solutions, which means the errors remain inevitable constituents within the algorithms. Rising levels of automation correspond to a rising level of errors, which can lead to confusion and misdirection of the algorithms that people use to manage their lives (O’Neil). As a result, software, code, machine learning algorithms, and facial/voice recognition technologies are scrutinised for producing and reproducing prejudices (Gray) and promoting conspiracies – often described as algorithmic bias (Bucher). Algorithmic bias occurs because algorithms are trained by historical data already embedded with social biases (O’Neil), and if that is not problematic enough, algorithms like Google’s search engine also learn and replicate the behaviours of Internet users (Benjamin 93), including conspiracy theorists and their followers. Technological errors, algorithmic bias, and increasing automation are further complicated by the fact that Google’s Internet service uses “2 billion lines of code” – a magnitude that is difficult to keep track of, including for “the programmers who designed the algorithm” (Christin 899). Understanding this level of code is not critical to understanding algorithmic logics, but we must be aware of the inscriptions such algorithms afford (Krasmann). As algorithms become more ubiquitous it is urgent to “demand that systems that hold algorithms accountable become ubiquitous as well” (O’Neil 231). This is particularly important because algorithms play a critical role in “providing the conditions for participation in public life”; however, the majority of the public has a modest to nonexistent awareness of algorithms (Gran et al. 1791). Given the heavy reliance of Internet users on Google’s search engine, it is necessary for research to provide a glimpse into the black boxes that people use to extract information especially when it comes to searching for information about conspiracy theorists. Our study fills a major gap in research as it examines a sub-category of Google’s autocomplete algorithm that has not been empirically explored before. Unlike the standard autocomplete feature that is primarily programmed according to popular searches, we examine the subtitle feature that operates as a fixed label for popular conspiracists within Google’s algorithm. Our initial foray into our research revealed that this is not only an issue with conspiracists, but also occurs with terrorists, extremists, and mass murderers. Method Using a reverse engineering approach (Bucher) from September to October 2021, we explored how Google’s autocomplete feature assigns subtitles to widely known conspiracists. The conspiracists were not geographically limited, and we searched for those who reside in the United States, Canada, United Kingdom, and various countries in Europe. Reverse engineering stems from Ashby’s canonical text on cybernetics, in which he argues that black boxes are not a problem; the problem or challenge is related to the way one can discern their contents. As Google’s algorithms are not disclosed to the general public (Christin), we use this method as an extraction tool to understand the nature of how these algorithms (Eilam) apply subtitles. To systematically document the search results, we took screenshots for every conspiracist we searched in an attempt to archive the Google autocomplete algorithm. By relying on previous literature, reports, and the figures’ public statements, we identified and searched Google for 37 Western-based and influencial conspiracy theorists. We initially experimented with other problematic figures, including terrorists, extremists, and mass murderers to see whether Google applied a subtitle or not. Additionally, we examined whether subtitles were positive, neutral, or negative, and compared this valence to personality descriptions for each figure. Using the standard procedures of content analysis (Krippendorff), we focus on the manifest or explicit meaning of text to inform subtitle valence in terms of their positive, negative, or neutral connotations. These manifest features refer to the “elements that are physically present and countable” (Gray and Densten 420) or what is known as the dictionary definitions of items. Using a manual query, we searched Google for subtitles ascribed to conspiracy theorists, and found the results were consistent across different countries. Searches were conducted on Firefox and Chrome and tested on an Android phone. Regardless of language input or the country location established by a Virtual Private Network (VPN), the search terms remained stable, regardless of who conducted the search. The conspiracy theorists in our dataset cover a wide range of conspiracies, including historical figures like Nesta Webster and John Robison, who were foundational in Illuminati lore, as well as contemporary conspiracists such as Marjorie Taylor Greene and Alex Jones. Each individual’s name was searched on Google with a VPN set to three countries. Results and Discussion This study examines Google’s autocomplete feature associated with subtitles of conspiratorial actors. We first tested Google’s subtitling system with known terrorists, convicted mass shooters, and controversial cult leaders like David Koresh. Garry et al. (154) argue that “while conspiracy theories may not have mass radicalising effects, they are extremely effective at leading to increased polarization within societies”. We believe that the impact of neutral subtitling of conspiracists reflects the integral role conspiracies plays in contemporary politics and right-wing extremism. The sample includes contemporary and historical conspiracists to establish consistency in labelling. For historical figures, the labels are less consequential and simply reflect the reality that Google’s subtitles are primarily neutral. Of the 37 conspiracy theorists we searched (see Table 1 in the Appendix), seven (18.9%) do not have an associated subtitle, and the other 30 (81%) have distinctive subtitles, but none of them reflects the public knowledge of the individuals’ harmful role in disseminating conspiracy theories. In the list, 16 (43.2%) are noted for their contribution to the arts, 4 are labelled as activists, 7 are associated with their professional affiliation or original jobs, 2 to the journalism industry, one is linked to his sports career, another one as a researcher, and 7 have no subtitle. The problem here is that when white nationalists or conspiracy theorists are not acknowledged as such in their subtitles, search engine users could possibly encounter content that may sway their understanding of society, politics, and culture. For example, a conspiracist like Alex Jones is labeled as an “American Radio Host” (see Figure 1), despite losing two defamation lawsuits for declaring that the shooting at Sandy Hook Elementary School in Newtown, Connecticut, was a ‘false flag’ event. Jones’s actions on his InfoWars media platforms led to parents of shooting victims being stalked and threatened. Another conspiracy theorist, Gavin McInnes, the creator of the far-right, neo-fascist Proud Boys organisation, a known terrorist entity in Canada and hate group in the United States, is listed simply as a “Canadian writer” (see Figure 1). Fig. 1: Screenshots of Google’s subtitles for Alex Jones and Gavin McInnes. Although subtitles under an individual’s name are not audio, video, or image content, the algorithms that create these subtitles are an invisible infrastructure that could cause harm through their uninterrogated status and pervasive presence. This could then be a potential conduit to media which could cause harm and develop distrust in electoral and civic processes, or all institutions. Examples from our list include Brittany Pettibone, whose subtitle states that she is an “American writer” despite being one of the main propagators of the Pizzagate conspiracy which led to Edgar Maddison Welch (whose subtitle is “Screenwriter”) travelling from North Carolina to Washington D.C. to violently threaten and confront those who worked at Comet Ping Pong Pizzeria. The same misleading label can be found via searching for James O’Keefe of Project Veritas, who is positively labelled as “American activist”. Veritas is known for releasing audio and video recordings that contain false information designed to discredit academic, political, and service organisations. In one instance, a 2020 video released by O’Keefe accused Democrat Ilhan Omar’s campaign of illegally collecting ballots. The same dissembling of distrust applies to Mike Lindell, whose Google subtitle is “CEO of My Pillow”, as well as Sidney Powell, who is listed as an “American lawyer”; both are propagators of conspiracy theories relating to the 2020 presidential election. The subtitles attributed to conspiracists on Google do not acknowledge the widescale public awareness of the negative role these individuals play in spreading conspiracy theories or causing harm to others. Some of the selected conspiracists are well known white nationalists, including Stefan Molyneux who has been banned from social media platforms like Twitter, Twitch, Facebook, and YouTube for the promotion of scientific racism and eugenics; however, he is neutrally listed on Google as a “Canadian podcaster”. In addition, Laura Loomer, who describes herself as a “proud Islamophobe,” is listed by Google as an “Author”. These subtitles can pose a threat by normalising individuals who spread conspiracy theories, sow dissension and distrust in institutions, and cause harm to minority groups and vulnerable individuals. Once clicking on the selected person, the results, although influenced by the algorithm, did not provide information that aligned with the associated subtitle. The search results are skewed to the actual conspiratorial nature of the individuals and associated news articles. In essence, the subtitles do not reflect the subsequent search results, and provide a counter-labelling to the reality of the resulting information provided to the user. Another significant example is Jerad Miller, who is listed as “American performer”, despite the fact that he is the Las Vegas shooter who posted anti-government and white nationalist 3 Percenters memes on his social media (SunStaff), even though the majority of search results connect him to the mass shooting he orchestrated in 2014. The subtitle “performer” is certainly not the common characteristic that should be associated with Jerad Miller. Table 1 in the Appendix shows that individuals who are not within the contemporary milieux of conspiracists, but have had a significant impact, such as Nesta Webster, Robert Welch Junior, and John Robison, were listed by their original profession or sometimes without a subtitle. David Icke, infamous for his lizard people conspiracies, has a subtitle reflecting his past football career. In all cases, Google’s subtitle was never consistent with the actor’s conspiratorial behaviour. Indeed, the neutral subtitles applied to conspiracists in our research may reflect some aspect of the individuals’ previous careers but are not an accurate reflection of the individuals’ publicly known role in propagating hate, which we argue is misleading to the public. For example, David Icke may be a former footballer, but the 4.7 million search results predominantly focus on his conspiracies, his public fora, and his status of being deplatformed by mainstream social media sites. The subtitles are not only neutral, but they are not based on the actual search results, and so are misleading in what the searcher will discover; most importantly, they do not provide a warning about the misinformation contained in the autocomplete subtitle. To conclude, algorithms automate the search engines that people use in the functions of everyday life, but are also entangled in technological errors, algorithmic bias, and have the capacity to mislead the public. Through a process of reverse engineering (Ashby; Bucher), we searched 37 conspiracy theorists to decode the Google autocomplete algorithms. We identified how the subtitles attributed to conspiracy theorists are neutral, positive, but never negative, which does not accurately reflect the widely known public conspiratorial discourse these individuals propagate on the Web. This is problematic because the algorithms that determine these subtitles are invisible infrastructures acting to misinform the public and to mainstream conspiracies within larger social, cultural, and political structures. This study highlights the urgent need for Google to review the subtitles attributed to conspiracy theorists, terrorists, and mass murderers, to better inform the public about the negative nature of these actors, rather than always labelling them in neutral or positive ways. Funding Acknowledgement This project has been made possible in part by the Canadian Department of Heritage – the Digital Citizen Contribution program – under grant no. R529384. The title of the project is “Understanding hate groups’ narratives and conspiracy theories in traditional and alternative social media”. References Ashby, W. Ross. An Introduction to Cybernetics. Chapman & Hall, 1961. Baker, Paul, and Amanda Potts. "‘Why Do White People Have Thin Lips?’ Google and the Perpetuation of Stereotypes via Auto-Complete Search Forms." Critical Discourse Studies 10.2 (2013): 187-204. Benjamin, Ruha. Race after Technology: Abolitionist Tools for the New Jim Code. Polity, 2019. Bucher, Taina. If... Then: Algorithmic Power and Politics. OUP, 2018. Broussard, Meredith. Artificial Unintelligence: How Computers Misunderstand the World. MIT P, 2018. Christin, Angèle. "The Ethnographer and the Algorithm: Beyond the Black Box." Theory and Society 49.5 (2020): 897-918. D'Ignazio, Catherine, and Lauren F. Klein. Data Feminism. MIT P, 2020. Dörr, Dieter, and Juliane Stephan. "The Google Autocomplete Function and the German General Right of Personality." Perspectives on Privacy. De Gruyter, 2014. 80-95. Eilam, Eldad. Reversing: Secrets of Reverse Engineering. John Wiley & Sons, 2011. Epstein, Robert, and Ronald E. Robertson. "The Search Engine Manipulation Effect (SEME) and Its Possible Impact on the Outcomes of Elections." Proceedings of the National Academy of Sciences 112.33 (2015): E4512-E4521. Garry, Amanda, et al. "QAnon Conspiracy Theory: Examining its Evolution and Mechanisms of Radicalization." Journal for Deradicalization 26 (2021): 152-216. Gillespie, Tarleton. "Algorithmically Recognizable: Santorum’s Google Problem, and Google’s Santorum Problem." Information, Communication & Society 20.1 (2017): 63-80. Google. “Update your Google knowledge panel.” 2022. 3 Jan. 2022 <https://support.google.com/knowledgepanel/answer/7534842?hl=en#zippy=%2Csubtitle>. Gran, Anne-Britt, Peter Booth, and Taina Bucher. "To Be or Not to Be Algorithm Aware: A Question of a New Digital Divide?" Information, Communication & Society 24.12 (2021): 1779-1796. Gray, Judy H., and Iain L. Densten. "Integrating Quantitative and Qualitative Analysis Using Latent and Manifest Variables." Quality and Quantity 32.4 (1998): 419-431. Gray, Kishonna L. Intersectional Tech: Black Users in Digital Gaming. LSU P, 2020. Karapapa, Stavroula, and Maurizio Borghi. "Search Engine Liability for Autocomplete Suggestions: Personality, Privacy and the Power of the Algorithm." International Journal of Law and Information Technology 23.3 (2015): 261-289. Krasmann, Susanne. "The Logic of the Surface: On the Epistemology of Algorithms in Times of Big Data." Information, Communication & Society 23.14 (2020): 2096-2109. Krippendorff, Klaus. Content Analysis: An Introduction to Its Methodology. Sage, 2004. Noble, Safiya Umoja. Algorithms of Oppression. New York UP, 2018. O'Neil, Cathy. Weapons of Math Destruction: How Big Data Increases Inequality and Threatens Democracy. Crown, 2016. Pasquale, Frank. The Black Box Society. Harvard UP, 2015. Robertson, Ronald E., David Lazer, and Christo Wilson. "Auditing the Personalization and Composition of Politically-Related Search Engine Results Pages." Proceedings of the 2018 World Wide Web Conference. 2018. Staff, Sun. “A Look inside the Lives of Shooters Jerad Miller, Amanda Miller.” Las Vegas Sun 9 June 2014. <https://lasvegassun.com/news/2014/jun/09/look/>. Webb, Amy. The Big Nine: How the Tech Titans and Their Thinking Machines Could Warp Humanity. Hachette UK, 2019. Appendix Table 1: The subtitles of conspiracy theorists on Google autocomplete Conspiracy Theorist Google Autocomplete Subtitle Character Description Alex Jones American radio host InfoWars founder, American far-right radio show host and conspiracy theorist. The SPLC describes Alex Jones as "the most prolific conspiracy theorist in contemporary America." Barry Zwicker Canadian journalist Filmmaker who made a documentary that claimed fear was used to control the public after 9/11. Bart Sibrel American producer Writer, producer, and director of work to falsely claim the Apollo moon landings between 1969 and 1972 were staged by NASA. Ben Garrison American cartoonist Alt-right and QAnon political cartoonist Brittany Pettibone American writer Far-right, political vlogger on YouTube and propagator of #pizzagate. Cathy O’Brien American author Cathy O’Brien claims she was a victim of a government mind control project called Project Monarch. Dan Bongino American radio host Stakeholder in Parler, Radio Host, Ex-Spy, Conspiracist (Spygate, MAGA election fraud, etc.). David Icke Former footballer Reptilian humanoid conspiracist. David Wynn Miller (No subtitle) Conspiracist, far-right tax protester, and founder of the Sovereign Citizens Movement. Jack Posobiec American activist Alt-right, alt-lite political activist, conspiracy theorist, and Internet troll. Editor of Human Events Daily. James O’Keefe American activist Founder of Project Veritas, a far-right company that propagates disinformation and conspiracy theories. John Robison Foundational Illuminati conspiracist. Kevin Annett Canadian writer Former minister and writer, who wrote a book exposing the atrocities to Indigenous Communities, and now is a conspiracist and vlogger. Laura Loomer Author Far-right, anti-Muslim, conspiracy theorist, and Internet personality. Republican nominee in Florida's 21st congressional district in 2020. Marjorie Taylor Greene United States Representative Conspiracist, QAnon adherent, and U.S. representative for Georgia's 14th congressional district. Mark Dice American YouTuber Right-wing conservative pundit and conspiracy theorist. Mark Taylor (No subtitle) QAnon minister and self-proclaimed prophet of Donald Trump, the 45th U.S. President. Michael Chossudovsky Canadian economist Professor emeritus at the University of Ottawa, founder of the Centre for Research on Globalization, and conspiracist. Michael Cremo(Drutakarmā dāsa) American researcher Self-described Vedic creationist whose book, Forbidden Archeology, argues humans have lived on earth for millions of years. Mike Lindell CEO of My Pillow Business owner and conspiracist. Neil Patel English entrepreneur Founded The Daily Caller with Tucker Carlson. Nesta Helen Webster English author Foundational Illuminati conspiracist. Naomi Wolf American author Feminist turned conspiracist (ISIS, COVID-19, etc.). Owen Benjamin American comedian Former actor/comedian now conspiracist (Beartopia), who is banned from mainstream social media for using hate speech. Pamela Geller American activist Conspiracist, Anti-Islam, Blogger, Host. Paul Joseph Watson British YouTuber InfoWars co-host and host of the YouTube show PrisonPlanetLive. QAnon Shaman (Jake Angeli) American activist Conspiracy theorist who participated in the 2021 attack on Capitol Hil. Richard B. Spencer (No subtitle) American neo-Nazi, antisemitic conspiracy theorist, and white supremacist. Rick Wiles (No subtitle) Minister, Founded conspiracy site, TruNews. Robert W. Welch Jr. American businessman Founded the John Birch Society. Ronald Watkins (No subtitle) Founder of 8kun. Serge Monast Journalist Creator of Project Blue Beam conspiracy. Sidney Powell (No subtitle) One of former President Trump’s Lawyers, and renowned conspiracist regarding the 2020 Presidential election. Stanton T. Friedman Nuclear physicist Original civilian researcher of the 1947 Roswell UFO incident. Stefan Molyneux Canadian podcaster Irish-born, Canadian far-right white nationalist, podcaster, blogger, and banned YouTuber, who promotes conspiracy theories, scientific racism, eugenics, and racist views Tim LaHaye American author Founded the Council for National Policy, leader in the Moral Majority movement, and co-author of the Left Behind book series. Viva Frei (No subtitle) YouTuber/ Canadian Influencer, on the Far-Right and Covid conspiracy proponent. William Guy Carr Canadian author Illuminati/III World War Conspiracist Google searches conducted as of 9 October 2021.

Screens, as technological but also narrative and social devices, alter reading and writing practices. Users consume vids, read stories on the Web, and produce creative contents on blogs or Web archives, etc. Uses of seriality and transmediality are here discussed, that is watching, reading, and writing as interpreting, as well as respective and reciprocal uses of iteration and interaction (with technologies and with others). A specific figure of users or readers will be defined as a skilful and literate audience: fans on archives (FanFiction.net-FFNet, and Archive of Our Own-AO3). Fans produce serial and transmedia narratives based upon their favourite TV Shows, publish on-line, and often produce discourses or meta-discourse on this writing practice or on writing in general.The broader perspective of reception studies allows us to develop a three-step methodology that develops into a process. The first step is an ethnographic approach based on practices and competencies of users. The second step develops and clarifies the ethnographic dimension into an ethno-narrative approach, which aims at analysing mutual links between signs, texts, and uses of reading and writing. The main question is that of significance and meaning. The third step elaborates upon interactions in a technological and mediated environment. Social, participative, or collaborative and multimodal dimensions of interacting are yet regarded as key elements in reshaping a reading-writing cultural practice. The model proposed is a socio-narrative device, which hangs upon three dimensions: techno-narrative, narratological, and socio-narrative. These three dimensions of a shared narrative universe illustrate the three steps process. Each step also offers specific uses of interacting: an ethnographic approach of fictional expectation, a narrative ethnography of iteration and transformation, and a socio-narrative perspective on dialogism and recognition. A specific but significant example of fans' uses of reading and interacting will illustrate each step of the methodology. This qualitative approach of individual uses aims to be representative of fans' cultural practice (See Appendix 1). We will discuss cultural uses of appropriation. How do reading, interpreting, writing, and rewriting, that is to say interacting, produce meaning, create identities, and build up our relation to others and to the (story)world? Given our interest in embodied and appropriated meanings, appropriation will be revealed as an open cultural process, which can question the conflict and/or the convergence of the old and the new in cultural practices, and the way former and formal dichotomies have to be re-evaluated. We will take an interest in the composition of meaning that unfolds a cultural and critical process, from acknowledgement to recognition, a process where iteration and transformation are no longer opposites but part of a continuum.From Users' Competencies to the Composition of Narrative and Social Skills: A Fictional ExpectationThe pragmatic question of real uses steers our approach toward reading and writing in a mediated environment. Michel de Certeau's work first encourages us to apply his concepts of strategies and tactics to institutional strategies of engaging the audience and to real audience tactics of appropriation or diversion. Real uses are traceable on forums, discussions groups, weblogs, and archives. A model can be built upon digital tracks of use left on fan fiction archives: types of audience, interactions, and types of usage are here considered.Media Types Interaction Types Usage Types Media audienceConsumerSkilfulViewingReadingInformation searchContent production (informative, critical, and creative)Multimedia audienceConsumerSkilful+Online readingE-shoppingSharingRecommendationDiscussionInformative content productionCross-media audienceConsumerSkilful+SerendipityPutting objects in perspectiveNetworkingCritical content productionTransmedia audienceConsumerSkilfulInvolvedPrecursor+Understanding enhanced narrativesValue judgments, evaluationUnderstanding economic dimensions of the media systemCreative content productionTable 1 (Cailler and Masoni Lacroix)Users gear their reading and writing practices toward one medium, or toward multiple media in multi-, cross-, and trans- dimensions. These dimensions engage different and specific kinds of content production, and also the way users think about their relation to the media system. We focus on cumulative uses needed in an evolving media system. Depending on their desire for cultural products issued from creative and entertainment industries, audiences can be consumer-oriented or skilful, but also what we term "involved" or "precursor." Their interactive capacity within these industries allows audiences to produce informative, narrative, discursive, creative (or re-creative), and critical content. An ethnographic approach, based upon uses, understands that accumulating, crossing, and mastering different uses requires available and potential competencies and literacies, which may be immediately usable, or which have to be gained.Figure 1 (Masoni Lacroix and Cailler)The English language enables us to use different words to specify competencies, from ability to skill (when multiple abilities tend towards appropriation), to capability and competency (when multiple skills tend towards cultural practice). This introduces an enhancement process, which describes the way users accumulate and cross competencies to enhance their capability of understanding a multimedia or transmedia system, shaped by multiple semiotic systems and literacies.Abilities and skills represent different literacies that can be distributed in four groups-literacy, graphic literacy, digital literacy and interactive literacy, converging to a core of competencies including cognitive capability, communicative capability, cultural capability and critical capability. Note that critical skills appear below in bold italics. Digital LiteracyTechnical ability / Computational ability / Digital ability or skill Informational skill Visual LiteracyGraphic abilityVisual abilitySemiotic skillSymbolic skill Core of CompetenciesCognitive capabilityCommunicative capabilityCultural capabilityCritical capability Interactive LiteracyInteractional abilitySpectatorial abilityCollective abilityAffective skill LiteracyNarrative ability or skill / Linguistic ability / Reading and interpreting ability / Mimetic and fictional ability Discursive skillTable 2 (Masoni Lacroix and Cailler)Our first illustration exhibits the diversity, even the profuse and confused multiplicity, of cultural influences and preferences of a fan, which he or she comprehends as a whole.Gabihime, born on 6 October in Lafayette, Louisiana, in the United States, joined FFNet in 2001, and last updated her profile in September of 2010. She has written 44 stories for a variety of fandoms, and she belongs to two fandom communities. She has written one story about Twin Peaks (1990-) for an annual fandom gift exchange in 2008. Within Twin Peaks, her favourite and only romantic pair is Audrey Horne and Dale Cooper. Pairing represents a formal and cultural use of fan fiction writing, and also a favourite variation of the original text. Gabihime proposes notes to follow the story:I love Twin Peaks, and I love Audrey Horne particularly, and the rich stilted imagery of the show certainly […] I started watching my favourite season one episodes and reading the script notes for them. When I got to the 4-5 episode break (when Cooper comes back from visiting Jacques's cabin to the delightful sounds of the Icelandic junket roaring at their big shindig and finds Audrey in his bed) I discovered that this scene was originally intended to be left extremely ambiguous.Two main elements can be highlighted. Love founds fans' relation to the characters and the text. Interaction is based on this affect or emotion. Ambiguity, real or presumed, leads to what can be called a fictional expectation. This strong motive to interact within a text means that readers have to fill in the blanks of the text (Jenkins, "Transmedia"). They fill it with their desire for a character, a pairing, and a story. Another illustration of a fan's affective investment, Lynzee005 (see below) specifies that her fiction, "shows what I hope happened in between the scenes to which we were treated in the series."Gabihime does not write fan fiction stories anymore. She has a web site where she posts her stories and links to other fan art, vids, or fiction, as well as a blog where she writes her original fiction, and various meta-narrative and/or meta-discursive productions, including a wiki, Tumblr account, LiveJournal page, and Twitter account.A Narrative Ethnography of Fans' Production Content: Acculturation as Iteration and TransformationWe can briefly focus on another partial but significant example of narratives and discourses of a fan, in the perspective of a qualitative and iterative approach. We will then emphasise that narratives and discourses circulate, in other words that they are written and reformulated in and on different periods and platforms, but also that narratives use iteration and variation (Eco 1985).Lynzee005 was born in 1985 in Canada. She joined FFNet in 2008 and last updated her profile in September 2015. She has a beta profile, which means that she reads and reviews other fans' work-in-progress. We can also clarify that publishing chapter-by-chapter and being re-read on FFNet appears to be a principle of writing and of writing circulation. So, writing reveals an iterative and participative practice.Prior to this updating she wrote:When I read, I look for an emotional connection with the characters and I hope to be genuinely invested in where the story is going. […] I tackle everything in chunks, concentrating on the big issues (consistent characterization, believable plot lines, etc.) before moving down to the smaller ones (spelling, punctuation). Once I finish reading a "chunk," I put it together in the whole and see if it works against the other "chunks," and if not, then I go back and start over.She has written 17 stories for 7 different fandoms. She wrote five stories for Twin Peaks including a crossover with another fandom. She joined AO3 in December 2014 and completed her Twin Peaks trilogy. Her profile no longer underlines this serial process of chunking and dispersal, stressed by Jenkins ("Transmedia"), but only evokes how scenes can be stitched together. She now insists on the outcome of unity or continuity rather than on the process of serialization and fragmentation.Stories about fans, their affective and interpretive relations to a story universe and their uses of reading and writing in and out a fandom, can illustrate a diversity of attachments and interests. We can briefly describe a range of attachments. Attachment to the character, described above, can move towards self-narration, to the exhibit of self both as a person and a character, to a self-distancing, an identity affect. Attachment also has interpretative and critical dimensions. Attached to a narrative universe, attached to storytelling, fans promote a writing normalisation and a narrative format (genre, pairing, tagging, memes, etc.). Every fan seems to iterate and alter this conduct. This appropriation renews self-imposed narrative codes. The use of writing by fans, based on attachments, is both iterative and transformative. The Organization for Transformative Works (OTW), AO3's parent apparatus, asserts that derivative fans' work is transformative.According to Umberto Eco's vision of a postmodern aesthetics of seriality, "Something is offered as original and different […] this something is repeating something else that we already know; and […] just because of it we like it" (167). There is an "enjoyment of variations" (174). "Seriality and repetition are not opposed to innovation" (175). Eco claims a dialectic between repetition and innovation, that is to say a: "dialectic between order and novelty -in other words, between scheme and innovation," where "the variation is no longer more appreciable than the scheme" (173). We acknowledge the "inseparable knot of scheme-variation" he is stressing (Eco 180), and we intend to put narrative fragmentation and narration dispersal forward to their reconstruction in a narrative universe as a whole, within the socio-narrative device. The knot illustrates the dialogical principle of exceeding dichotomies that will be discussed hereunder.The plurality of uses and media calls for an accumulation of competencies, which engage users in the process of media acculturation. A "literate" or skilful user should be able to comprehend "the flow of content across multiple media platforms," the media industries' cooperation, "the migratory behavior of media audiences," and the "technological, industrial, cultural, and social changes" that the word convergence manages to describe (Jenkins, Convergence, 3).Acculturation conveys an appropriation process, borrowed from "French" sociology of uses. Audiences become gradually intimate with the context of the evolving media environment. Scholars progressively understand how audiences are familiarizing themselves with competencies until they master literacies, where competencies are gathered. Users become sensitive, as well as mindful of time and space in literacy (Literacy), and of how writing can be spatialised (Graphic Literacy), of how the media space is technologized (Digital Literacy), and of what kind of structural interactions are emerging (Interactive Literacy).Thus, the research question takes shape: "What kind of interactions can users establish with objects that are both technical and cultural?" Which also means: "In a study of effective uses, can the researcher find appropriation logics or tactics in the way users, specifically here readers and writers, improve their cultural practices?" As Davallon and Le Marec furthered it, uses have to be included in a process of cultural growth. Users can cross technical and cultural dimensions of an object in two main ways: They can compare the object with other cultural products they are used to, or they can grasp its novelty when engaging a cognitive and cultural capability of adaptation. Acknowledgment and adaption are part of the social process of cultural growth. In this sense, use can be an integrated activity or a novel one.The model of cultural growth means that different and dispersed uses are progressively entering a meaning-making process. The question of meaning holds together, even unifies, multiple uses of reading and writing in a cultural practice of reading-writing. With this in mind, the core of competencies described above accurately displays the importance of critical skills (semiotic, informational, affective, symbolic, narrative, and discursive) nourishing a critical capability. Critically literate, users are able to question the place to which they have been attributed and the place they can gain, in an evolving (and even uncertain) media system. They can elaborate a critical reflection on their own practices of reading and writing.Two Principles of a Socio-Narrative Device: Dialogism and RecognitionUses of reading and writing online invite us to visualize and think through the convergence of a narrative object (technical, visual, and cultural), its medium and format(s), and the audiences involved. Here, multimodality has to be (re)considered. This is not only a question of different modes but a question of multiplicity in reading and writing uses, that leads us to the way a fan attachment creates his or her participation in the meaning of the text, and more generally leads us to the polyphonic form of writing questions. Dispersed uses converging into a cultural and social practice bring to light dialogical dimensions of writing, in the sense pointed out by Bakhtin in the early 1930s. Dialogism expands the notion of intertextuality to a social practice; enunciation appears polyphonic, and speakers are interacting. Every discourse is oriented to other discourses, interacting and responding to pre-existing discourses addressing the same object. Discourse is always others' discourse and shows a multiple and inter-relational subject.A fan producing meta-narratives or meta-discourses on media and fan fiction is an inter-relational subject. By way of illustration, Slaymesoftly, displays her stories on AO3, on her own Web site, and on specialized archives. She does not justify fan fiction writing through warnings or disclaimers but defines broadly what fiction is and how she uses fiction in her stories. She analyses publishing, describes her universe and the alternative universes that she explores, and depicts how stories become a series. Slaymesoftly can be considered a literate fan, approaching writing with emotion or attachment and critical rationality, or more precisely, leading her attachment to writing with the distance that critical thought allows. She writes "Essays -about writing, vampires, and whatever else I decide to blather on about" on her Web site or on her LiveJournal, where she also joined a community. In the main, Slaymesoftly experiences multiple variations, in the sense of Eco, variations that oppose and tie a character to a canon, or a loving writing object to what could be newly told. Slaymesoftly also exposes the desire for recognition engaged by fans' uses of interaction. This process of mutual recognition, stated in Hegel's Phenomenology of Spirit highlights and questions fans' attachment, individual identity, and normative foundation. Mutual recognition could strengthen communitarianism or conformism in writing, but it can also offer a way for attachments to be shared, a way to initiate a narrative, and a social practice of dialog.Dialogical dimensions of cultural practices of reading-writing (both in production and reception) design a fragmented narrative universe, unfinished but one, that can be comprehend in a socio-narrative device.Figure 2 (Masoni Lacroix & Cailler)Texts, authors, writers, and readers are not opposed but are part of a socio-narrative continuity. This device crosses three complementary and evolving dimensions of the narrative universe: techno-narrative, socio-narrative (playful, creative, and critical, in their interactivity), and narratological. Uses of literacy generating multimedia, cross-media, and transmedia productions also question the multimodal form of writing and invite us to an iterative, open, dialogical, and interrogative practice of multimodality. A (post)narratological activity opens up to an interrogative practice. This practice dialogs with others' discourse and narrative. The questioning complexity remains open. In a proximate meaning, a transmedia narrative is fragmented, open to incompletion, but enrolled in a continuum (Jenkins, "Transmedia").Looking back, through the overtaken dichotomy between production and reception, a social and narrative process has been described that leads to the reshaping of multiple uses of literacies into cultural practices, and further on, to a cultural and social practice of reading-writing blended into interactivity. Competencies, dictated uses of reading and writing and alterna(rra)tive upsurges (as fans' production content) can be questioned. What can be questioned is either the fragmentation, the incompletion, and the continuity of narratives, that Jenkins no longer brings into conflict ("Transmedia"). This is also what the social and narrative form of dialogism teaches us: dichotomies, as a tool or a structure of thought, appear suspect or no longer significant. There is continuity in the acculturation process, from acknowledgement to recognition, continuity in the multiple uses of interacting, continuity from narrative to discourse, continuity from emotion to writing critically, a transformative continuity in iteration and variation, a polyphonic continuity.ReferencesBakhtin, Michaïl, and V.N. Volosinov. Marxism and the Philosophy of Language. Cambridge: Harvard UP, 1973.Cailler, Bruno, and Céline Masoni Lacroix. "El 'French Touch' Transmediatico: Un Inventario." Transmediación: Espacios, Reflexiones y Experiencias. Eds. Denis Porto Renó et al. Bogotá, Colombia: Editorial Universidad del Rosario, 2012. 181-98.Davallon, Jean, and Joëlle Le Marec. "L'Usage en son Contexte. Sur les Usages des Interactifs des Céderons des Musées." Réseaux 101 (2000): 173-95.De Certeau, Michel. L'Invention du Quotidien. Paris: Folio Essais, 1990.Eco, Umberto. "Innovation and Repetition: Between Modern and Postmodern Aesthetics." Daedalus 114 (1985): 161-84.Hegel, G.W.F. Phénoménologie de l'Esprit. Trans. Bernard Bourgeois. Paris: Vrin, 2006.Jenkins, Henry. Convergence Culture. Where Old and New Media Collide. New York UP, 2006.———. "Transmedia 202: Further Reflections." 2011. <http://henryjenkins.org/2011/08/defining_transmedia_further_re.html>.Masoni Lacroix, Céline. "Mise en Récit des Fictions de Fans de Séries Télévisées: Variations, Granularité et Réflexivité." Tension narrative et Storytelling. Eds. Nicolas Pélissier and Marc Marti. Paris: L'harmattan, 2014. 83-100.———. "Narrativités 2.0: Fragmentation-Organisation d'un Métadiscours." Cahiers de Narratologie 32 (2017). <http://journals.openedition.org/narratologie/7781>.———, and Bruno Cailler. "Fans versus Universitaires, l'Hypothèse Dialogique de la Transmédialité au sein d'un Dispositif Socio-narratif." Revue française des sciences de l'information et de la communication 7 (2015). <http://journals.openedition.org/rfsic/1662>.———, and Bruno Cailler. "Principes Co-extensifs de la Fiction Sérielle, de la Distribution Diffusée à une Pratique Interprétative Dialogique: une Nouvelle Donne Socio-narrative?" Cahiers de Narratologie 31 (2016). <http://narratologie.revues.org/7576>. TV Show Fandoms ExploredBuffy The Vampire Slayer (Joss Whedon).Sherlock (Mark Gatiss & Steven Moffat).Twin Peaks (Mark Frost & David Lynch).Wallander (from Henning Mankell to Philip Martin).

Photo ID 131102170 © Geckophotos | Dreamstime.com INTRODUCTION Medical tourism should contribute to developing a more robust healthcare system that acts in the best interests of patients and ensures equal access to healthcare. This paper examines medical tourism in Colombia and argues that developing a system that aligns with bioethical principles is necessary. People traveling for care should have access to the Ministry of Health rather than only the Ministry of Industry and Tourism, emphasizing their purpose as patients seeking medical procedures or treatments rather than tourists engaging in leisure activities. Additionally, in the interest of justice, Colombian patients should benefit from the revenue derived from medical tourism. It is crucial to recognize that both patients traveling for care and people in the destination country can derive benefits from medical tourism. The Colombian government can protect the rights and well-being of patients seeking care and ensure that any benefits are distributed fairly among Colombian citizens. I. Background Medical tourism refers to people traveling to foreign countries to obtain health care.[1] Many individuals from high-income countries seek health care in less developed countries to take advantage of the lower costs. Destination countries are increasingly showing interest in becoming medical tourism hubs due to the significant financial potential of this multi-billion dollar industry. The global medical tourism market is projected to reach $207.9 billion by 2027.[2] This growth not only generates income but also creates employment opportunities and business prospects for local residents in sectors such as tourism, pharmaceuticals, and infrastructure. By establishing themselves as medical tourism destinations, countries can stimulate economic development and enhance their healthcare structure. Colombia is among the fastest-growing medical tourism destinations in the world. It has become a popular destination for medical tourists due to its advanced healthcare infrastructure, biotechnology, and highly skilled physicians who cater to international patients at affordable prices.[3] The healthcare entities in Colombia offer a wide range of medical procedures, including cardiovascular, bariatric, orthopedics, cosmetic surgery, dental care, and fertility treatments. [4] The Colombian government has actively promoted medical tourism to position the country as a destination for world-class medical services.[5] Through strategic economic policies, effective regulation, and digital marketing, medical tourism has emerged as a significant contributor to Colombia’s income. The Colombian Ministry of Industry and Tourism, which regulates medical tourism in Colombia, forecasts at least 2.8 million health tourists and a revenue of at least $6.3 billion by 2032.[6] Colombia intends to have medical tourism play a significant role in its economy. However, ethical issues exist. The Colombia Ministry of Industry and Tourism is more involved in medical tourism than the Ministry of Health is. Additionally, the government has not been held accountable for the shortcomings in the medical tourism industry. There should be an organization advocating for the rights and well-being of medical tourists. Furthermore, using public funds to attract international patients may divert funds from local communities. Last, the negative impacts of medical tourism on Colombian patients deserve attention. This paper aims to explore these ethical issues from two perspectives: that of medical tourists and that of Colombian citizens. I argue that the benefits of medical tourism outweigh the harms but that those traveling for health care deserve protection. II. Patients: Are They International Patients or Tourists? When medical tourists seek hospitals and physicians in a destination country, facilitators may direct them to non-licensed practitioners and questionable facilities. These facilitators, who receive commissions, may not act in the patient’s best interest. Rather, like travel agents, they base their referrals on the referral fees that hospitals or physicians pay.[7] International patients risk getting lower-quality health care from unregulated hospitals or providers. This can interfere with informed consent and increase the risk of infections. There may be an absence of medical malpractice coverage from physicians. Unregulated or unlicensed medical care may even lead to patient fatalities. Therefore, it is crucial for international patients to carefully evaluate the risks associated with “booking” their healthcare options. To mitigate these risks, it is important for international patients to thoroughly assess the accreditation status of the hospital or clinic they plan to visit. The Joint Commission International (JCI) accreditation can provide patients with an external quality assessment and assist them in making an informed decision.[8] International patients should proactively seek out certified and reputable healthcare providers and institutions to ensure both their safety and a high quality of care. Colombia has five hospitals and clinics with JCI accreditation.[9] Colombia is the third most-used destination for plastic surgery in the world; the first is Brazil, and the second is Turkey. In Colombia, one out of every three plastic surgery patients is an international patient.[10] The Colombian Association for Plastic Surgery advises all patients to check the hospital's accreditation. Patients should check the website of the local Secretary of Health in each city and see if the physician conducting the plastic surgery is listed.[11] Institutions and doctors must fully comply with requirements, including describing the procedure and obtaining informed consent from patients. It is very common to read in the media plastic surgeries conducted in what is known in Latin America as “clinicas de garage” (garage clinics) with negative results and deaths.[12] Official data covers plastic surgeries conducted at accredited institutions with registered doctors. There is a lack of data on garage clinics. There are a few things the government can do to make medical tourism safer. First, the Ministry of Health’s website should maintain a list of healthcare providers with JCI accreditation. In each city, the local Secretary of Health is responsible for providing patients with information about the quality of care of the hospitals in its region. Second, the government should take responsibility for providing accurate and comprehensive information to international patients, enabling them to make fully informed decisions regarding their medical procedures. In the context of informed consent, patients may have trouble understanding due to language barriers, terminology, and the complexity of the risks involved in medical procedures. Lastly, Congress should enact a legal framework that determines the responsibility of all parties involved in medical tourism.[13] In the unfortunate event that a medical tourist requires intensive care, it becomes imperative to determine who will bear the responsibility for their well-being and any potential financial implications. Medical tourists are not protected from errors and failures of medical procedures because the Colombia Constitution specifies that the healthcare system exclusively caters to its citizens, while coverage for foreigners is limited to emergencies only. The US State Department recommends that those traveling to Colombia have international health insurance.[14] International patients can sue doctors in Colombia for medical malpractice, referred to as medical liability.[15] The government should take responsibility for certifying medical institutions and issuing medical visas with specific requirements and regulations specific to medical tourism.[16] A new medical visa system is in place. Changing the terminology may help the government see those traveling for care as medical patients rather than medical tourists. That may lead to a different mindset and spur the government to protect them and ensure high-quality care. It may also help those traveling avoid tourism industry facilitators and find reputable surgeons and hospitals. III. Are Colombian Patients and the Local Healthcare System Benefiting from Medical Tourism? The main reason for the growth of medical tourism from developed countries to developing countries like Colombia is the excessive cost of treatment in wealthier nations.[17] Other reasons include the long queues for certain types of medical services in the home country, the availability of better technologies abroad, inadequate (or absence of) health insurance, and the unavailability[18] (or prohibition) of certain medical services in the home country.[19] The Colombian Constitution recognizes health as a fundamental right for all citizens.[20] Pursuant to the Constitution’s health mandate, Colombia designed a mandatory universal social health insurance system in 1993. It aims to achieve a fair distribution of resources, opportunities, and services while holding the government accountable.[21] Before 1993, less than 25 percent of the population had coverage; now, between 94 and 99 percent have it, regardless of income level or employment.[22] However, universal care does not entitle Colombian citizens to many of the modern surgical centers, technology, and doctors that tourists access. Local wealthy Colombian citizens tend to purchase private insurance that allows them many more healthcare options.[23] The OECD reports that only 41 percent of Colombian citizens were satisfied with the availability of the quality of care, while the OECD average is 67 percent. According to the OECD, the out-of-pocket health expenditure in Colombia is 14 percent, which is lower than the OECD average of 18 percent. Despite its recognized right to health care, the current system is not providing the quality of care that the people would prefer. Those traveling to Colombia for care are not covered by universal social health insurance and must pay for their health care[24] out of pocket or through their private insurers using international coverage.[25] Like local supplemental private insurance, medical tourists and their insurance plans tend to pay more for their care than the rate that the universal system would pay the providers for care provided to the general Colombian population. This situation often leads to higher revenue from medical tourists than local patients unless the local patients have supplemental private insurance. The mismatched payment schemes leave the local population with unequal access to healthcare resources[26] since healthcare providers prefer to cater to patients paying more than the government-subsidized insurance pays. Medical tourism “threatens to result in a dual market structure”[27] characterized by a higher-quality, expensive segment that serves wealthy nationals and foreigners alongside a lower-quality segment that caters to the poor, most of whom are covered by universal healthcare coverage.[28] Medical tourists should pay taxes or a special premium to improve the local healthcare system. While the medical tourism industry arguably generates tax revenue,[29] some additional money should flow from the medical tourists to the healthcare outlets that the local people use. Then, the country can benefit even more from promoting medical tourism while ensuring that the government and the healthcare system follow the principles of justice, beneficence, and public welfare.[30] In Colombia, Fundación Cardioinfantil, a private non-profit hospital known as “La Cardio,” is a good example of a regional leader committed to providing clinical excellence to both national and international patients.[31] About 20 years ago, La Cardio, well known for its cardiovascular health care, aimed to become the top hospital in the region (Latin America and the Caribbean) to obtain financial resources for improving its facilities. It became the first hospital in Colombia to achieve the JCI accreditation, attracting patients from countries with inadequate cardiovascular healthcare systems.[32] Foreign governments covered their citizens’ medical expenses, allowing La Cardio to fund system improvement. Currently ranked as the fifth-best clinic in Latin America and having won the Gold Award for Corporate Social Responsibility, La Cardio has received recognition for its dedication to serving economically disadvantaged Colombian patients.[33] This example demonstrates how introducing a high-paying market has not led to neglecting local patients, as resources from medical tourists are used to enhance the healthcare system for the local population. CONCLUSION The Colombian government needs to recognize that international patients are seeking medical services, not tourism or vacation experiences. Therefore, a new policy should categorize international patients separately from the tourism sector and treat them purely as patients. The introduction of medical visas may help this. Once establishing international patients are patients and not tourists, the Colombian government could impose taxes on them and allocate the funds generated to reinvest in the healthcare needs of its citizens, ensuring justice and promoting awareness of the ethical rights of international patients. At the same time, home country governments directing patients to a destination country should conduct thorough due diligence of the ethical principles applied to international patients as well as the accreditation of the destination country’s hospitals. Colombia may be aware of the implications of the difference in terms but unwilling to modify the language due to the associated costs, liabilities, and risks involved. - [1] Gaines, J., Lee, C. V. (2019). Medical tourism. Travel Medicine, 371–375. https://doi.org/10.1016/b978-0-323-54696-6.00039-2 https://www.sciencedirect.com/science/article/pii/B9780323546966000392 [2] Forecasted Evolution of Medical Travels, 2023-2027: A Segmental View. ReportLinker. (2023, December). https://www.reportlinker.com/p06473784/Medical-Tourism-Market-Size-Share-Trends-and-Analysis-by-Region-Service-Provider-and-Segment-Forecast.html [3] Forecasted Evolution of Medical Travels, 2023-2027: A Segmental View. ReportLinker. (2023, December). [4] Arias-Aragonés, F.J.A., Payares, A.M.C., & Jiménez, O.J. (2020). Characterization of the healthcare tourism in the city of Bogotá and the District of Cartagena. Clío América, 14 (28), 486-492. https://doi.org/10.21676/23897848.3941 [5] Arias-Aragonés, et al. (2020). [6] Arias- Aragones, et al. (2020). https://www.colombiaproductiva.com/ptp-sectores/historico/turismo-salud (citing the Colombian Production Transformation Program (PTP)) [7] Glenn Cohen, Patients with Passports Medical Tourism, Law, and Ethics. New York Oxford University Press, 2015, p. 25 [8] Glenn, Cohen. (2015), p. 23-24. [9] A Global Leader for Health Care Quality and Patient Safety. Joint Commission International. https://www.jointcommissioninternational.org/ (The five Colombian hospitals and clinics with JCI accreditation are two hospitals in the capital city Bogota (la Cardio and Fundación Hospital Universitario Santa Fé de Bogotá), one hospital in Cali (Clinica Inbanaco), one hospital in Medellín (Hospital Pablo Tobón), and one clinic in Florida Blanca (Fundación Cardiovascular de Colombia). Nearby countries such as Venezuela and Trinidad Tobago do not have any accredited hospitals or clinics. Ecuador and Panamá have one each, Perú has eleven, and Brazil has seventy-one.) [10] International Society of Aesthetic Plastic Surgery ISAPS (2023), ISAPS International Survey on Aesthetic/Cosmetic Procedures performed in 2022, p. 52. https://www.isaps.org/discover/about-isaps/global-statistics/reports-and-press-releases/global-survey-2022-full-report-and-press-releases/ (most frequently cited countries of foreign patients in Colombia are the US, Spain, and Panama.) [11] Why choose a member of the SCCP. (2023). Colombia Plastic Surgery Association (SCCP). https://cirugiaplastica.org.co/porque-elegir-un-miembro-de-la-sccp/ See also: To Find a Surgeon. (2023). Colombia Plastic Surgery Association (SCCP). https://cirugiaplastica.org.co (This website is helpful for checking the list of members of the SCCP.) [12] Cosmetic Surgeries Performed in Garage Offices can Become a Public Health Problem. Concejo de Bogotá D.C. (2022). https://concejodebogota.gov.co/cirugias-esteticas-practicadas-en-consultorios-de-garaje-se-pueden/cbogota/2015-07-17/100100.php (There are many cases of deaths resulting from illegal plastic surgeries. The local government in Bogota is aware of the deaths, as reported in the Bogota Counsel (2015)). See also Travel.State.Gov, US Department of State, Bureau of Consular Affairs. (August 17, 2023). https://travel.state.gov/content/travel/en/international-travel/International-Travel-Country-Information-Pages/Colombia.html (There is a warning that says: “Although Colombia has many elective/cosmetic surgery facilities that are on par with those found in the United States, the quality of care varies widely. If you plan to undergo surgery in Colombia, carefully research the doctor and recovery facility you plan to use. Make sure that emergency medical facilities are available, and that professionals are accredited and qualified. Share all health information (e.g., medical conditions, medications, allergies) with your doctor before surgery.") [13] Arias-Aragonés, F.J.A., Payares, A.M.C., & Jiménez, O.J. (2020), p. 490. (report “the absence of regulation and a legal framework that determines the responsibilities of each link in the production chain” as a difficulty that affects competitivity to become a leader in medical tourism in the Latin American region.) See also: Trujillo, M. A. (2023, November 24). Colombia’s New Bill on Regulating Cosmetic Surgeries. BNN Breaking. https://bnn.network/breaking-news/health/colombia-to-regulate-cosmetic-surgeries-a-step-towards-patient-safety/ (On November 22, 2023, as a response to rising cases of death and injuries associated with plastic surgeries, a bill was introduced in the Colombian House of Representatives to regulate the practice of cosmetic surgeries and protect the integrity of patients) [14] U.S. Department of State, Travel.State.Gov, Colombia. (August 17, 2023). Traveler’s Checklist, https://travel.state.gov/content/travel/en/international-travel/International-Travel-Country-Information-Pages/Colombia.html [15] U.S. Department of State, Travel.State.Gov, Colombia. (August 17, 2023). Traveler’s Checklist. See also: Medical Tourism and Elective Surgery. The Department of State informs that “U.S. citizens have suffered serious complications or died during or after having cosmetic surgery or other elective surgery“ and “the legal options in cases of malpractice are very limited in Colombia,” https://travel.state.gov/content/travel/en/international-travel/International-Travel-Country-Information-Pages/Colombia.html See also: The law firm Alvarez Gonzalez Tolosa Attorneys. (August 8, 2023). Medical Malpractice in Colombia, includes medical malpractice as one of the areas of expertise of the firm. https://www.agtattorneys.com/blog/medical-malpractice-in-colombia/ [16] Colombia recently enacted a new visa regulation (Resolution 5477 from July 22, 2022, issued by the Ministry of Foreign Affairs) effective as of October 22, 2022. No data currently exists about a "medical treatment" visa because it is a new legislation. Even though the regulation refers to the visitor as a patient and includes requirements such as (1) a letter from the medical institution explaining the treatment and approximate duration, (2) a letter explaining costs and who will pay for the treatment, (3) insurance policy, and (4) the general requirements for tourists, the regulation specifically explains that this kind of visa is considered as a TOURISM visa (art 37). [17] Glenn, Cohen. 2015 [18] Frequently Asked Questions. Bioxcellerator. https://www.bioxcellerator.com/faqs (For example, Bioxellerator stem cell therapies conducted in Medellin, Colombia, are not FDA-approved.) [19] Vovk, Viktoriia, Lyudmila Beztelesna, and Olha Pliashko. (2021). "Identification of Factors for the Development of Medical Tourism in the World" International Journal of Environmental Research and Public Health 18, no. 21: 11205. https://doi.org/10.3390/ijerph182111205 [20] Colombian Constitution. (1991). art. 49 [21] Ministry of Health and Protection. Columbia Ministry of Health. (2023). https://www.minsalud.gov.co/English/Paginas/Ministry.aspx [22] “Does Colombia’s Health System Need an Overhaul?” (March 2, 2023). The Dialogue, Latin America Advisor. https://www.thedialogue.org/analysis/does-colombias-health-system-need-an-overhaul/ [23] Health at a Glance 2021 Colombia Country Note. OECD. (2023). https://search.oecd.org/colombia/health-at-a-glance-Colombia-EN.pdf [24] Travel.State.Gov, US Department of State, Bureau of Consular Affairs. https://travel.state.gov/content/travel/en/international-travel/International-Travel-Country-Information-Pages/Colombia.html [25] Glenn, Cohen. (2015). p. 2-9. [26] Banco de la República. (2023). Regional Health Inequalities in Colombia. https://www.banrep.gov.co/en/regional-health-inequalities-colombia (The Central Bank of Colombia (“Banco de la República”) in reports that despite having relatively high health coverage compared with other countries, empirical results show persistent inequalities in the healthcare system. The aim is to reduce and eventually eliminate such inequalities.) [27] Glenn, Cohen (2015), p. 158-160, citing Rupa Chanda, an Indian business professor, Trade in Health Services, 80 Bull. World Health Org. 158, 160 (2002). [28] Banco de la República. (2023). Regional Health Inequalities in Columbia. https://investiga.banrep.gov.co/es/be-1233. (Under Colombian law, it is mandatory for all employees and employers to pay 4 percent and 8 percent of the applicable salary, respectively, to the universal healthcare system (EPS) to obtain coverage for the employee and family members. This is known as the contributive system, and the funding is known as parafiscal. The unemployed obtain coverage through the government-subsidized system known as SISBEN (System of Identification of Beneficiaries of Social programs), funded with taxpayers’ money, known as fiscal funding. According to the Central Bank of Colombia (Banco de la República), “in recent years, the healthcare sector has faced financial and administrative problems that have increased the need for fiscal resources for its financing and that could affect its sustainability. Regarding the composition of the outflow, it is worth noting the cost of ensuring the contributory and subsidized regime, which on average explains 80 percent of the total system expenses during the period 2011-2022.” “Additionally, pressures derived from the Covid-19 pandemic, Venezuelan migration” and expenses derived from the increase in the subsidized system due to the high rate of unemployment and informal employment are negatively impacting financing of the healthcare system in Colombia. Additional fiscal resources are needed because the health care Colombians receive costs more than what beneficiaries pay.) [29] Statista. (2023). Revenue of the medical tourism sector in Colombia from 2019 to 2024 https://www.statista.com/statistics/1156551/colombia-revenue-medical-tourism/ [30] Glenn, Cohen. (2015), p.218 (The beneficence principle is the general moral obligation to act for the benefit of others, and some of those acts are obligatory, as is the government’s obligation concerning healthcare.) [31] Hospital Cardioinfantil Bogotá, Colombia. https://cardioinfantil.org [32] Hospital Cardioinfantil https://cardioinfantil.org (Trinidad and Tobago, Aruba, Curacao, and Panamá were the first countries with international agreements with La Cardio.) [33] Hospital Cardioinfantil Bogotá, Colombia. https://www.lacardio.org/historia/