Artykuły w czasopismach na temat „Michigan Equal Suffrage Association”

AbstractThis paper explores the movement of the New York City Interborough Association of Women Teachers (IAWT) for “equal pay for equal work” in teaching salaries, which it won in 1911. The IAWT’s success sheds light on the possibilities and limits of women teachers advocating for change within a feminized profession. Leading the movement were of a group of women teachers, organizing before woman’s suffrage and in an era of sex-differentiated work and pay, who convinced the city’s public and state’s legislators that they deserved pay equal to what men teachers received. They did so by strategic maneuvering in city and state politics and making equal pay look reasonable. And they did so by narrowly defining their goals and leaning on their identities as women to push a theoretically sex-neutral claim of justice. Their success, though limited, was nonetheless a victory in shifting ideas about women’s societal and professional status in New York City and the state.

This study examined the history of band tournaments governed by the Michigan State Band Association (MSBA), beginning with the first competition in 1877 and ending with the disbandment of the Association and tournaments in 1884. The research focused specifically on the (a) organization, rules, and procedures of the tournaments; (b) details surrounding the individual competitions held throughout the state; and (c) influence of the tournaments on local culture, participating ensembles, and future band activities in Michigan. The first Michigan State Band Tournament met in Port Huron in June 1877. Festivities included parades, massed performances, and competitions for prizes consisting of silver cups, cash, and new instruments. To ensure equal opportunity among the ensembles, bands were divided into classifications based at first on size and instrumentation and then on ability. Officials added a solo cornet contest in 1878 and expanded this event to other instruments the following year. In 1879, bandmasters met at Lansing to organize the MSBA to standardize rules, select the location of the annual competition, and ensure fairness among participants. The Association and tournaments ended six years later, probably because of the failure of the competitions to generate a profit for the sponsors.

Introduction: the diabetic foot is one of the most serious complications of diabetes mellitus. About 50% of non-traumatic amputations occur in these patients. In addition, it is an important public health problem and constitutes a chronic and complex metabolic disorder that is characterized by impaired metabolism of glucose and other complications in essential organs for the maintenance of life. Objective: to evaluate the sensitivity and specificity of diabetic neuropathy using the Michigan self-assessment and physical examination in type 1 and type 2 diabetics. Methods: this is a cross-sectional study. The “Michigan Neuropathy Screening Instruments” classification was used to assess the degree of peripheral neuropathy, in which participants answered the questionnaire and were evaluated for the presence of foot lesions. All participants were stratified by the risk of developing foot ulcers according to the IWGDF protocol. Results: the sample had 200 participants. Regarding the IWGDF classification, 23 patients were classified as moderate risk (11.50%) and 61 as high risk for developing foot ulcers (30.50%). Using a cutoff of 2.5 on the physical examination score to diagnose neuropathy, a sensitivity of 97.62% and a specificity of 47.41% were obtained. Using a score greater than or equal to 6 in the self-assessment for the diagnosis of neuropathy, a sensitivity of 50.00% and a specificity of 94.83% were found. Conclusion: the association of the Michigan physical examination (high sensitivity) with self-assessment (high specificity) increases the accuracy for the diagnosis of diabetic neuropathy.

Background: Chronic complications of diabetes mellitus have a significant role in increased morbidity, mortality, disability, and health cost as the population increases every year. Promotive and preventive actions are needed to decrease the prevalence of peripheral diabetic neuropathy. The screening tool for peripheral diabetic neuropathy is Michigan Neuropathy Screening Instrument (MNSI), which consists questionnaire and physical examination. Objective: The purpose of this study was to understand the association of the duration of type 2 diabetes mellitus with the prevalence of peripheral diabetic neuropathy in the Outpatient Unit of Gotong Royong Hospital Surabaya. Method: A cross-sectional study was done using 50 patients in the Outpatient Unit of Gotong Royong Hospital Surabaya. The sampling technique used consecutive sampling with filling out the Michigan Neuropathy Screening Instrument (MNSI) questionnaire. The score of the MNSI questionnaire is analyzed using Chi-Square Test. Result: Among 50 subjects who participated in the study, most were women (78%). The prevalence of patients with peripheral diabetic neuropathy was 28% from all subjects. This chronic complication is divided into two groups based on the duration of diabetes mellitus type 2 with the prevalence of peripheral diabetic neuropathy with a duration of diabetes <5 years (18,2%) and peripheral diabetic neuropathy with the duration of diabetes more than equal to five years old (35,7%). From the analysis with Chi-Square, we did not find a significant association between the duration of type 2 diabetes mellitus and peripheral diabetic neuropathy (p = 0.004). Conclusion: There was no statistically significant association between the duration of type 2 diabetes mellitus and the prevalence of peripheral diabetic neuropathy.

Abstract Michigan has a long history of adverse environmental exposures, many of which are still ongoing, like the Flint water crisis, extreme air pollution burden, and widespread PFAS exposure. Michigan is also home to a diverse population of Latinx, Black, White, and Middle Eastern/North African (MENA) Americans. Because minority populations are underrepresented in environment and cancer research despite being at greater risk of being exposed to environmental hazards and having worse cancer outcomes, Michigan is uniquely positioned for studying the associations between environmental exposures and cancer risk. In June 2022, the Michigan Cancer and Research on the Environment Study (MI-CARES) began recruitment with a goal of establishing a cohort of over 100,000 Michiganders to examine these associations. Any Michigander aged 18-49 is eligible to enroll in MI-CARES. By focusing on this age range, we will capture exposures during important windows of susceptibility prior to the onset of most cancers.While recruitment is open to all state-wide, efforts are focused on six environmental injustice hotspots, identified using the MiEJScreen tool, a relative summary score capturing pollution burden and population vulnerability: the metro areas of Kalamazoo, Grand Rapids, Flint, Lansing, Detroit, and Bay City-Saginaw.MI-CARES will enroll equal numbers of Black, Latinx, MENA, and White participants. To support participation in diverse communities, study materials are available in Arabic, English, and Spanish. MI-CARES has employed a multifaceted community engagement strategy and is recruiting from these communities directly and with the help of community partners. An incentive of $10 is also provided to participants who successfully complete the questionnaire.To democratize participation, MI-CARES enrollment can be completely remote, but in-person and paper-based enrollment is available. Enrollment includes a baseline questionnaire, consent for data linkage, and annual follow-up surveys. Participants are also asked to provide saliva and blood spot samples via a mailed at-home biospecimen collection kit. Biospecimens will be analyzed for environmental exposures like heavy metals and for intermediate cancer markers including inflammation, cellular aging, immune function, and altered metabolism. Participant data will be linked to neighborhood-level exposure databases, administrative databases like cancer registries and death indices, and to the Michigan Neonatal Biobank. More than 4,000 Michiganders have enrolled in MI-CARES. Data on initial cohort members including environmental exposure history and demographic characteristics will be presented. MI-CARES is part of the Cohorts for Environmental Exposures and Cancer Risk (CEECR) consortium, which is funded by the National Cancer Institute and the National Institute for Environmental Health Sciences. Citation Format: Lilah Khoja, Maxwell Salvatore, Minh Tung Phung, Isabella De Sa, Heatherlun Uphold, Justin Colacino, Alison M. Mondul, Bhramar Mukherjee, Dana Dolinoy, Celeste Leigh Pearce. Michigan cancer and research on the environment study (MI-CARES) cohort: Baseline methods and participant characteristics [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 830.

BackgroundNeuroticism has been consistently correlated with the post-traumatic stress disorder (PTSD) response to traumatic events. Interpretation of these findings is limited by the retrospective nature of these findings: neuroticism was measured after the trauma had occurred. The prospective association of neuroticism with PTSD has not been examined (the relationship of neuroticism with PTSD symptoms was examined in a few prospective studies). We evaluate prospectively the relationship of neuroticism, measured at baseline, with the cumulative occurrence of PTSD during the subsequent 10 years, using data from a longitudinal epidemiological study of young adults.MethodA sample of 1007 young adults randomly selected from the membership of a large health maintenance organization in southeast Michigan was assessed at baseline and followed up at 3, 5 and 10 years later. We conducted a series of multinomial logistic regressions to estimate the relative risk (RR) of exposure to trauma and PTSD by neuroticism at baseline, adjusting for history of major depression (n = 990).ResultsDuring the 10-year follow-up, 50.2% of the sample experienced traumatic events and 5.2% developed PTSD. Neuroticism score at baseline increased significantly the RR of PTSD response to trauma. Additional analysis revealed that, among persons with history of major depression at baseline, RR for PTSD associated with neuroticism was equal to the null value of 1, but was increased significantly among those with no history of major depression.ConclusionsThe results confirm the role of neuroticism as diathesis in the PTSD response to traumatic experiences.

Background: Antibiotics are frequently prescribed–and overprescribed–at hospital discharge, leading to adverse-events and patient harm. Our understanding of how to optimize prescribing at discharge is limited. Recently, we published the ROAD (Reducing Overuse of Antibiotics at Discharge) Home Framework, which identified potential strategies to improve antibiotic prescribing at discharge across 3 tiers: Tier 1–Critical infrastructure, Tier 2–Broad inpatient interventions, Tier 3–Discharge-specific strategies. Here, we used the ROAD Home Framework to assess the association of stewardship strategies with antibiotic overuse at discharge and to describe pathways toward improved discharge prescribing. Methods: In fall 2019, we surveyed 39 Michigan hospitals on their antibiotic stewardship strategies. For patients hospitalized at participating hospitals July 1, 2017, through July 30, 2019, and treated for community-acquired pneumonia (CAP) and urinary tract infection (UTI), we assessed the association of reported strategies with days of antibiotic overuse at discharge. Days of antibiotic overuse at discharge were defined based on national guidelines and included unnecessary therapy, excess duration, and suboptimal fluoroquinolone use. We evaluated the association of stewardship strategies with days of discharge antibiotic overuse 2 ways: (1) all stewardship strategies were assumed to have equal weight, and (2) strategies weighted using the ROAD Home Framework with tier 3 (discharge-specific) strategies had the highest weight. Results: Overall, 39 hospitals with 20,444 patients (56.5% CAP; 43.5% UTI) were included. The survey response rate was 100% (39 of 39). Hospitals reported a median of 12 (IQR, 9–14) of 33 possible stewardship strategies (Fig. 1). On bivariable analyses, review of antibiotics prior to discharge was the only strategy consistently associated with lower antibiotic overuse at discharge (aIRR, 0.543; 95% CI, 0.335–0.878). On multivariable analysis, weighting by ROAD Home tier predicted antibiotic overuse at discharge for both CAP and UTI. For diseases combined, having more weighted strategies was associated with lower antibiotic overuse at discharge (aIRR per weighted intervention, 0.957; 95% CI, 0.927–0.987). Discharge-specific stewardship strategies were associated with a 12.4% relative decrease in antibiotic overuse days at discharge. Based on these findings, 3 pathways emerged to improve antibiotic use at discharge (Fig. 2): inpatient-focused strategies, “doing it all,” and discharge-focused strategies. Conclusions: The more stewardship strategies reported, the lower a hospitals’ antibiotic overuse at discharge. However, different pathways to improve discharge antibiotic use exist. Thus, discharge stewardship strategies should be tailored. Specifically, hospitals with limited stewardship resources and infrastructure should consider implementing a discharge-specific strategy straightaway. In contrast, hospitals that already have substantial inpatient infrastructure may benefit from proactively incorporating discharge into their existing strategies.Funding: NoneDisclosures: None

The meta-legal basis of the provincial autonomy of Vojvodina appeared in political form only after the state fusion in 1918. A crossanalysis of the material on Vojvodina political autonomism points to its origin in the historical law of the Habsburg Empire, which was accepted by a group of few political outsiders and landowners of Vojvodina. The new modern state effectively and quickly solved problems: currency, tax and agrarian issues, improvement of trade, association and achieving sustainability of independent farms in Vojvodina. Then the Vojvodina autonomists looked for arguments in the backward standpoints of the past. The narcissism of cultural "superiority", negative prejudice against "Serbianians", the confusion of the concepts of regionalism, decentralization, autonomy and self-government became the political material for the future meta-legal construction of the autonomy of Vojvodina modeled on the "crown land" of the Habsburg real union. Already at the time of the fusion of Banat, Bačka and Baranja with Serbian, there were certain tendencies for the distinctiveness of the administration of these united area. At that time, happened first political attempts of a small number of politicians for the "State of Slovenes, Serbs and Croats" to receive a certain role in the fusion of those areas with Serbia, by dint in Zagreb. In the area of Vojvodina, the right to self-determination of the people meant breaking the state ties with Hungary and fusion to Serbia. For this purpose was formed the Great National Assembly of Serbs, Bunjevs and other Slavs of Banat, Bačka and Baranja was formed. At the end of 1918, the Assembly elected by direct, equal and general suffrage of the population. This was the realization of the people's right to self-determination in a modern democratic form. The Assembly elected the administrative bodies of the temporary management of the area. Those bodies were not effective due to outdated understandings, unclear legal nature, and lack of distinction between administrative work, legal authorisation and legal competence. The problems caused by the temporary regional administration make dificulties the subsequent work of the authorities of the Kingdom of Serbs, Croats and Slovenes, causing great intolerance towards "centralism." The government of the new state effectively solved administrative problems, currency, tax and agrarian issues under democratic conditions, and developed local selfgovernment. As the public became aware of the benefits of democratic modernity, general support for the new order grew. Opponents of the new order were a small number of nationalized landowners, economically stable officials and privileged individuals of the former Habsburg order. Among them, Serbian opposition politicians and Croatian nationalists sought support. Vojvodina's political autonomism is from the beginning linked to the political work of Croatian nationalists, the political fashion of "regionalism" and the historical sentiments of the Habsburg era. From the beginning formulated political ideas of Vojvodina autonomy, two phenomena stand out conspicuously: the support of Croatian nationalists and emotional intolerance towards Serbia and "Serbians." These phenomena are paradigmatically shown by two historical sources: Mihovil Tomandl's article "Serbian hegemony" (1923) and the proclamation of the Independent Democratic Party published under the title "Vojvodina wants to be its own" (1924).

Objective:Obstructive sleep apnea (OSA) may be a modifiable risk factor for late-life cognitive impairment. We previously demonstrated that non-Hispanic Black older adults are less likely to be diagnosed with OSA despite having equal or greater health risk for OSA compared to non-Hispanic White older adults, and this disparity in diagnosis was strongest among individuals with lower education. Here, we aimed to determine 1) whether there are racial differences in continuous positive airway pressure (CPAP) treatment, 2) how CPAP treatment may influence OSA-cognition associations, and 3) whether CPAP differentially influences OSA-cognition associations across racial groups.Participants and Methods:Cross-sectional data were obtained from 424 socioeconomically diverse community-dwelling adults ages 55-83 (63.4±3.2 years, 41.7% male, 53.5% Black) from the Michigan Cognitive Aging Project. Physician-diagnosed OSA and current CPAP use were self-reported. Global cognition was operationalized as a composite of five factor scores derived from a comprehensive neuropsychological battery. Racial group differences were investigated with chi-square and Fisher’s exact tests with statistical significance set at the .05 level. Associations between OSA and cognition (adjusted for age, gender, race, and years of education) were investigated with linear regressions. Subsequent models isolated effects of uncontrolled OSA by excluding individuals using CPAP. Racial differences in OSA-cognition associations were investigated with race-stratified models.Results:Fewer Black participants (9.2%) reported diagnosed OSA compared to White participants (12.3%; x2 (1, N=424) =5.314, p=.021, cp=.112). In the whole sample, 47.3% of participants with diagnosed OSA reported CPAP use, and this proportion did not differ across race (x2 [1, N=86] =.048, p=.826). In the whole sample, OSA diagnosis was only associated with cognition when CPAP users were excluded (excluding CPAP users: ß=-.085, SE=.037, p=.024; including CPAP users: ß=-.067, SE=.036, p=.062). In race-stratified models, diagnosed OSA was only associated with cognition among Black participants, and this association was stronger when CPAP users were excluded (excluding CPAP users: ß=-.142, SE=.060, p=.018; including CPAP users: ß=-.126, SE=.058, p=.030). Diagnosed OSA was not associated with cognition among White participants, irrespective of whether CPAP users were included (excluding CPAP users: ß=-.084,SE=.068, p=.215; including CPAP users: ß=-.056, SE=.064, p=.378).Conclusions:Our findings support CPAP treatment as a potential intervention to mitigate late-life cognitive impairment among those with OSA. Despite being less likely to receive a diagnosis of OSA, Black older adults were equally likely to engage in CPAP treatment as White older adults when diagnosed. The detrimental impact of OSA on cognition may be more salient among Black older adults, which may reflect racial disparities in cardiovascular risk and/or resources that promote cognitive reserve. However, CPAP appears to be an effective treatment to reduce OSA-related cognitive impairment for Black older adults, highlighting the critical importance of diagnosis and treatment in this group. Intervention efforts that abate racial inequalities in access to quality healthcare in order to facilitate acquisition of a formal OSA diagnosis and CPAP treatment may help to reduce preventable cognitive health disparities among older adults.

Abstract Background Strategies to optimize antibiotic prescribing at discharge are not well understood. Methods In fall 2019, we surveyed 39 Michigan hospitals on their antibiotic stewardship strategies. The association of reported strategies with discharge antibiotic overuse (unnecessary, excess, suboptimal fluoroquinolones) for community-acquired pneumonia (CAP) and urinary tract infection (UTI) was evaluated in 2 ways: (1) all strategies assumed equal weight and (2) strategies were weighted based on the ROAD (Reducing Overuse of Antibiotics at Discharge) Home Framework (ie, Tier 1—Critical infrastructure, Tier 2—Broad inpatient interventions, Tier 3—Discharge-specific strategies) with Tier 3 strategies receiving the highest weight. Results Between 1 July 2017 and 30 July 2019, 39 hospitals with 20 444 patients (56.5% CAP; 43.5% UTI) were included. Survey response was 100%. Hospitals reported a median (interquartile range [IQR]) 12 (9–14) of 34 possible stewardship strategies. On analyses of individual stewardship strategies, the Tier 3 intervention, review of antibiotics prior to discharge, was the only strategy consistently associated with lower antibiotic overuse at discharge (adjusted incident rate ratio [aIRR] 0.543, 95% confidence interval [CI]: .335–.878). On multivariable analysis, weighting by ROAD Home tier predicted antibiotic overuse at discharge for both CAP and UTI. For diseases combined, having more weighted strategies was associated with lower antibiotic overuse at discharge (aIRR 0.957, 95% CI: .927–.987, per weighted intervention); discharge-specific stewardship strategies were associated with a 12.4% relative decrease in antibiotic overuse days at discharge. Conclusions The more stewardship strategies a hospital reported, the lower its antibiotic overuse at discharge. However, Tier 3, or discharge-specific strategies, appeared to have the largest effect on antibiotic prescribing at discharge.

Background and Objectives: It is estimated that over 200,000 adults experience in-hospital cardiac arrest each year. Overall survival to discharge has remained relatively unchanged for decades and survival rates remain at about 20% (Elenbach et al., 2009). Get With The Guidelines-Resuscitation (GWTG-R) is an in-hospital quality improvement program designed to improve adherence to evidence-based care of patients who experience an in-hospital resuscitation event. GWTG-R focuses on four achievement measures. The measures for adult patients include time to first chest compression of less than or equal to one minute, device confirmation of correct endotracheal tube placement, patients with pulseless VF/VT as the initial documented rhythm with a time to first shock of less than or equal to two minutes, and events in which patients were monitored or witnessed at the time of cardiac arrest. The objective of this abstract is to examine the association between hospital adherence to GWTG-R and in-hospital cardiac arrest survival rates. Methods: A retrospective review of adult in-hospital cardiopulmonary arrest (CPA) patients (n=1849) from 21 Michigan, Illinois, and Indiana hospitals using the GWTG-R database was conducted from January 2014 through December 2014. This study included adult CPA patients that did and did not survive to discharge. Results: The review found that hospitals that had attained 84.6% or higher thresholds in all four achievement measures for at least one year, which is award recognition status, had a significantly improved in-hospital CPA survival to discharge rate of 29.6%. Hospitals that did not obtain award status had a CPA survival to discharge rate of 24.3%. The national survival rate for in-hospital adult CPA survival to discharge is 20%. Hospitals that did not achieve award recognition status still demonstrated improvement in survival rate when compared to the national survival rate, indicating the importance of a quality improvement program such as GWTG-R. No significant difference was found between in-hospital adult CPA survival rate and race between GWTG-R award winning and non-award winning hospitals. Hospitals that earned award recognition from GWTG-R had a survival to discharge rate of 30.2% for African Americans and 29.6% for whites. Hospitals that were did not earn award recognition from GWTG-R had a survival to discharge rate of 20.0% for African Americans and 20.1% for whites. Conclusions: Survival of in-hospital adult CPA patients improved significantly when GWTG-R measures are adhered to. Survival of in-hospital adult CPA patients also improves with implementation of GWTG-R. It is crucial that hospitals collect and analyze data regarding resuscitation processes and outcomes. Quality improvement measures can then be implemented in order to assist with improving in-hospital CPA survival rates.

This study compares the short term and long term functional outcomes of bone marrow derived multipotent progenitor cells (MPC) transplantation. In the short term study, the LAD was occluded distal to the 2 nd diagonal branch with PTCA balloon dilatation for 60 minutes (IR, 1 month follow-up) and MPC were delivered through a transarterial catheter, while in the long term study, the coronary artery was occluded with ligation (OCCL, 4 months follow-up). In both IR and OCCL cases, intra-myocardial injection of 50 million LacZ labeled MPC (Cell) was performed in the periscar region with 5 equal injections immediately after myocardial infarction, while in control animals (CONT) saline was injected. The myocardial bioenergetics (P-31 MRS) and LV function (MRI) were followed-up monthly (Table ). MPC transplantation resulted in improvement of ejection fraction in the OCCL study, which persists for 4 months. In the IR study, although the EF was not significantly different between the two groups at 7days postinfarction, Cell induced a significant improvement of EF at week 4 (Table ). The myocardial phosphorylation potential that is reflected by the PCr/ATP ratio was significantly higher in CELL treated group of both studies, which persists during high cardiac workstates secondary to catecholamine stimulation. Although the engraftment was low (less than 0.35%), a small portion of the engrafted cells were found co-staining positive for troponin T and/or N-cadherin suggesting differentiation to myogenic cells. The infarct size was similar between the groups at 10 days. However, the infarct size was significantly reduced at 4 months in the Cell group that was not observed in the CONT. These data demonstrate that MPC transplantation associated improvement in ventricular function and myocardial energetics persists for 4 months follow-up. The beneficial effects are likely caused by cell transplantation induced mobilization and differentiation of endogenous cardiac progenitors. This research has received full or partial funding support from the American Heart Association, AHA Midwest Affiliate (Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, South Dakota & Wisconsin). Improvement in Ejection Fraction after MPC transplantation

This article explores how fat women protesting challenges norms of womanhood, the place of women in society, and who has the power to have their say in public spaces. We use the term fat as a political reclamation; Fat Studies scholars and fat activists prefer the term fat, over the normative term “overweight” and the pathologising term “obese/obesity” (Lee and Pausé para 3). Who is and who isn’t fat, we suggest, is best left to self-determination, although it is generally accepted by fat activists that the term is most appropriately adopted by individuals who are unable to buy clothes in any store they choose. Using a tweet from conservative commentator Ann Coulter as a leaping-off point, we examine the narratives around women in the public sphere and explore how fat bodies might transgress further the norms set by society. The public representations of women in politics and protest are then are set in the context of ‘activist wisdom’ (Maddison and Scalmer) from two sides of the globe. Activist wisdom gives preference to the lived knowledge and experience of activists as tools to understand social movements. It seeks to draw theoretical implications from the practical actions of those on the ground. In centring the experiences of ourselves and other activists, we hope to expand existing understandings of body politics, gender, and political power in this piece. It is important in researching social movements to look both at the representations of protest and protestors in all forms of media as this is the ‘public face’ of movements, but also to examine the reflections of the individuals who collectively put their weight behind bringing social change.A few days after the 45th President of the United States was elected, people around the world spilled into the streets and participated in protests; precursors to the Women’s March which would take place the following January. Pictures of such marches were shared via social media, demonstrating the worldwide protest against the racism, misogyny, and overall oppressiveness, of the newly elected leader. Not everyone was supportive of these protests though; one such conservative commentator, Ann Coulter, shared this tweet: Image1: A tweet from Ann Coulter; the tweet contains a picture of a group of protestors, holding signs protesting Trump, white supremacy, and for the rights of immigrants. In front of the group, holding a megaphone is a woman. Below the picture, the text reads, “Without fat girls, there would be no protests”.Coulter continued on with two more tweets, sharing pictures of other girls protesting and suggesting that the protestors needed a diet programme. Kivan Bay (“Without Fat Girls”) suggested that perhaps Coulter was implying that skinny girls do not have time to protest because they are too busy doing skinny girl things, like buying jackets or trying on sweaters. Or perhaps Coulter was arguing that fat girls are too visible, too loud, and too big, to be taken seriously in their protests. These tweets provide a point of illustration for how fat women protesting challenge norms of womanhood, the place of women in society, and who has the power to have their say in public spaces While Coulter’s tweet was most likely intended as a hostile personal attack on political grounds, we find it useful in its foregrounding of gender, bodies and protest which we consider in this article, beginning with a review of fat girls’ role in social justice movements.Across the world, we can point to fat women who engage in activism related to body politics and more. Australian fat filmmaker and activist Kelli Jean Drinkwater makes documentaries, such as Aquaporko! and Nothing to Lose, that queer fat embodiment and confronts body norms. Newly elected Ontario MPP Jill Andrew has been fighting for equal rights for queer people and fat people in Canada for decades. Nigerian Latasha Ngwube founded About That Curvy Life, Africa’s leading body positive and empowerment site, and has organised plus-size fashion show events at Heineken Lagos Fashion and Design Week in Nigeria in 2016 and the Glitz Africa Fashion Week in Ghana in 2017. Fat women have been putting their bodies on the line for the rights of others to live, work, and love. American Heather Heyer was protesting the hate that white nationalists represent and the danger they posed to her friends, family, and neighbours when she died at a rally in Charlottesville, North Carolina in late 2017 (Caron). When Heyer was killed by one of those white nationalists, they declared that she was fat, and therefore her body size was lauded loudly as justification for her death (Bay, “How Nazis Use”; Spangler).Fat women protesting is not new. For example, the Fat Underground was a group of “radical fat feminist women”, who split off from the more conservative NAAFA (National Association to Aid Fat Americans) in the 1970s (Simic 18). The group educated the public about weight science, harassed weight-loss companies, and disrupted academic seminars on obesity. The Fat Underground made their first public appearance at a Women’s Equality Day in Los Angeles, taking over the stage at the public event to accuse the medical profession of murdering Cass Elliot, the lead singer of the folk music group, The Mamas and the Papas (Dean and Buss). In 1973, the Fat Underground produced the Fat Liberation Manifesto. This Manifesto began by declaring that they believed “that fat people are full entitled to human respect and recognition” (Freespirit and Aldebaran 341).Women have long been disavowed, or discouraged, from participating in the public sphere (Ginzberg; van Acker) or seen as “intruders or outsiders to the tough world of politics” (van Acker 118). The feminist slogan the personal is political was intended to shed light on the role that women needed to play in the public spheres of education, employment, and government (Caha 22). Across the world, the acceptance of women within the public sphere has been varied due to cultural, political, and religious, preferences and restrictions (Agenda Feminist Media Collective). Limited acceptance of women in the public sphere has historically been granted by those ‘anointed’ by a male family member or patron (Fountaine 47).Anti-feminists are quick to disavow women being in public spaces, preferring to assign them the role as helpmeet to male political elite. As Schlafly (in Rowland 30) notes: “A Positive Woman cannot defeat a man in a wrestling or boxing match, but she can motivate him, inspire him, encourage him, teach him, restrain him, reward him, and have power over him that he can never achieve over her with all his muscle.” This idea of women working behind the scenes has been very strong in New Zealand where the ‘sternly worded’ letter is favoured over street protest. An acceptable route for women’s activism was working within existing political institutions (Grey), with activity being ‘hidden’ inside government offices such as the Ministry of Women’s Affairs (Schuster, 23). But women’s movement organisations that engage in even the mildest form of disruptive protest are decried (Grey; van Acker).One way women have been accepted into public space is as the moral guardians or change agents of the entire political realm (Bliss; Ginzberg; van Acker; Ledwith). From the early suffrage movements both political actors and media representations highlighted women were more principled and conciliatory than men, and in many cases had a moral compass based on restraint. Cartoons showed women in the suffrage movement ‘sweeping up’ and ‘cleaning house’ (Sheppard 123). Groups like the Women’s Christian Temperance Union were celebrated for protesting against the demon drink and anti-pornography campaigners like Patricia Bartlett were seen as acceptable voices of moral reason (Moynihan). And as Cunnison and Stageman (in Ledwith 193) note, women bring a “culture of femininity to trade unions … an alternative culture, derived from the particularity of their lives as women and experiences of caring and subordination”. This role of moral guardian often derived from women as ‘mothers’, responsible for the physical and moral well-being of the nation.The body itself has been a sight of protest for women including fights for bodily autonomy in their medical decisions, reproductive justice, and to live lives free from physical and sexual abuse, have long been met with criticisms of being unladylike or inappropriate. Early examples decried in NZ include the women’s clothing movement which formed part of the suffrage movement. In the second half of the 20th century it was the freedom trash can protests that started the myth of ‘women burning their bras’ which defied acceptable feminine norms (Sawer and Grey). Recent examples of women protesting for body rights include #MeToo and Time’s Up. Both movements protest the lack of bodily autonomy women can assert when men believe they are entitled to women’s bodies for their entertainment, enjoyment, and pleasure. And both movements have received considerable backlash by those who suggest it is a witch hunt that might ensnare otherwise innocent men, or those who are worried that the real victims are white men who are being left behind (see Garber; Haussegger). Women who advocate for bodily autonomy, including access to contraception and abortion, are often held up as morally irresponsible. As Archdeacon Bullock (cited in Smyth 55) asserted, “A woman should pay for her fun.”Many individuals believe that the stigma and discrimination fat people face are the consequences they sow from their own behaviours (Crandall 892); that fat people are fat because they have made poor decisions, being too indulgent with food and too lazy to exercise (Crandall 883). Therefore, fat people, like women, should have to pay for their fun. Fat women find themselves at this intersection, and are often judged more harshly for their weight than fat men (Tiggemann and Rothblum). Examining Coulter’s tweet with this perspective in mind, it can easily be read as an attempt to put fat girl protestors back into their place. It can also be read as a warning. Don’t go making too much noise or you may be labelled as fat. Presenting troublesome women as fat has a long history within political art and depictions. Marianne (the symbol of the French Republic) was depicted as fat and ugly; she also reinforced an anti-suffragist position (Chenut 441). These images are effective because of our societal views on fatness (Kyrölä). Fatness is undesirable, unworthy of love and attention, and a representation of poor character, lack of willpower, and an absence of discipline (Murray 14; Pausé, “Rebel Heart” para 1).Fat women who protest transgress rules around body size, gender norms, and the appropriate place for women in society. Take as an example the experiences of one of the authors of this piece, Sandra Grey, who was thrust in to political limelight nationally with the Campaign for MMP (Grey and Fitzsimmons) and when elected as the President of the New Zealand Tertiary Education Union in 2011. Sandra is a trade union activist who breaches too many norms set for the “good woman protestor,” as well as the norms for being a “good fat woman”. She looms large on a stage – literally – and holds enough power in public protest to make a crowd of 7,000 people “jump to left”, chant, sing, and march. In response, some perceive Sandra less as a tactical and strategic leader of the union movement, and more as the “jolly fat woman” who entertains, MCs, and leads public events. Though even in this role, she has been criticised for being too loud, too much, too big.These criticisms are loudest when Sandra is alongside other fat female bodies. When posting on social media photos with fellow trade union members the comments often note the need of the group to “go on a diet”. The collective fatness also brings comments about “not wanting to fuck any of that group of fat cows”. There is something politically and socially dangerous about fat women en masse. This was behind the responses to Sandra’s first public appearance as the President of TEU when one of the male union members remarked “Clearly you have to be a fat dyke to run this union.” The four top elected and appointed positions in the TEU have been women for eight years now and both their fatness and perceived sexuality present as a threat in a once male-dominated space. Even when not numerically dominant, unions are public spaces dominated by a “masculine culture … underpinned by the undervaluation of ‘women’s worth’ and notions of womanhood ‘defined in domesticity’” (Cockburn in Kirton 273-4). Sandra’s experiences in public space show that the derision and methods of putting fat girls back in their place varies dependent on whether the challenge to power is posed by a single fat body with positional power and a group of fat bodies with collective power.Fat Girls Are the FutureOn the other side of the world, Tara Vilhjálmsdóttir is protesting to change the law in Iceland. Tara believes that fat people should be protected against discrimination in public and private settings. Using social media such as Facebook and Instagram, Tara takes her message, and her activism, to her thousands of followers (Keller, 434; Pausé, “Rebel Heart”). And through mainstream media, she pushes back on fatphobia rhetoric and applies pressure on the government to classify weight as a protected status under the law.After a lifetime of living “under the oppression of diet culture,” Tara began her activism in 2010 (Vilhjálmsdóttir). She had suffered real harm from diet culture, developing an eating disorder as a teen and being told through her treatment for it that her fears as a fat woman – that she had no future, that fat people experienced discrimination and stigma – were unfounded. But Tara’s lived experiences demonstrated fat stigma and discrimination were real.In 2012, she co-founded the Icelandic Association for Body Respect, which promotes body positivity and fights weight stigma in Iceland. The group uses a mixture of real life and online tools; organising petitions, running campaigns against the Icelandic version of The Biggest Loser, and campaigning for weight to be a protected class in the Icelandic constitution. The Association has increased the visibility of the dangers of diet culture and the harm of fat stigma. They laid the groundwork that led to changing the human rights policy for the city of Reykjavík; fat people cannot be discriminated against in employment settings within government jobs. As the city is one of the largest employers in the country, this was a large step forward for fat rights.Tara does receive her fair share of hate messages; she’s shared that she’s amazed at the lengths people will go to misunderstand what she is saying (Vilhjálmsdóttir). “This isn’t about hurt feelings; I’m not insulted [by fat stigma]. It’s about [fat stigma] affecting the livelihood of fat people and the structural discrimination they face” (Vilhjálmsdóttir). She collects the hateful comments she receives online through screenshots and shares them in an album on her page. She believes it is important to keep a repository to demonstrate to others that the hatred towards fat people is real. But the hate she receives only fuels her work more. As does the encouragement she receives from people, both in Iceland and abroad. And she is not alone; fat activists across the world are using Web 2.0 tools to change the conversation around fatness and demand civil rights for fat people (Pausé, “Rebel Heart”; Pausé, “Live to Tell").Using Web 2.0 tools as a way to protest and engage in activism is an example of oppositional technologics; a “political praxis of resistance being woven into low-tech, amateur, hybrid, alternative subcultural feminist networks” (Garrison 151). Fat activists use social media to engage in anti-assimilationist activism and build communities of practice online in ways that would not be possible in real life (Pausé, “Express Yourself” 1). This is especially useful for those whose protests sit at the intersections of oppressions (Keller 435; Pausé, “Rebel Heart” para 19). Online protests have the ability to travel the globe quickly, providing opportunities for connections between protests and spreading protests across the globe, such as SlutWalks in 2011-2012 (Schuster 19). And online spaces open up unlimited venues for women to participate more freely in protest than other forms (Harris 479; Schuster 16; Garrison 162).Whether online or offline, women are represented as dangerous in the political sphere when they act without male champions breaching norms of femininity, when their involvement challenges the role of woman as moral guardians, and when they make the body the site of protest. Women must ‘do politics’ politely, with utmost control, and of course caringly; that is they must play their ‘designated roles’. Whether or not you fit the gendered norms of political life affects how your protest is perceived through the media (van Acker). Coulter’s tweet loudly proclaimed that the fat ‘girls’ protesting the election of the 45th President of the United States were unworthy, out of control, and not worthy of attention (ironic, then, as her tweet caused considerable conversation about protest, fatness, and the reasons not to like the President-Elect). What the Coulter tweet demonstrates is that fat women are perceived as doubly-problematic in public space, both as fat and as women. They do not do politics in a way that is befitting womanhood – they are too visible and loud; they are not moral guardians of conservative values; and, their bodies challenge masculine power.ReferencesAgenda Feminist Media Collective. “Women in Society: Public Debate.” Agenda: Empowering Women for Gender Equity 10 (1991): 31-44.Bay, Kivan. “How Nazis Use Fat to Excuse Violence.” Medium, 7 Feb. 2018. 1 May 2018 <https://medium.com/@kivabay/how-nazis-use-fat-to-excuse-violence-b7da7d18fea8>.———. “Without Fat Girls, There Would Be No Protests.” Bullshit.ist, 13 Nov. 2016. 16 May 2018 <https://bullshit.ist/without-fat-girls-there-would-be-no-protests-e66690de539a>.Bliss, Katherine Elaine. Compromised Positions: Prostitution, Public Health, and Gender Politics in Revolutionary Mexico City. Penn State Press, 2010.Caha, Omer. Women and Civil Society in Turkey: Women’s Movements in a Muslim Society. London: Ashgate, 2013.Caron, Christina. “Heather Heyer, Charlottesville Victim, Is Recalled as ‘a Strong Woman’.” New York Times, 13 Aug. 2017. 1 May 2018 <https://www.nytimes.com/2017/08/13/us/heather-heyer-charlottesville-victim.html>.Chenut, Helen. “Anti-Feminist Caricature in France: Politics, Satire and Public Opinion, 1890-1914.” Modern & Contemporary France 20.4 (2012): 437-452.Crandall, Christian S. "Prejudice against Fat People: Ideology and Self-Interest." Journal of Personality and Social Psychology 66.5 (1994): 882-894.Damousi, Joy. “Representations of the Body and Sexuality in Communist Iconography, 1920-1955.” Australian Feminist Studies 12.25 (1997): 59-75.Dean, Marge, and Shirl Buss. “Fat Underground.” YouTube, 11 Aug. 2016 [1975]. 1 May 2018 <https://youtu.be/UPYRZCXjoRo>.Fountaine, Susan. “Women, Politics and the Media: The 1999 New Zealand General Election.” PhD thesis. Palmerston North, NZ: Massey University, 2002.Freespirit, Judy, and Aldebaran. “Fat Liberation Manifesto November 1973.” The Fat Studies Reader. Eds. Esther Rothblum and Sondra Solovay. New York: NYU P, 2009. 341-342.Garber, Megan. “The Selective Empathy of #MeToo Backlash.” The Atlantic, 11 Feb 2018. 5 Apr. 2018 <https://www.theatlantic.com/entertainment/archive/2018/02/the-selective-empathy-of-metoo-backlash/553022/>.Garrison, Edith. “US Feminism – Grrrl Style! Youth (Sub)Cultures and the Technologics of the Third Wave.” Feminist Studies 26.1 (2000): 141-170.Garvey, Nicola. “Violence against Women: Beyond Gender Neutrality.” Looking Back, Moving Forward: The Janus Women’s Convention 2005. Ed. Dale Spender. Masterton: Janus Trust, 2005. 114-120.Ginzberg, Lori D. Women and the Work of Benevolence: Morality, Politics, and Class in the Nineteenth-Century United States. Yale UP, 1992.Grey, Sandra. “Women, Politics, and Protest: Rethinking Women's Liberation Activism in New Zealand.” Rethinking Women and Politics: New Zealand and Comparative Perspectives. Eds. John Leslie, Elizabeth McLeay, and Kate McMillan. Victoria UP, 2009. 34-61.———, and Matthew Fitzsimons. “Defending Democracy: ‘Keep MMP’ and the 2011 Electoral Referendum.” Kicking the Tyres: The New Zealand General Election and Electoral Referendum of 2011. Eds. Jon Johansson and Stephen Levine. Victoria UP, 2012. 285-304.———, and Marian Sawer, eds. Women’s Movements: Flourishing or in Abeyance? London: Routledge, 2008.Harris, Anita. “Mind the Gap: Attitudes and Emergent Feminist Politics since the Third Wave.” Australian Feminist Studies 25.66 (2010): 475-484.Haussegger, Virginia. “#MeToo: Beware the Brewing Whiff of Backlash.” Sydney Morning Herald, 7 Mar. 2018. 1 Apr. 2018 <https://www.smh.com.au/national/metoo-beware-the-brewing-whiff-of-backlash-20180306-p4z33s.html>.Keller, Jessalynn. “Virtual Feminisms.” Information, Communication and Society 15.3(2011): 429-447.Kirston, Gill. “From ‘a Woman’s Place Is in Her Union’ to ‘Strong Unions Need Women’: Changing Gender Discourses, Policies and Realities in the Union Movement.” Labour & Industry: A Journal of the Social and Economic Relations of Work 27.4 (2017): 270-283.Kyrölä, Katariina. The Weight of Images. London: Routledge, 2014.Ledwith, Sue. “Gender Politics in Trade Unions: The Representation of Women between Exclusion and Inclusion.” European Review of Labour and Research 18.2 (2012): 185-199.Lyndsey, Susan. Women, Politics, and the Media: The 1999 New Zealand General Election. Dissertation. Massey University, 2002.Maddison, Sarah, and Sean Scalmer. Activist Wisdom: Practical Knowledge and Creative Tension in Social Movements. Sydney: UNSW P, 2006. Moynihan, Carolyn. A Stand for Decency: Patricia Bartlett & the Society for Promotion of Community Standards, 1970-1995. Wellington: The Society, 1995.Murray, Samantha. "Pathologizing 'Fatness': Medical Authority and Popular Culture." Sociology of Sport Journal 25.1 (2008): 7-21.Pausé, Cat. “Live to Tell: Coming Out as Fat.” Somatechnics 21 (2012): 42-56.———. “Express Yourself: Fat Activism in the Web 2.0 Age.” The Politics of Size: Perspectives from the Fat-Acceptance Movement. Ed. Ragen Chastain. Praeger, 2015. 1-8.———. “Rebel Heart: Performing Fatness Wrong Online.” M/C Journal 18.3 (2015).Rowland, Robyn, ed. Women Who Do and Women Who Don’t Join the Women’s Movement. London: Routledge, 1984.Schuster, Julia. “Invisible Feminists? Social Media and Young Women’s Political Participation.” Political Science 65.1 (2013): 8-24.Sheppard, Alice. "Suffrage Art and Feminism." Hypatia 5.2 (1990): 122-136.Simic, Zora. “Fat as a Feminist Issue: A History.” Fat Sex: New Directions in Theory and Activism. Eds. Helen Hester and Caroline Walters. London: Ashgate, 2015. 15-36.Spangler, Todd. “White-Supremacist Site Daily Stormer Booted by Hosting Provider.” Variety, 13 Aug. 2017. 1 May 2018 <https://variety.com/2017/digital/news/daily-stormer-heather-heyer-white-supremacist-neo-nazi-hosting-provider-1202526544/>.Smyth, Helen. Rocking the Cradle: Contraception, Sex, and Politics in New Zealand. Steele Roberts, 2000.Tiggemann, Marika, and Esther D. Rothblum. "Gender Differences in Social Consequences of Perceived Overweight in the United States and Australia." Sex Roles 18.1-2 (1988): 75-86.Van Acker, Elizabeth. “Media Representations of Women Politicians in Australia and New Zealand: High Expectations, Hostility or Stardom.” Policy and Society 22.1 (2003): 116-136.Vilhjálmsdóttir, Tara. Personal interview. 1 June 2018.

Photo by lafayett zapata montero on Unsplash INTRODUCTION Mid-level providers are not new to the field of medicine. Nurse practitioners and physician assistants have been providing direct care for patients with the oversight of licensed physicians for many years. As a result of their assistance, physicians can focus on complex cases and oversee a larger patient base. This, in turn, creates a more accessible healthcare system. Although many gaps remain between medicine and dentistry, mid-level providers may be the answer to expanding access to dental healthcare needs. Recently, mid-level providers have entered the field of dentistry in multiple states in the US. People commonly refer to this role as a dental therapist. A dental therapist works under a licensed dentist providing preventive and routine restorative care to expand dental healthcare to underserved populations.[1] This new addition to the workforce has proven to be beneficial in some regions but has opened a door to ethical debate among dentists and public health officials. In 2009 Minnesota approved the first state-wide legislation in the US to legalize the role of dental therapists after seeing a drastic decline in their dentist-to-population ratio. The congregation of dentists in high-income and highly populated areas have left many communities in the US in need of dental care but unable to receive it locally. A case study performed by dental hygienists Minnesota, from 2003 to 2007, concluded that one in four primary school children presented with visible decay, and half of these cases were deemed urgent due to symptoms including toothaches and other oral pain.[2] Minnesota health professionals performed another case study which presented results that they believed to further strengthen the need for dental reform in the state. Over the course of a year, health professionals surveyed seven hospitals in the Minneapolis-St. Paul metropolitan area. The results showed over 10,000 emergency room visits were from dental-related problems such as abscesses or toothaches. These patients had untreated oral health problems, eventually leading to infection and unbearable pain. The total cost for these emergency room visits exceeded $4.7 million in out-of-pocket payments and insurance costs.[3] These issues surrounding dental health care are evident on a national level as well. To visualize the need for expanded oral care on a larger scale, in 2022 researchers recorded that over 69 million people in the US live in areas that have a dental health professional shortage. According to federal regulations, a shortage of providers indicates a population-to-provider ratio that meets or exceeds 5,000:1.[4] Integrating the role of dental therapists into the healthcare system has solved similar issues elsewhere. Alaskan Native communities and countries including the UK, Canada, and New Zealand have used dental therapists for decades.[5] In recent years Maine, Oregon, Washington, Arizona, Michigan, Idaho, New Mexico, Connecticut, and Nevada joined this list.[6] As of 2022, there are five dental therapy licensing programs in the US, located in Alaska, Washington and Minnesota. Dental therapists are required to have a bachelor’s degree in dental therapy and can pursue a master’s in dental therapy to extend their license and perform more advanced procedures.[7] Differences in education, allowed procedures, and state-specific requirements in Minnesota are depicted in Table 1 (state-to-state specifics may vary). Table 1: The Varying Degrees of Dental Therapy *State of Minnesota, Minnesota Administrative Rules, 150A.105, https://www.revisor.mn.gov/ statutes/?id=150a.105; State of Minnesota, Minnesota Session Laws (2009), Regular Session, Chapter 95—S.F. No. 2083, http://www.dentalboard.state.mn.us/Portals/3/Licensing/Dental%20Therapist/DTLEG.pdf; and Minnesota Board of Dentistry, “Dental Therapist Scope of Practice,” http://www.dentalboard.state.mn.us/Portals/3/Licensing/Dental%20 Therapist/DTSCOPE.pdf. I. Regional Outcomes of Employing Dental Therapists The goal of integrating dental therapists was to increase access to care in underserved areas. Results from a 2017 data collection on dental therapists in Alaska provide evidence that the region met this goal. Residents in communities where dental therapists practiced presented with more restorative care and fewer extractions than in communities without.[8] Another statistic reported an increase in private practices opening their doors to Medicaid patients after the addition of a dental therapist to their team. One practice recorded that their dental therapist treated over 200 Medicaid patients and earned nearly $24,000 in additional profit for the practice that year.[9] Expanding dental care to patients enrolled in Medicaid programs has been an ongoing issue. According to the American Dental Association, in 2018, around 30 percent of practicing dentists accepted Medicaid. In 2012, a case study was conducted in Alaska, which collected the statistics produced by Rochelle Furry, a certified dental therapist. Over the course of a year, Furry saw 750 patients and performed 5,000 procedures. Furry’s addition to the team cost the supervising dentist $180,009 in overhead. Furry’s collections totaled $385,338, with a yearly net profit of $205,329.[10] Another benefit reported by dentists when integrating a dental therapist into their team was the ability to prioritize their focus toward more complex cases, leaving routine fillings and other minimally invasive procedures in the hands of the dental therapist. With the reduced education of dental therapists comes reduced costs per procedure. This may encourage patients who are uninsured or owe out-of-pocket payments and entice them to follow through with the diagnosed treatment. II. Areas of Debate Despite providing benefits to patients and supervising dentists, dental therapists are not prevalent throughout the US. Similar to the debate regarding mid-level providers like physician’s assistants and nurse practitioners, there are disputes between healthcare officials on whether the addition of dental therapists is an ethical solution to the disparities in access to oral care. The different levels of education between dentists and dental therapists spark debates on whether dental therapists have enough training to treat patients. Dentists are required to complete both a bachelor’s and a doctorate program, as well as pass rigorous board exams usually totaling eight years of additional education after a high-school degree. Although dental therapists perform more routine procedures that are minimally invasive, they are primarily working with populations that have received minimal oral care in the past, usually presenting with larger amounts of decay. This increases the complexity of cases that a healthcare worker with minimal training compared to a DDS or DMD attends to. While some patients prefer the low costs of procedures done by a dental therapist, others prioritize quality of treatment and believe only dentists are well-trained enough to provide it. Some argue that a doctorate-level medical professional should do irreversible procedures involving the permanent removal of the tooth surfaces, such as fillings, crowns, or extractions. This position also brings up the issue of a two-tiered healthcare system in which patients of low socioeconomic status are treated by providers with less training, while mid to upper class patients are treated by doctors. Some public health professionals argue there are better solutions. For example, the Academy of General Dentistry “White Paper on Increasing Access to and Utilization of Oral Health Care Services" suggests that one of the biggest challenges in achieving optimal oral health for all is “underutilization of available oral health care.”[11] This argument addresses the noneconomic barriers in seeking professional care, including the patient's behavioral factors, levels of oral health literacy, transportation, location, and cultural or linguistic preferences. This author concludes that increased access can be achieved with the current dentist supply, if optimally utilized, along with public health officials increasing public knowledge and awareness regarding oral health.[12] CONCLUSION The remaining question is what may be the best way forward for the health of the US population. The goal of equal and accessible healthcare is not easily obtainable. The introduction of dental therapists to the workforce has provided a possible solution to this problem by expanding access to healthcare to affected populations. Some regions have documented benefits from this addition, but disagreements remain among healthcare professionals on whether this is the ethical solution to the problem of oral health disparities. The practice of integrating dental therapists into all regions with oral health care shortages throughout the US comes down to whether licensed dental therapists are competent in rendering quality treatment in underserved areas. Some are content with the addition of dental therapists, while others continue to look for other solutions, such as better dental education on prevention and optimizing access to already established practices. - [1] Corr, Allison. “What Are Dental Therapists?” The Pew Charitable Trusts, The Pew Charitable Trusts, 9 Oct. 2019, www.pewtrusts.org/en/research-and-analysis/articles/2019/10/09/what-are-dental-therapists. [2] The Pew Center on the States. “The State of Children’s Dental Health: Making Coverage Matter.” Pew Children’s Dental Campaign, Sept. 2010. https://www.pewtrusts.org/~/media/legacy/uploadedfiles/wwwpewtrustsorg/reports/state_policy/childrensdental50statereport2011pdf.pdf. [3] Pew Center on the States (2010). [4] Health Workforce Shortage Areas, Health Resources and Services Administration (HRSA), 31 Mar. 2023, https://data.hrsa.gov/topics/health-workforce/shortage-areas. [5] David A. Nash, Jay W. Friedman, Kavita R. Mathu-Muju, Peter G. Robinson, Julie Satur, Susan Moffat, Rosemary Kardos, Edward C.M. Lo, Anthony H.H. Wong, Nasruddin Jaafar, Jos van den Heuvel, Prathip Phantumvanit, Eu Oy Chu, Rahul Naidu, Lesley Naidoo, Irvi. “A Review of the Global Literature on Dental Therapists.” Community Dentistry and Oral EpidemiologyVolume 42, Issue 1 p. 1-10, Wiley Library Online, 3 May 2013, https://doi.org/10.1111/cdoe.12052. [6] Corr (2019). [7] Urahn, S. and Schuler, A. (2014) Expanding the Dental Team. The Pew Charitable Trust. https://www.pewtrusts.org/-/media/assets/2014/06/27/expanding_dental_case_studies_report.pdf [8] Corr (2019). [9] Corr (2019). [10] Nash, et al. (2013). [11] White Paper on Increasing Access to and Utilization of Oral Health Care Services, Academy of General Dentistry, July 2008, https://www.agd.org/docs/default-source/advocacy-papers/agd-white-paper-increasing-access-to-and-utilization-of-oral-health-care-services.pdf?sfvrsn=2%20. [12] Burton L. Edelstein, DDS, MPH. “Examining Whether Dental Therapists Constitute a Disruptive Innovation in US Dentistry.” American Journal of Public Health, American Public Health Association, Oct. 2011, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3222362/.

I want to argue here that the use of terms like “disabled” has very concrete and practical consequences; such language choices are significant and constitutive, not simply the abstract subject of a theoretical debate or a “politically correct” storm in a teacup. In this paper I want to examine some significant moments of conflict over and resistance to definitions of “disability” in an arts project, “In the Picture”, run by one of the UK’s largest disability charities, Scope. In the words of its webpages, this project “aims to encourage publishers, illustrators and writers to embrace diversity - so that disabled children are included alongside others in illustrations and story lines in books for young readers” (http://www.childreninthepicture.org.uk/aboutus.htm). It sought to raise awareness of “ableism” in the book world and through its webpage, offer practical advice and examples of how to include disabled children in illustrated children’s books. From 2005 to 2007, I tracked the progress of the project’s Stories strand, which sought to generate exemplary inclusive narratives by drawing on the experiences of disabled people and families of disabled children. My research drew on participant observation and interviews, but also creative audience research — a process where, in the words of David Gauntlett, “participants are asked to create media or artistic artefacts themselves.” Consequently, when I’m talking here about definitions of “disability’, I am discussing not just the ways people talk about what the word “disabled” might mean, but also the ways in which such identities might appear in images. These definitions made a real difference to those participating in various parts of the project and the types of inclusive stories they produced. Scope has been subject to substantial critique from the disability movement in the past (Benjamin; Carvel; Shakespeare, "Sweet Charity"). “In the Picture” was part of an attempt to resituate the charity as a campaigning organization (Benjamin; O’Hara), with the campaign’s new slogan “Time to get Equal” appearing prominently at the top of each page of the project’s website. As a consequence the project espoused the social model of disability, with its shift in focus from individual peoples’ bodily differences, towards the exclusionary and unequal society that systematically makes those differences meaningful. This shift in focus generates, some have argued, a performative account of disability as an identity (Sandhal; Breivik). It’s not simply that non-normative embodiment or impairment can be (and often is) acquired later in life, meaning that non-disabled people are perhaps best referred to as TABs — the “temporarily able bodied” (Duncan, Goggin and Newell). More significantly, what counts as a “disabled person” is constituted in particular social, physical and economic environments. Changing that environment can, in essence, create a disabled person, or make a person cease to be dis-abled. I will argue that, within the “In the Picture” project, this radically constructionist vision of disablement often rubbed against more conventional understandings of the term “disabled people”. In the US, the term “people with disabilities” is favoured as a label, because of its “people first” emphasis, as well as its identification of an oppressed minority group (Haller, Dorries and Rahn, 63; Shakespeare, Disability Rights). In contrast, those espousing the social model of disability in the UK tend to use the phrase “disabled people”. This latter term can flag the fact that disability is not something emanating from individuals’ bodily differences, but a social process by which inaccessible environments disable particular people (Oliver, Politics). From this point of view the phrase “people with disabilities” might appear to ascribe the disability to the individual rather than the society — it suggests that it is the people who “have” the disability, not the society which disables. As Helen Meekosha has pointed out, Australian disability studies draws on both US civil rights languages and the social model as understood in the UK. While I’ve chosen to adopt the British turn of phrase here, the broader concept from an Australian point of view, is that the use of particular sets of languages is no simple key to the perspectives adopted by individual speakers. My observations suggest that the key phrase used in the project — “ disabled people” — is one that, we might say, “passes”. To someone informed by the social model it clearly highlights a disabling society. However, it is a phrase that can be used without obvious miscommunication to talk to people who have not been exposed to the social model. Someone who subscribes to a view of “disability” as impairment, as a medical condition belonging to an individual, might readily use the term “disabled people”. The potentially radical implications of this phrase are in some ways hidden, unlike rival terms like “differently abled”, which might be greeted with mockery in some quarters (eg. Purvis; Parris). This “passing” phrase did important work for the “In the Picture” project. As many disability activists have pointed out, “charity” and “concern” for disabled people is a widely espoused value, playing a range of important psychic roles in an ableist society (eg. Longmore; Hevey). All the more evocative is a call to support disabled children, a favoured object of the kinds of telethons and other charitable events which Longmore discusses. In the words of Rosemarie Garland Thomson, the sentimentality often used in charity advertising featuring children “contains disability’s threat in the sympathetic, helpless child for whom the viewer is empowered to act” (Garland Thomson, 63). In calling for publishers to produce picture books which included disabled children, the project had invested in this broad appeal — who could argue against such an agenda? The project has been successful, for example, in recruiting support from many well known children’s authors and illustrators, including Quentin Blake and Dame Jackie Wilson. The phrase “disabled children”, I would argue, smoothed the way for such successes by enabling the project to graft progressive ideas —about the need for adequate representation of a marginalized group — onto existing conceptions of an imagined recipient needing help from an already constituted group of willing givers. So what were the implications of using the phrase “disabled children” for the way the project unfolded? The capacity of this phrase to refer to both a social model account of disability and more conventional understandings had an impact on the recruitment of participants for writing workshops. Participants were solicited via a range of routes. Some were contacted through the charity’s integrated pre-school and the networks of the social workers working beside it. The workshops were also advertised via a local radio show, through events run by the charity for families of disabled people, through a notice in the Disabled Parents site, and announcements on the local disability arts e- newsletter. I am interested in the way that those who heard about the workshops might have been hailed by —or resisted the lure of — those labels “disabled person” or “parent of a disabled child” or at least the meaning of those labels when used by a large disability charity. For example, despite a workshop appearing on the programme of Northwest Disability Arts’ Deaf and Disability Arts Festival, no Deaf participants became involved in the writing workshops. Some politicised Deaf communities frame their identities as an oppressed linguistic minority of sign language users, rather than as disabled people (Corker; Ladd). As such, I would suggest that they are not hailed by the call to “disabled people” with which the project was framed, despite the real absence of children’s books drawing on Deaf culture and its rich tradition of visual communication (Saunders; Conlon and Napier). Most of those who attended were (non-disabled) parents or grandparents of disabled children, rather than disabled people, a fact critiqued by some participants. It’s only possible to speculate about the reasons for this imbalance. Was it the reputation of this charity or charities in general (see Shakespeare, "Sweet Charity") amongst politicised disabled people that discouraged attendance? A shared perspective with those within the British disabled peoples’ movement who emphasise the overwhelming importance of material changes in employment, education, transport rather than change in the realm of “attitudes” (eg Oliver, Politics)? Or was it the association of disabled people undertaking creative activities with a patronising therapeutic agenda (eg Hevey, 26)? The “pulling power” of a term even favoured by the British disability movement, it seems, might be heavily dependent on who was using it. Nonetheless, this term did clearly speak to some people. In conversation it emerged that most of those who attended the workshops either had young family members who were disabled or were imbricated in educational and social welfare networks that identified them as “disabled” — for example, by having access to Disability Living Allowance. While most of the disabled children in participants’ families were in mainstream education, most also had an educational “statement” enabling them to access extra resources, or were a part of early intervention programmes. These social and educational institutions had thus already hailed them as “families of disabled children” and as such they recognised themselves in the project’s invitation. Here we can see the social and institutional shaping of what counts as “disabled children” in action. One participant who came via an unusual route into the workshops provides an interesting reflection of the impact of an address to “disabled people”. This man had heard about the workshop because the local charity he ran had offices adjacent to the venue of one of the workshops. He started talking to the workshop facilitator, and as he said in an interview, became interested because “well … she mentioned that it was about disabilities and I’m interested in people’s disabilities – I want to improve conditions for them obviously”. I probed him about the relationship between his interest and his own experiences as a person with dyslexia. While he taught himself to read in his thirties, he described his reading difficulties as having ongoing impacts on his working life. He responded: first of all it wasn’t because I have dyslexia, it was because I’m interested in improving people’s lives in general. So, I mean particularly people who are disabled need more care than most of us don’t they? …. and I’d always help whenever I can, you know what I mean. And then thinking that I had a disability myself! The dramatic double-take at the end of this comment points to the way this respondent positions himself throughout as outside of the category of “disabled”. This self- identification points towards the stigma often attached to the category “disabled”. It also indicates the way in which this category is, at least in part, socially organised, such that people can be in various circumstances located both inside and outside it. In this writer’s account “people who are disabled” are “them” needing “more care than most of us”. Here, rather than identifying as a disabled person, imagined as a recipient of support, he draws upon the powerful discourses of charity in a way that positions him giving to and supporting others. The project appealed to him as a charity worker and as a campaigner, and indeed a number of other participants (both “disabled” and “non-disabled”) framed themselves in this way, looking to use their writing as a fundraising tool, for example, or as a means of promoting more effective inclusive education. The permeability of the category of “disabled” presented some challenges in the attempt to solicit “disabled peoples’” voices within the project. This was evident when completed stories came to be illustrated by design, illustration and multimedia students at four British universities: Liverpool John Moores University, the University of Wolverhampton, the University of Teeside and the North East Wales Institute. Students attending an initial briefing on the project completed a questionnaire which included an item asking whether they considered themselves to be disabled. While around eight of the eighty respondents answered “yes” to this question, the answers of these students and some others were by no means clear cut. A number of students identified themselves as dyslexic, but contested the idea that this diagnosis meant that they were disabled. One respondent commented along similar lines: “My boyfriend was very upset that the university considers him to be disabled because he is dyslexic”. How can we make sense of these responses? We could note again that the identity of “disabled” is highly stigmatised. Many disabled students believe that they are seen as lazy, demanding excessive resources, or even in the case of some students with non- visible impairments, lying (Kleege; Olney and Brockman). So we could view such responses as identity management work. From this point of view, an indicator of the success of the project in shifting some of the stigma attached to the label of “disabled” might be the fact that at least one of the students participants “came out” as dyslexic to her tutors in the course of her participation in the project. The pattern of answers on questionnaire returns suggests that particular teaching strategies and administrative languages shape how students imagine and describe themselves. Liverpool John Moores University, one of the four art schools participating in the project, had a high profile programme seeking to make dyslexic students aware of the technical and writing support available to them if they could present appropriate medical certification (Lowy). Questionnaires from LJMU included the largest number of respondents identifying themselves as both disabled and dyslexic, and featured no comment on any mismatch between these labels. In the interests of obtaining appropriate academic support and drawing on a view of dyslexia not as a deficit but as a learning style offering significant advantages, it might be argued, students with dyslexia at this institution had been taught to recognise themselves through the label “disabled”. This acknowledgement that people sharing some similar experiences might describe themselves in very different ways depending on their context suggests another way of interpreting some students’ equivocal relationship to labels like “dyslexia” and “disabled”. The university as an environment demanding the production of very formal styles of writing and rapid assimilation of a high volume of written texts, is one where particular learning strategies of people with dyslexia come to be disabling. In many peoples’ day to day lives – and perhaps particularly in the day to day lives of visual artists – less conventional ways of processing written information simply may not be disabling. As such, students’ responses might be seen less as resistance to a stigmatised identity and more an acknowledgement of the contingent nature of disablement. Or perhaps we might understand these student responses as a complex mix of both of these perspectives. Disability studies has pointed to the coexistence of contradictory discourses around disability within popular culture (eg, Garland-Thomson; Haller, Dorries and Rahn). Similarly, the friezes, interactive games, animations, illustrated books and stand-alone images which came out of this arts project sometimes incorporate rival conceptions of disability side by side. A number of narratives, for example, include pairs of characters, one of which embodies conventional narratives of disability (for example, being diagnostically labelled or ‘cured’), while the other articulates alternative accounts (celebrating diversity and enabling environments). Both students and staff reported that participation in the project prompted critical thinking about accessible design and inclusive representation. Some commented in interviews that their work on the project had changed their professional practice in ways they thought might have longer term impact on the visual arts. However, it is clear that in student work, just as in the project itself, alternative conceptions of what “disability” might mean were at play, even as reframing such conceptions are explicitly the aim of the enterprise. Such contradictions point towards the difficulties of easily labelling individual stories or indeed the wider project “progressive” or otherwise. Some illustrated narratives and animations created by students were understood by the project management to embody the definitions of “disabled children” within the project’s ten principles. This work was mounted on the website to serve as exemplars for the publishing industry (http://www.childreninthepicture.org.uk/stories.htm). Such decisions were not unreflective, however. There was a good deal of discussion by students and project management about how to make “disabled children” visible without labelling or pathologising. For example, one of the project’s principles is that “images of disabled children should be used casually or incidentally, so that disabled children are portrayed playing and doing things alongside their non- disabled peers” (see also Bookmark). Illustrator Jane Ray commented wryly in an article on the website on her experience of including disabled characters in a such a casual way in her published work that no-one notices it! (Ray). As I’ve discussed in more detail elsewhere (Matthews, forthcoming), the social model, espoused by the project, with its primary focus on barriers to equality rather than individual impaired bodies, presented some challenges to such aims. While both fairytales and, increasingly, contemporary books for young people, do sometimes engage with violence, marginalisation and social conflict (Saunders), there is a powerful imperative to avoid such themes in books for very young children. In trying to re-narrativise disabled children outside conventional paradigms of “bravery overcoming adversity”, the project may have also pushed writers and illustrators away from engaging with barriers to equality. The project manager commented in an interview: “probably in the purest form the social model would show in stories the barriers facing disabled children, whereas we want to show what barriers have been knocked down and turn it round into a more positive thing”. While a handful of the 23 stories emerging from the writing workshops included narratives around bullying and or barriers to equal access, many of the stories chose to envisage more utopian, integrated environments. If it is barriers to inequality that, at least in part, create “disabled people”, then how is it possible to identify disabled children with little reference to such barriers? The shorthand used by many student illustrators, and frequently too in the “images for inspiration” part of the project’s website, has been the inclusion of enabling technologies. A white cane, a wheelchair or assistive and augmentative communication technologies can be included in an image without making a “special” point of these technologies in the written text. The downside to this shorthand, however, is the way that the presence of these technologies can serve to naturalise the category of “disabled children”. Rather than being seen as a group identity constituted by shared experiences of discrimination and exclusion, the use of such “clues” to which characters “are disabled” might suggest that disabled people are a known group, independent of particular social and environmental settings. Using this arts project as a case study, I have traced here some of the ways people are recognised or recognise themselves as “disabled”. I’ve also suggested that within this project other conceptions of what “disabled” might mean existed in the shadows of the social constructionist account to which it declared its allegiances. Given the critiques of the social model which have emerged within disability studies over the last fifteen years (e.g. Crowe; Shakespeare, Disability Rights), this need not be a damning observation. 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